CurrentAmbetter NevadaPolicy CP.MP.121

Homocysteine Testing

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Defines medical necessity criteria and not‑medically‑necessary indications for laboratory measurement of homocysteine for members/enrollees of the health plan; applicable to ordering providers and claims reviewers.

Policy Summary

PayerAmbetter Nevada

PolicyHomocysteine Testing

Policy CodePolicy CP.MP.121

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionDocument clinical justification that the patient meets criteria for suspected homocystinuria (family history, markedly elevated homocysteine, or characteristic physical findings) when ordering homocysteine testing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Covered primary indication group

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CurrentAmbetter NevadaPolicy CP.MP.121

Homocysteine Testing

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Policy Summary

PayerAmbetter Nevada

PolicyHomocysteine Testing

Policy CodePolicy CP.MP.121

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Covered primary indication group

Coverage Criteria

Medically Necessary: Suspected homocystinuria

Covered when ALL of the following are met for suspected homocystinuria due to cystathionine beta-synthase deficiency.

Primary criteria set

Supporting findings (any one): A. First-degree relative with homocystinuria; B. Markedly elevated serum and urine homocysteine; C. Characteristic physical findings including developmental delay; marfanoid appearance; osteoporosis; ocular abnormalities (ectopia lentis); thromboembolic disease; severe premature atherosclerosis.
Presence of any one of these findings supports testing for cystathionine beta-synthase–related homocystinuria.

Evaluation for suspected homocystinuria caused by cystathionine beta-synthase deficiency

Covered when there is a first-degree relative with homocystinuria, markedly elevated serum/urine homocysteine, or characteristic physical findings.

Covered indications (any one): A. First-degree relative with homocystinuria; B. Markedly elevated serum and urine homocysteine; C. Characteristic physical findings (one or more): developmental delay; marfanoid appearance; osteoporosis; ocular abnormalities (ectopia lentis); thromboembolic disease; severe premature atherosclerosis.

Any one of these indications is sufficient to justify homocysteine testing for suspected cystathionine beta-synthase deficiency.

Not proven to improve outcomes / Not medically necessary

Not proven to improve outcomes (testing considered not medically necessary/unsupported for these indications):

Not-proven indications: Cardiovascular risk testing; Borderline vitamin B12 deficiency; Dementia; Idiopathic (unprovoked) venous thromboembolism, recurrent venous thromboembolism, thrombosis occurring at < 45 years of age, or thrombosis at an unusual site; Testing for all other conditions.

Evidence does not demonstrate improved outcomes for these uses; testing is considered not medically necessary for these indications.

Use of homocysteine testing is listed as not medically necessary for a set of specified diagnoses and encounter types. The policy lists multiple dementia-related ICD-10 codes and general screening/preprocedural encounter codes as not supported (examples include F01.*, F03.*, G30.*, G31.0, R41.81, and screening/preprocedural codes such as Z00.00, Z00.01, Z01.810–Z01.818, Z13.6, Z13.21). Homocysteine testing billed with these codes is considered unsupported unless an exception in the policy applies.

Coverage of homocysteine testing is subject to the member's evidence of coverage, certificate of coverage, policy or contract and all other terms, conditions, exclusions and limitations contained in those documents. When state Medicaid provisions conflict with this clinical policy, state Medicaid requirements take precedence. Providers should consult applicable Health Plan administrative policies and the member's coverage documents before ordering or submitting claims for homocysteine testing.

Homocysteine testing is considered not medically necessary for use as a cardiovascular risk assessment tool, for evaluation of borderline vitamin B12 deficiency, and for dementia-related indications. The policy also specifies that testing is not supported for idiopathic (unprovoked) venous thromboembolism, recurrent VTE, thrombosis occurring at < 45 years of age, or thrombosis at an unusual site. For these indications, evidence does not show improved outcomes compared with other technologies, and testing is therefore generally not covered; specific ICD-10 diagnosis codes associated with these unsupported indications are listed in the policy.

This clinical policy is a coverage and medical necessity guide and does not constitute medical advice or a recommendation for treatment. Providers are expected to exercise independent professional medical judgment in diagnosing and treating patients and remain solely responsible for the medical care of members/enrollees. The policy is not a contract or guarantee of payment and may be amended or withdrawn by the Health Plan.

Testing billed for indications identified as unsupported is listed as not covered. Examples explicitly called out include: cardiovascular risk assessment; borderline B12 deficiency; dementia-related diagnoses; idiopathic or recurrent venous thromboembolism; thrombosis at age < 45 years; and thrombosis at unusual sites. Claims for homocysteine testing associated with these indications or the specific dementia and screening ICD-10 codes in the policy may be denied.

Coding

Covered CPT CodesCPT

83090

Homocysteine

Not Medically Necessary ICD-10 CodesICD-10Not Covered

F01.511	Vascular dementia, unspecified severity, with agitation
F01.518	Vascular dementia, unspecified severity, with other behavioral disturbance
F01.52	Vascular dementia, unspecified severity, with psychotic disturbance
F01.53	Vascular dementia, unspecified severity, with mood disturbance
F01.54	Vascular dementia, unspecified severity, with anxiety
F01.A4	Vascular dementia, mild, with anxiety
F01.B4	Vascular dementia, moderate, with anxiety
F01.C4	Vascular dementia, severe, with anxiety
F03.9	Unspecified dementia, unspecified severity
F03.A4	Vascular dementia, mild, with anxiety

1–10 of 29

1/3

Homocysteine concentration categories

Basal (normal)5–15 μmol/L

Moderate hyperhomocysteinemia15–30 μmol/L

Intermediate hyperhomocysteinemia30–100 μmol/L

Severe hyperhomocysteinemia>100 μmol/L

Provider Actions and Administrative Requirements

Prior Authorization

Prior authorization / coding

CPT 83090 (Homocysteine) is the referenced procedure code. Check the member's coverage documents and Health Plan administrative policies for any prior authorization requirements before ordering homocysteine testing.

Affected code: CPT 83090 (Homocysteine)

Prior Authorization

Prior authorization — verify coverage and policies

Providers must check the member's coverage documents (e.g., evidence of coverage, certificate of coverage, policy or contract) and applicable Health Plan administrative policies and procedures prior to ordering homocysteine testing. Coverage decisions and administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents.

Step Therapy

Step therapy

Ordering Requirements

Documentation Required

Ordering requires documentation of covered indication

Order should be accompanied by clinical documentation demonstrating that one of the covered indications is met (first‑degree relative with homocystinuria; markedly elevated serum/urine homocysteine; or characteristic physical findings such as developmental delay, marfanoid appearance, osteoporosis, ectopia lentis, thromboembolic disease, or severe premature atherosclerosis).

Note

Provider judgment and policy check required

Providers must exercise professional medical judgment when ordering tests and should check applicable coverage documents and plan administrative policies for ordering and billing requirements.

Frequency Limits

Homocysteine (CPT 83090)

Referenced CPT code83090 (Homocysteine)

Coding sourceCurrent Procedural Terminology (CPT) — AMA copyrighted descriptions

Usage noteCode referenced for frequency and coding context for homocysteine testing

Definitions

Homocystinuria

DefinitionHomocystinuria — a rare inherited condition with inability to properly metabolize methionine, often due to cystathionine-β-synthase deficiency, leading to severe elevations in plasma and urine homocysteine.

PathophysiologyMutations in cystathionine-β-synthase (transsulfuration pathway) cause excess homocysteine and increased risk of premature thrombotic events.

Clinical impactMarked elevations in homocysteine characterize homocystinuria and are associated with thromboembolic disease and other systemic manifestations.

Hyperhomocysteinemia thresholds

Basal (normal)5–15 μmol/L

Moderate15–30 μmol/L

Background

This clinical policy is intended to guide coverage determinations and the administration of benefits and is not intended to direct clinical care. It does not replace clinical judgment, and providers should consult with treating clinicians and follow accepted standards of care when making diagnostic and treatment decisions.