ModifiedAmbetter NevadaPolicy CP.MP.121

Homocysteine Testing

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This policy establishes medical necessity and coverage criteria for homocysteine testing. Testing is covered for suspected cystathionine beta-synthase deficiency-related homocystinuria when specified clinical criteria are met; other listed indications are not medically necessary.

Policy Summary

PayerAmbetter Nevada

PolicyHomocysteine Testing

Policy CodePolicy CP.MP.121

Change TypeModified

Effective DateN/A

Last ReviewMar 1, 2024

Next Review DateN/A

Key ActionFor Medicare members, review all applicable Medicare National Coverage Determinations, Local Coverage Determinations, and Medicare Coverage Articles before applying this clinical policy.

SourceLink

POLICY UPDATE CHANGES

The March 2024 revision expanded medically necessary criteria to include a first-degree relative with homocystinuria, markedly elevated serum and urine homocysteine, and specified characteristic physical findings.

Dementia was added as a not medically necessary indication for homocysteine testing.

The March 2024 revision removed the table of medically necessary ICD-10 codes and replaced it with a table of not medically necessary ICD-10 codes.

1Covered CPT code listed

6Supporting physical findings

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ModifiedAmbetter NevadaPolicy CP.MP.121

Homocysteine Testing

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Sign up for Ambetter Nevada Policy CP.MP.121 alerts

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Policy Summary

PayerAmbetter Nevada

PolicyHomocysteine Testing

Policy CodePolicy CP.MP.121

Change TypeModified

Effective DateN/A

Last ReviewMar 1, 2024

Next Review DateN/A

Key ActionFor Medicare members, review all applicable Medicare National Coverage Determinations, Local Coverage Determinations, and Medicare Coverage Articles before applying this clinical policy.

SourceLink

POLICY UPDATE CHANGES

Dementia was added as a not medically necessary indication for homocysteine testing.

The March 2024 revision removed the table of medically necessary ICD-10 codes and replaced it with a table of not medically necessary ICD-10 codes.

1Covered CPT code listed

6Supporting physical findings

Medical Necessity and Noncovered Indications

Medically Necessary Testing

Covered when both the suspected condition and at least one supporting criterion are present.

Required criteria

Suspected condition: Suspected homocystinuria caused by cystathionine beta-synthase deficiency.
At least one supporting criterion
- Family history: First-degree relative with homocystinuria.
- Laboratory finding: Markedly elevated serum and urine homocysteine.Markedly elevated
- Characteristic physical finding
  - Developmental delay.
  - Marfanoid appearance.
  - Osteoporosis.
  - Ocular abnormality: Ocular abnormalities, including ectopia lentis.
  - Thromboembolic disease.
  - Severe premature atherosclerosis.

Homocysteine testing has not been proven to improve outcomes compared with other technologies when used for cardiovascular risk testing, borderline vitamin B12 deficiency, dementia, specified venous thromboembolism or thrombosis indications, or testing for other conditions.

Homocysteine testing for cardiovascular risk testing is not medically necessary because improved outcomes compared with other technologies have not been established for this indication.

Homocysteine testing for borderline vitamin B12 deficiency is not medically necessary because improved outcomes compared with other technologies have not been established for this indication.

Homocysteine testing for dementia is not medically necessary because improved outcomes compared with other technologies have not been established for this indication.

Homocysteine testing is not medically necessary for idiopathic or unprovoked venous thromboembolism, recurrent venous thromboembolism, thrombosis occurring at less than 45 years of age, or thrombosis at an unusual site. Improved outcomes compared with other technologies have not been established for these indications.

Homocysteine testing for all other conditions is not medically necessary because improved outcomes compared with other technologies have not been established.

Covered Testing Indication

Suspected Homocystinuria Caused by Cystathionine Beta-Synthase Deficiency

Homocysteine testing is medically necessary for suspected cystathionine beta-synthase deficiency-related homocystinuria when at least one of the following is also present:

Suspected condition and supporting finding

Suspected homocystinuria caused by cystathionine beta-synthase deficiency.
ONE or more supporting criteria
- First-degree relative with homocystinuria.
- Markedly elevated serum and urine homocysteine.Markedly elevated
- ONE or more characteristic physical findings

Not Covered Indications

Homocysteine testing is not covered for cardiovascular risk testing, borderline vitamin B12 deficiency, dementia, idiopathic or unprovoked venous thromboembolism, recurrent venous thromboembolism, thrombosis before age 45, thrombosis at an unusual site, or testing for other conditions.

Codes and Homocysteine Ranges

Referenced CPT CodeCPT

83090

Homocysteine

Not Medically Necessary ICD-10-CM 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 27

1/3

Basal Homocysteine

ClassificationBasal homocysteine

Concentration range5 to 15 μmol/L

Measurement unitμmol/L

Moderate Hyperhomocysteine

ClassificationModerate hyperhomocysteine

Concentration range15 to 30 μmol/L

Measurement unitμmol/L

Coverage Review and Denial Risks

Note

Review Medicare Coverage Authorities

For Medicare members/enrollees, review all applicable Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles before applying this clinical policy. Refer to the CMS website for additional information.

Review applicable NCDs, LCDs, and Medicare Coverage Articles for Medicare members/enrollees.
Use the applicable Medicare guidance together with this policy when determining coverage.

Denial Risk

Noncovered Indications

Homocysteine testing is not proven to improve outcomes compared with other technologies for the indications below and may be denied as not medically necessary.

Cardiovascular risk testing.
Borderline vitamin B12 deficiency.
Dementia.

Clinical Background

Homocysteine is an intermediary amino acid generated during the conversion of methionine to cysteine. Its concentration is influenced by folate, vitamin B6, and vitamin B12 metabolism. Homocystinuria is a rare inherited disorder associated with severe elevations in plasma and urine homocysteine; mutations affecting cystathionine beta-synthase can result in excess homocysteine and premature thrombotic events.

Key Terms

Homocysteine

TermHomocysteine

DefinitionA nonproteinogenic intermediary amino acid generated during the conversion of methionine to cysteine.

Biochemical contextIts levels are influenced by pathways involved in methionine-to-cysteine conversion.

Homocystinuria

TermHomocystinuria

DefinitionA rare inherited condition associated with inability to properly produce or metabolize methionine.

Laboratory characteristicSevere elevations in plasma and urine homocysteine concentrations.