K21.01 coverage policies: Medicare and commercial payers

38 active Medicare policies list K21.01, 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 K21.01

LCD · NOVITAS-JH-L35022

Bariatric Surgical Management of Morbid Obesity

JH · Effective Oct 1, 2015

LCD · NOVITAS-JL-L35022

Bariatric Surgical Management of Morbid Obesity

JL · Effective Oct 1, 2015

LCD · PALMETTO-JJ-L34415

CT of the Abdomen and Pelvis

JJ · Effective Oct 1, 2015

LCD · PALMETTO-JM-L34415

CT of the Abdomen and Pelvis

JM · Effective Oct 1, 2015

LCD · FIRST_COAST-L33583

Diagnostic and Therapeutic Esophagogastroduodenoscopy

J9 · Effective Oct 1, 2015

LCD · WPS-J5-L34659

Endoscopic Treatment of GERD

J5 · Effective Oct 1, 2015

LCD · WPS-J8-L34659

Endoscopic Treatment of GERD

J8 · Effective Oct 1, 2015

LCD · NORIDIAN-JE-L39262

MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia

JE · Effective May 28, 2023

LCD · NORIDIAN-JF-L39262

MolDX: Molecular Testing for Detection of Upper Gastrointestinal Metaplasia, Dysplasia, and Neoplasia

JF · Effective May 28, 2023

LCD · PALMETTO-JJ-L39256

Commercial payer policies listing K21.01

1 policy from 1 payer

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

Aetna

Aetna policies listing K21.01, with the code’s status in each
Policy	Effective	Status of K21.01
Gastroesophageal Reflux Disease (GERD)PayerPolicy · AETNA-CPB-0213	Apr 25, 2023	Covered