M17.4 coverage policies: Medicare and commercial payers

53 active Medicare policies list M17.4, 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 M17.4

LCD · NORIDIAN-JE-L39116

Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

JE · Effective Nov 12, 2023

LCD · NORIDIAN-JF-L39116

Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

JF · Effective Nov 12, 2023

LCD · PALMETTO-JJ-L39128

Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

JJ · Effective Apr 30, 2023

LCD · PALMETTO-JM-L39128

Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

JM · Effective Apr 30, 2023

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 · NGS-J6-L33394

Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

J6 · Effective Oct 1, 2015

LCD · NGS-JK-L33394

Drugs and Biologicals, Coverage of, for Label and Off-Label Uses

JK · Effective Oct 1, 2015

LCD · NGS-J6-L40333

Commercial payer policies listing M17.4

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 M17.4, with the code’s status in each
Policy	Effective	Status of M17.4
ViscosupplementationPayerPolicy · AETNA-CPB-0179	Jan 1, 2024	Covered

UnitedHealthcare

UnitedHealthcare policies listing M17.4, with the code’s status in each
Policy	Effective	Status of M17.4
Sodium HyaluronatePayerPolicy · UHC-POL-sodium-hyaluronate	Oct 1, 2026	Covered