M53.1 coverage policies: Medicare and commercial payers

42 active Medicare policies list M53.1, 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 M53.1

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-L38033

Cervical Disc Replacement

JJ · Effective Oct 28, 2019

LCD · PALMETTO-JM-L38033

Cervical Disc Replacement

JM · Effective Oct 28, 2019

LCD · FIRST_COAST-L38914

Cosmetic and Reconstructive Surgery

J9 · Effective Jul 11, 2021

LCD · NOVITAS-JH-L35090

Cosmetic and Reconstructive Surgery

JH · Effective Oct 1, 2015

LCD · NOVITAS-JL-L35090

Cosmetic and Reconstructive Surgery

Commercial payer policies listing M53.1

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 M53.1, with the code’s status in each
Policy	Effective	Status of M53.1
Back Pain - Invasive ProceduresPayerPolicy · AETNA-CPB-0016	Mar 13, 2024	Covered

Cigna

Cigna policies listing M53.1, with the code’s status in each
Policy	Effective	Status of M53.1
Intraoperative MonitoringPayerPolicy · CIGNA-0509	Sep 15, 2025	Covered