M53.87 coverage policies: Medicare and commercial payers

53 active Medicare policies list M53.87, 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 M53.87

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 · CGS-J15-L38773

Facet Joint Interventions for Pain Management

J15 · Effective May 2, 2021

LCD · NGS-J6-L35936

Facet Joint Interventions for Pain Management

J6 · Effective Oct 1, 2015

LCD · NGS-JK-L35936

Facet Joint Interventions for Pain Management

JK · Effective Oct 1, 2015

LCD · NORIDIAN-JE-L38801

Facet Joint Interventions for Pain Management

JE · Effective Apr 25, 2021

LCD · NORIDIAN-JF-L38801

Facet Joint Interventions for Pain Management

Commercial payer policies listing M53.87

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 M53.87, with the code’s status in each
Policy	Effective	Status of M53.87
Continuous Passive Motion (CPM) MachinesPayerPolicy · AETNA-CPB-0010	Mar 15, 2024	Covered