K86.89 coverage policies: Medicare and commercial payers

26 active Medicare policies list K86.89, 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 K86.89

LCD · PALMETTO-JJ-L33459

Computerized Axial Tomography (CT), Thorax

JJ · Effective Oct 1, 2015

LCD · PALMETTO-JM-L33459

Computerized Axial Tomography (CT), Thorax

JM · 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 · PALMETTO-JJ-L39400

Magnesium

JJ · Effective Jan 22, 2023

LCD · PALMETTO-JM-L39400

Magnesium

JM · Effective Jan 22, 2023

LCD · NOVITAS-JH-L35350

Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)

JH · Effective Oct 1, 2015

LCD · NOVITAS-JL-L35350

Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)

JL · Effective Oct 1, 2015

LCD · PALMETTO-JJ-L34434

Upper Gastrointestinal Endoscopy and Visualization

JJ · Effective Oct 1, 2015

LCD · PALMETTO-JM-L34434

Upper Gastrointestinal Endoscopy and Visualization

Commercial payer policies listing K86.89

2 policies from 2 payers

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

Aetna

Aetna policies listing K86.89, with the code’s status in each
Policy	Effective	Status of K86.89
In Vivo Analysis of Gastro-Intestinal and Urothelial LesionsPayerPolicy · AETNA-CPB-0783	Oct 17, 2023	Covered

Anthem

Anthem policies listing K86.89, with the code’s status in each
Policy	Effective	Status of K86.89
Laboratory Evaluation of Vitamin B12Clinical Guideline · ANTHEM-CG-LAB-19	Jan 6, 2026	Covered