G81.04 coverage policies: Medicare and commercial payers

76 active Medicare policies list G81.04, 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 G81.04

LCD · FIRST_COAST-L36767

Aortography and peripheral angiography

J9 · Effective Oct 31, 2016

LCD · CGS-J15-L38694

Computed Tomography Cerebral Perfusion Analysis (CTP)

J15 · Effective Nov 2, 2020

LCD · NGS-J6-L38667

Computed Tomography Cerebral Perfusion Analysis (CTP)

J6 · Effective Nov 1, 2020

LCD · NGS-JK-L38667

Computed Tomography Cerebral Perfusion Analysis (CTP)

JK · Effective Nov 1, 2020

LCD · NORIDIAN-JE-L38709

Computed Tomography Cerebral Perfusion Analysis (CTP)

JE · Effective Dec 13, 2020

LCD · NORIDIAN-JF-L38709

Computed Tomography Cerebral Perfusion Analysis (CTP)

JF · Effective Dec 13, 2020

LCD · PALMETTO-JJ-L38769

Computed Tomography Cerebral Perfusion Analysis (CTP)

JJ · Effective Feb 7, 2021

LCD · PALMETTO-JM-L38769

Computed Tomography Cerebral Perfusion Analysis (CTP)

JM · Effective Feb 7, 2021

LCD · PALMETTO-JJ-L34417

CT of the Head

JJ · Effective Oct 1, 2015

LCD · PALMETTO-JM-L34417

Commercial payer policies listing G81.04

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 G81.04, with the code’s status in each
Policy	Effective	Status of G81.04
Visual Field TestingPayerPolicy · AMBETTER-CP-VP-63	Not recorded	Covered