H53.121 coverage policies: Medicare and commercial payers

74 active Medicare policies list H53.121, and 3 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 H53.121

LCD · FIRST_COAST-L36767

Aortography and peripheral angiography

J9 · Effective Oct 31, 2016

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 · FIRST_COAST-L37398

Electroretinography (ERG)

J9 · Effective Feb 2, 2018

LCD · NOVITAS-JH-L37371

Electroretinography (ERG)

JH · Effective Jan 25, 2018

LCD · NOVITAS-JL-L37371

Electroretinography (ERG)

JL · Effective Jan 25, 2018

LCD · PALMETTO-JJ-L34424

Magnetic Resonance Angiography

JJ · Effective Oct 1, 2015

LCD · PALMETTO-JM-L34424

Magnetic Resonance Angiography

JM · Effective Oct 1, 2015

LCD · NGS-J6-L33633

Magnetic Resonance Angiography (MRA)

J6 · Effective Oct 1, 2015

LCD · NGS-JK-L33633

Magnetic Resonance Angiography (MRA)

JK · Effective Oct 1, 2015

Commercial payer policies listing H53.121

3 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 H53.121, with the code’s status in each
Policy	Effective	Status of H53.121
Extended OphthalmoscopyPayerPolicy · AMBETTER-CP-VP-26	Not recorded	Covered
Visual Field TestingPayerPolicy · AMBETTER-CP-VP-63	Not recorded	Covered

Anthem

Anthem policies listing H53.121, with the code’s status in each
Policy	Effective	Status of H53.121
Fundus PhotographyClinical Guideline · ANTHEM-CG-MED-47	Apr 15, 2026	Covered