ModifiedArkansas Blue Cross and Blue ShieldPolicy 2024056

Venous and Arterial Thrombosis Risk

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This policy governs coverage of plasma thrombophilia testing for protein C, protein S, and antithrombin III deficiencies, with limited coverage for related genetic testing and specified clinical situations. It applies to members seeking evaluation of venous or arterial thrombosis risk.

Policy Summary

PayerArkansas Blue Cross and Blue Shield

PolicyVenous and Arterial Thrombosis Risk

Policy CodePolicy 2024056

Change TypeModified

Effective DateSeptember 15, 2026

Next Review DateN/A

Key ActionDocument that plasma testing is performed at least six weeks after the acute thrombotic event and while the patient is not taking anticoagulants.

SourceLink

POLICY UPDATE CHANGES

Coverage for venous and arterial thrombosis risk testing was removed for women age 50 or younger who smoke and have a history of myocardial infarction.

The coverage criteria for this policy were updated.

3Primary plasma deficiency tests addressed

6 weeksMinimum interval after an acute thrombotic event

8Specified clinical situations for covered testing

Removed

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ModifiedArkansas Blue Cross and Blue ShieldPolicy 2024056

Venous and Arterial Thrombosis Risk

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Sign up for arkansas_blue_cross_blue_shield Policy 2024056 alerts

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Policy Summary

PayerArkansas Blue Cross and Blue Shield

PolicyVenous and Arterial Thrombosis Risk

Policy CodePolicy 2024056

Change TypeModified

Effective DateSeptember 15, 2026

Next Review DateN/A

Key ActionDocument that plasma testing is performed at least six weeks after the acute thrombotic event and while the patient is not taking anticoagulants.

SourceLink

POLICY UPDATE CHANGES

Coverage for venous and arterial thrombosis risk testing was removed for women age 50 or younger who smoke and have a history of myocardial infarction.

The coverage criteria for this policy were updated.

3Primary plasma deficiency tests addressed

6 weeksMinimum interval after an acute thrombotic event

8Specified clinical situations for covered testing

Removed

Coverage Criteria

Covered plasma thrombophilia testing

Covered when all of the following criteria are met:

General plasma testing criteria

No recurrent VTE risk factors: The individual does not have recurrent venous thromboembolism risk factors, such as surgery, prolonged immobilization, collagen vascular disease, malignancy, or certain hematologic disorders.
At least one covered clinical situation
- DVT or PE before age 50: The individual is less than 50 years of age and has experienced any deep venous thrombosis or pulmonary embolism.Age <50 years
- Unusual-site DVT: The individual has experienced a deep venous thrombosis in an unusual site, such as the hepatic, mesenteric, or cerebral veins.
- Strong family history: The individual has experienced a deep venous thrombosis and has a strong family history of thrombotic disease.
- Pregnancy or oral contraceptive use: The individual has experienced a deep venous thrombosis and is pregnant or taking oral contraceptives.
- Affected relative: The individual is a first- or second-degree relative of a person who experienced a deep venous thrombosis before age 50.Relative DVT before age 50
- Targeted pre-contraceptive testing: The individual has a personal or family history of deep venous thrombosis and is being tested before administration of oral contraceptives.Before oral contraceptive administration
- Pediatric arterial ischemic stroke: The individual is a pediatric patient who has suffered a pediatric arterial ischemic stroke.Pediatric patient

Protein C and protein S testing for specific conditions

Plasma testing for protein C deficiency and protein S deficiency is covered when either of the following conditions is present:

Specified protein C or protein S indications

Warfarin-induced skin necrosis: The patient has warfarin-induced skin necrosis.
Neonatal purpura fulminans: The patient is an infant who develops neonatal purpura fulminans.Infant

The former indication for women age 50 or younger who smoke and have a history of myocardial infarction was removed effective September 15, 2026. Testing for venous and arterial thrombosis risk is no longer covered under this indication.

Covered Clinical Indications

Covered plasma testing indications

Covered plasma testing for protein C deficiency, protein S deficiency, and antithrombin III deficiency requires both the absence of recurrent VTE risk factors and at least one qualifying clinical situation.

Covered plasma testing indication

No recurrent VTE risk factors: The individual does not have recurrent venous thromboembolism risk factors, including surgery, prolonged immobilization, collagen vascular disease, malignancy, or certain hematologic disorders.
One qualifying clinical situation
- DVT or PE before age 50: The individual is less than 50 years of age and has experienced any DVT or PE.Age <50 years

Documentation and Testing Requirements

Documentation Required

Document the qualifying clinical indication

Document the relevant clinical history supporting a covered indication for thrombophilia testing, including the applicable thrombotic event, family history, reproductive history, or specific neonatal or pediatric presentation.

DVT or PE before age 50
DVT at an unusual site, such as hepatic, mesenteric, or cerebral veins
DVT with a strong family history of thrombotic disease
DVT during pregnancy or oral contraceptive use
First- or second-degree relative with DVT before age 50
Targeted testing before oral contraceptive administration in a person with a personal or family history of DVT
Pediatric arterial ischemic stroke, warfarin-induced skin necrosis, or neonatal purpura fulminans

Documentation Required

Document testing conditions

Policy Background

This policy addresses laboratory evaluation for inherited or acquired thrombophilia associated with venous and arterial thrombotic events. Covered testing primarily includes plasma testing for protein C, protein S, and antithrombin III deficiencies in selected patients with events such as deep venous thrombosis or pulmonary embolism, unusual-site thrombosis, relevant family history, pregnancy or oral contraceptive use, and specified pediatric or neonatal presentations. Related genetic testing for Factor V Leiden and Prothrombin gene G20210A may also be beneficial when hereditary or acquired thrombophilia is suspected.

Definitions

DVT

AbbreviationDVT

DefinitionDeep venous thrombosis

Policy relevanceA DVT is a qualifying thrombotic event in specified coverage situations, including unusual-site DVT and DVT occurring before age 50.

AbbreviationPE

DefinitionPulmonary embolism

Policy relevanceA PE is a qualifying thrombotic event for individuals younger than 50 years of age under specified coverage criteria.

Not Covered

The following indication is not covered: women age 50 or younger who smoke and have a history of myocardial infarction. This indication was removed effective September 15, 2026 based on updated ACMG guidelines.

Policy Summary

PayerArkansas Blue Cross and Blue Shield

PolicyVenous and Arterial Thrombosis Risk

Policy CodePolicy 2024056

Change TypeModified

Effective DateSeptember 15, 2026

Next Review DateN/A

Key ActionDocument that plasma testing is performed at least six weeks after the acute thrombotic event and while the patient is not taking anticoagulants.

SourceLink

On This Page

Unusual-site DVT: The individual has experienced a DVT in an unusual site, such as the hepatic, mesenteric, or cerebral veins.

DVT with strong family history: The individual has experienced a DVT and has a strong family history of thrombotic disease.

DVT during pregnancy or oral contraceptive use: The individual has experienced a DVT and is pregnant or taking oral contraceptives.

Relative with DVT before age 50: The individual is a first- or second-degree relative of a person who experienced a DVT before age 50.Relative DVT before age 50

Targeted testing before oral contraceptives: The individual has a personal or family history of DVT and is being tested before administration of oral contraceptives.Before oral contraceptive administration

Pediatric arterial ischemic stroke: The individual is a pediatric patient who has suffered a pediatric arterial ischemic stroke.Pediatric patient

Protein C and protein S testing for warfarin-induced skin necrosis or neonatal purpura fulminans

Plasma testing for protein C deficiency and protein S deficiency is covered when either of the following conditions is present:

Warfarin-related or neonatal indication

Warfarin-induced skin necrosis: The patient has warfarin-induced skin necrosis.
Neonatal purpura fulminans: The patient is an infant who develops neonatal purpura fulminans.Infant

Genetic testing for Factor V Leiden and Prothrombin gene G20210A

Individuals suspected of having hereditary or acquired thrombophilia may benefit from risk-factor testing in addition to plasma testing.

Potentially beneficial genetic testing

Factor V Leiden testing: Genetic testing for Factor V Leiden may benefit the individual.
Prothrombin gene testing: Genetic testing for Prothrombin gene G20210A may benefit the individual.

Document that plasma testing is performed at least six weeks after the acute thrombotic event and while the patient is not taking anticoagulants.

Denial Risk

Assess recurrent VTE risk factors

Confirm that the individual does not have recurrent venous thromboembolism risk factors before ordering covered plasma testing. Testing may not meet coverage criteria when factors such as surgery, prolonged immobilization, collagen vascular disease, malignancy, or certain hematologic disorders are present.

Surgery
Prolonged immobilization
Collagen vascular disease
Malignancy
Certain hematologic disorders

Denial Risk

Support the covered indication

Testing outside one of the specified covered clinical situations may not meet the policy’s medical necessity criteria. Document the qualifying indication and its supporting clinical history before ordering testing.

Denial Risk

Avoid improper testing timing

Plasma testing performed during the first six weeks after an acute thrombotic event or while the patient is taking anticoagulants does not follow the policy guideline and may not meet coverage criteria.

VTE

AbbreviationVTE

DefinitionVenous thromboembolism

Policy relevanceThe policy evaluates testing for thrombophilia associated with venous thromboembolic events and excludes individuals with specified recurrent VTE risk factors from the primary criteria.

First-degree relatives

ParentsIncluded as first-degree relatives

Full siblingsIncluded as first-degree relatives

ChildrenIncluded as first-degree relatives

Second-degree relatives

Grandparents, aunts, and unclesIncluded as second-degree relatives

Nieces, nephews, and grandchildrenIncluded as second-degree relatives

Half siblingsIncluded as second-degree relatives