I63.39 coverage policies: Medicare and commercial payers

99 active Medicare policies list I63.39, 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 I63.39

LCD · FIRST_COAST-L36767

Aortography and peripheral angiography

J9 · Effective Oct 31, 2016

LCD · PALMETTO-JJ-L33457

Cardiac Radionuclide Imaging

JJ · Effective Oct 1, 2015

LCD · PALMETTO-JM-L33457

Cardiac Radionuclide Imaging

JM · Effective Oct 1, 2015

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 · PALMETTO-JJ-L34419

Homocysteine Level, Serum

JJ · Effective Oct 1, 2015

LCD · PALMETTO-JM-L34419

Homocysteine Level, Serum

JM · Effective Oct 1, 2015

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

Commercial payer policies listing I63.39

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 I63.39, with the code’s status in each
Policy	Effective	Status of I63.39
Visual Field TestingPayerPolicy · AMBETTER-CP-VP-63	Not recorded	Covered

Anthem

Anthem policies listing I63.39, with the code’s status in each
Policy	Effective	Status of I63.39
Mechanical Embolectomy for Treatment of StrokeClinical Guideline · ANTHEM-CG-SURG-115	Jan 6, 2026	Covered