H54.42A4 coverage policies: Medicare and commercial payers

30 active Medicare policies list H54.42A4, 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 H54.42A4

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 · 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 · NGS-J6-L33567

Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

J6 · Effective Oct 1, 2015

LCD · NGS-JK-L33567

Ophthalmology: Posterior Segment Imaging (Extended Ophthalmoscopy and Fundus Photography)

JK · Effective Oct 1, 2015

LCD · NGS-J6-L36831

Visual Electrophysiology Testing

J6 · Effective Mar 16, 2017

LCD · NGS-JK-L36831

Visual Electrophysiology Testing

JK · Effective Mar 16, 2017

LCD · WPS-J5-L37015

Visual Electrophysiology Testing

Commercial payer policies listing H54.42A4

2 policies from 1 payer

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

Ambetter

Ambetter policies listing H54.42A4, with the code’s status in each
Policy	Effective	Status of H54.42A4
Medically Necessary Optical HardwarePayerPolicy · AMBETTER-CP-VP-06	Not recorded	Covered
Visual Field TestingPayerPolicy · AMBETTER-CP-VP-63	Not recorded	Covered