G54.0 coverage policies: Medicare and commercial payers

58 active Medicare policies list G54.0, and 10 commercial payer policies list 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 G54.0

LCD · FIRST_COAST-L36767

Aortography and peripheral angiography

J9 · Effective Oct 31, 2016

LCD · PALMETTO-JJ-L37641

Continuous Peripheral Nerve Blocks (CPNB)

JJ · Effective Jan 29, 2018

LCD · PALMETTO-JM-L37641

Continuous Peripheral Nerve Blocks (CPNB)

JM · Effective Jan 29, 2018

LCD · NOVITAS-JH-L35003

Intraoperative Neurophysiological Testing

JH · Effective Oct 1, 2015

LCD · NOVITAS-JL-L35003

Intraoperative Neurophysiological Testing

JL · Effective Oct 1, 2015

LCD · WPS-J5-L34623

Intraoperative Neurophysiological Testing

J5 · Effective Oct 1, 2015

LCD · WPS-J8-L34623

Intraoperative Neurophysiological Testing

J8 · Effective Oct 1, 2015

LCD · NORIDIAN-JE-L35456

Nerve Blockade for Treatment of Chronic Pain and Neuropathy

JE · Effective Oct 1, 2015

LCD · NORIDIAN-JF-L35456

Nerve Blockade for Treatment of Chronic Pain and Neuropathy

JF · Effective Oct 1, 2015

LCD · CGS-J15-L35897

Commercial payer policies listing G54.0

10 policies from 3 payers

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

Aetna

Aetna policies listing G54.0, with the code’s status in each
Policy	Effective	Status of G54.0
Chiropractic ServicesPayerPolicy · AETNA-CPB-0107	Mar 23, 2023	Covered
Constraint-Induced TherapyPayerPolicy · AETNA-CPB-0665	Sep 14, 2023	Covered
Evoked Potential StudiesPayerPolicy · AETNA-CPB-0181	Oct 25, 2023	Covered
Orthopedic Casts, Braces and SplintsPayerPolicy · AETNA-CPB-0009	Mar 15, 2024	Covered
Positive Pressure VentilationPayerPolicy · AETNA-CPB-0452	Feb 16, 2024	Covered
Spinal UltrasoundPayerPolicy · AETNA-CPB-0628	Sep 12, 2023	Covered

Policy	Effective	Status of G54.0
Reduction MammaplastyClinical Guideline · ANTHEM-CG-SURG-71	Jul 1, 2026	Covered
Venous Angioplasty with or without Stent Placement or Venous Stenting AloneClinical Guideline · ANTHEM-CG-SURG-106	Apr 15, 2026	Covered