M54.89 coverage policies: Medicare and commercial payers

56 active Medicare policies list M54.89, and 3 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 M54.89

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-L39506

Cosmetic and Reconstructive Surgery

J15 · Effective May 28, 2023

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

JL · Effective Oct 1, 2015

LCD · PALMETTO-JJ-L33428

Cosmetic and Reconstructive Surgery

Commercial payer policies listing M54.89

3 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 M54.89, with the code’s status in each
Policy	Effective	Status of M54.89
Cryoanalgesia and Therapeutic ColdPayerPolicy · AETNA-CPB-0297	Mar 16, 2023	Covered
Pulsed RadiofrequencyPayerPolicy · AETNA-CPB-0735	Sep 20, 2023	Covered

Anthem

Anthem policies listing M54.89, with the code’s status in each
Policy	Effective	Status of M54.89
Outpatient Urine CultureClinical Guideline · ANTHEM-CG-LAB-24	Jan 6, 2026	Covered