M25.551 coverage policies: Medicare and commercial payers

78 active Medicare policies list M25.551, and 4 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 M25.551

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 · PALMETTO-JJ-L37641

Continuous Peripheral Nerve Blocks (CPNB)

JJ · Effective Jan 29, 2018

LCD · PALMETTO-JM-L37641

Continuous Peripheral Nerve Blocks (CPNB)

JM · Effective Jan 29, 2018

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-L33461

Implantable Infusion Pump

Commercial payer policies listing M25.551

4 policies from 3 payers

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

Aetna

Aetna policies listing M25.551, with the code’s status in each
Policy	Effective	Status of M25.551
Hip Preservation SurgeryPayerPolicy · AETNA-CPB-0736	Nov 20, 2023	Covered
Physical TherapyPayerPolicy · AETNA-CPB-0325	Jul 28, 2023	Covered

Anthem

Anthem policies listing M25.551, with the code’s status in each
Policy	Effective	Status of M25.551
Biomechanical Footwear TherapyClinical Guideline · ANTHEM-CG-DME-53	Apr 15, 2026	Not covered

EviCore by Evernorth

EviCore by Evernorth policies listing M25.551, with the code’s status in each
Policy	Effective	Status of M25.551