H02.401 coverage policies: Medicare and commercial payers

40 active Medicare policies list H02.401, 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 H02.401

LCD · CGS-J15-L33944

Blepharoplasty

J15 · Effective Oct 1, 2015

LCD · NORIDIAN-JE-L34194

Blepharoplasty, Eyelid Surgery, and Brow Lift

JE · Effective Oct 1, 2015

LCD · NORIDIAN-JF-L34194

Blepharoplasty, Eyelid Surgery, and Brow Lift

JF · Effective Oct 1, 2015

LCD · PALMETTO-JJ-L34411

Blepharoplasty, Eyelid Surgery, and Brow Lift

JJ · Effective Oct 1, 2015

LCD · PALMETTO-JM-L34411

Blepharoplasty, Eyelid Surgery, and Brow Lift

JM · 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 · FIRST_COAST-L34859

Nerve Conduction Studies and Electromyography

J9 · Effective Oct 1, 2015

LCD · NGS-J6-L35098

Nerve Conduction Studies and Electromyography

Commercial payer policies listing H02.401

2 policies from 2 payers

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

Anthem

Anthem policies listing H02.401, with the code’s status in each
Policy	Effective	Status of H02.401
Blepharoplasty, Blepharoptosis Repair, and Brow LiftClinical Guideline · ANTHEM-CG-SURG-03	Jan 6, 2026	Covered

Cigna

Cigna policies listing H02.401, with the code’s status in each
Policy	Effective	Status of H02.401
Electrodiagnostic Testing (EMG/NCV)PayerPolicy · CIGNA-CPG129	Sep 15, 2026	Covered