G54.4 coverage policies: Medicare and commercial payers

51 active Medicare policies list G54.4, and 2 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 G54.4

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-L34220

Lumbar MRI

JE · Effective Oct 1, 2015

LCD · NORIDIAN-JF-L34220

Lumbar MRI

JF · 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

Commercial payer policies listing G54.4

2 policies from 2 payers

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

Ambetter

Ambetter policies listing G54.4, with the code’s status in each
Policy	Effective	Status of G54.4
Evoked Potential TestingPayerPolicy · AMBETTER-CP-MP-134	Not recorded	Covered

Cigna

Cigna policies listing G54.4, with the code’s status in each
Policy	Effective	Status of G54.4
Peripheral Nerve Destruction for Pain ConditionsPayerPolicy · CIGNA-0525	Sep 15, 2026	Not covered