G04.1 coverage policies: Medicare and commercial payers

67 active Medicare policies list G04.1, and 1 commercial payer policy lists it. See each policy's status for the code and its official source. Listing a code is not a coverage decision: read each policy’s source for the requirements that apply.

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Medicare policies listing G04.1

LCD · CGS-J15-L39857

Botulinum Toxin Injections

J15 · Effective Feb 22, 2026

LCD · NGS-J6-L39832

Botulinum Toxin Injections

J6 · Effective Feb 22, 2026

LCD · NGS-JK-L39832

Botulinum Toxin Injections

JK · Effective Feb 22, 2026

LCD · NORIDIAN-L35170

Botulinum Toxin Injections

JE · Effective Oct 1, 2015

LCD · NORIDIAN-L35172

Botulinum Toxin Injections

JF · Effective Oct 1, 2015

LCD · PALMETTO-JJ-L39836

Botulinum Toxin Injections

JJ · Effective Feb 22, 2026

LCD · PALMETTO-JM-L39836

Botulinum Toxin Injections

JM · Effective Feb 22, 2026

LCD · WPS-J5-L39909

Botulinum Toxin Injections

J5 · Effective Feb 22, 2026

LCD · WPS-J5-L40381

Botulinum Toxin Injections

LCD · WPS-J8-L39909

Botulinum Toxin Injections

J8 · Effective Feb 22, 2026

LCD · WPS-J8-L40381

Commercial payer policies listing G04.1

1 policy from 1 payer

Summary of the payer’s published policy. Not a coverage determination — confirm with the payer before submitting.

Cigna

Cigna policies listing G04.1, with the code’s status in each
Policy	Effective	Status of G04.1
Electrodiagnostic Testing (EMG/NCV)PayerPolicy · CIGNA-CPG129	Sep 15, 2026	Covered