G21.4 coverage policies: Medicare and commercial payers

39 active Medicare policies list G21.4, 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 G21.4

LCD · PALMETTO-JJ-L34417

CT of the Head

JJ · Effective Oct 1, 2015

LCD · PALMETTO-JM-L34417

CT of the Head

JM · Effective Oct 1, 2015

LCD · NOVITAS-JH-L35049

Monitored Anesthesia Care

JH · Effective Oct 1, 2015

LCD · NOVITAS-JL-L35049

Monitored Anesthesia Care

JL · Effective Oct 1, 2015

LCD · NORIDIAN-JE-L37373

MRI and CT Scans of the Head and Neck

JE · Effective Oct 8, 2018

LCD · NORIDIAN-JF-L37373

MRI and CT Scans of the Head and Neck

JF · Effective Oct 8, 2018

LCD · CGS-J15-L35897

Nerve Conduction Studies and Electromyography

J15 · Effective Oct 1, 2015

LCD · NGS-J6-L35098

Nerve Conduction Studies and Electromyography

J6 · Effective Oct 1, 2015

LCD · NGS-JK-L35098

Nerve Conduction Studies and Electromyography

JK · Effective Oct 1, 2015

LCD · NORIDIAN-JE-L36524

Nerve Conduction Studies and Electromyography

JE · Effective Jun 1, 2016

Commercial payer policies listing G21.4

1 policy from 1 payer

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

Ambetter

Ambetter policies listing G21.4, with the code’s status in each
Policy	Effective	Status of G21.4
Medically Necessary Optical HardwarePayerPolicy · AMBETTER-CP-VP-06	Not recorded	Covered