S04.12XS coverage policies: Medicare and commercial payers

25 active Medicare policies list S04.12XS, 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 S04.12XS

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 · FIRST_COAST-L34859

Nerve Conduction Studies and Electromyography

J9 · Effective Oct 1, 2015

LCD · NOVITAS-JH-L35081

Nerve Conduction Studies and Electromyography

JH · Effective Oct 1, 2015

LCD · NOVITAS-JL-L35081

Nerve Conduction Studies and Electromyography

JL · Effective Oct 1, 2015

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 · NOVITAS-JH-L35070

Speech - Language Pathology (SLP) Services: Communication Disorders

Commercial payer policies listing S04.12XS

1 policy from 1 payer

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

Ambetter

Ambetter policies listing S04.12XS, with the code’s status in each
Policy	Effective	Status of S04.12XS
Visual Field TestingPayerPolicy · AMBETTER-CP-VP-63	Not recorded	Covered