S04.02XD coverage policies: Medicare and commercial

S04.02XD coverage policies: Medicare and commercial payers

23 active Medicare policies list S04.02XD, 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 S04.02XD

LCD · PALMETTO-JJ-L34417

CT of the Head

JJ · Effective Oct 1, 2015

LCD · PALMETTO-JM-L34417

CT of the Head

JM · Effective Oct 1, 2015

LCD · NORIDIAN-JE-L37373

MRI and CT Scans of the Head and Neck

JE · Effective Oct 8, 2018

LCD · NORIDIAN-JF-L37373

MRI and CT Scans of the Head and Neck

JF · Effective Oct 8, 2018

LCD · NOVITAS-JH-L34975

Neurophysiology Evoked Potentials (NEPs)

JH · Effective Oct 1, 2015

LCD · NOVITAS-JL-L34975

Neurophysiology Evoked Potentials (NEPs)

JL · Effective Oct 1, 2015

LCD · PALMETTO-JJ-L33467

Ophthalmology: Extended Ophthalmoscopy and Fundus Photography

JJ · Effective Oct 1, 2015

LCD · PALMETTO-JM-L33467

Ophthalmology: Extended Ophthalmoscopy and Fundus Photography

JM · Effective Oct 1, 2015

LCD · NGS-J6-L36831

Visual Electrophysiology Testing

J6 · Effective Mar 16, 2017

LCD · NGS-JK-L36831

Visual Electrophysiology Testing

Commercial payer policies listing S04.02XD

2 policies from 1 payer

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

Ambetter

Ambetter policies listing S04.02XD, with the code’s status in each
Policy	Effective	Status of S04.02XD
Fundus PhotographyPayerPolicy · AMBETTER-CP-VP-29	Not recorded	Covered
Visual Field TestingPayerPolicy · AMBETTER-CP-VP-63	Not recorded	Covered