G04.90 coverage policies: Medicare and commercial payers

30 active Medicare policies list G04.90, 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 G04.90

LCD · PALMETTO-JJ-L33461

Implantable Infusion Pump

JJ · Effective Oct 1, 2015

LCD · PALMETTO-JM-L33461

Implantable Infusion Pump

JM · Effective Oct 1, 2015

LCD · CGS-J15-L39038

MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J15 · Effective Apr 17, 2022

LCD · NORIDIAN-JE-L39001

MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

JE · Effective Apr 17, 2022

LCD · NORIDIAN-JF-L39001

MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

JF · Effective Apr 17, 2022

LCD · PALMETTO-JJ-L38988

MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

JJ · Effective Apr 17, 2022

LCD · PALMETTO-JM-L38988

MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

JM · Effective Apr 17, 2022

LCD · WPS-J5-L39044

MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

J5 · Effective Apr 17, 2022

LCD · WPS-J8-L39044

MolDX: Molecular Syndromic Panels for Infectious Disease Pathogen Identification Testing

Commercial payer policies listing G04.90

1 policy from 1 payer

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

Aetna

Aetna policies listing G04.90, with the code’s status in each
Policy	Effective	Status of G04.90
Autonomic Testing / Sudomotor TestsPayerPolicy · AETNA-CPB-0485	Jul 13, 2023	Covered