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Cardiovascular Disease Risk Assessment
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Defines BCBSNM reimbursement policy for laboratory tests used in cardiovascular disease (CVD) risk assessment and screening, including which lipid and biomarker tests are reimbursable or not, and applicable testing intervals for various clinical scenarios.
Changed routine screening interval from every 4 years to every 5 years for a specified population.
Removed allowance for hs-CRP as a general reimbursable test for CVD risk assessment; limited or conditional reimbursement applied.
Measurement of lipoprotein(a) (Lp(a)) once per lifetime (age ≥18) is considered reimbursable.
Added reimbursement code 83876 and later code 0541U and others across updates.
Annual lipid panel screening permitted for individuals at increased risk of dyslipidemia.
Coverage Criteria for CVD Risk Laboratory Testing
Reimbursable and non-reimbursable CVD risk tests and intervals
Specifies which tests and testing intervals are reimbursable for cardiovascular disease (CVD) risk assessment and which tests are excluded.
ALL of the following
General population
- Every 5 years for individuals ages 18–79 years (routine screening).
Increased CVD risk
- Annually for individuals at increased risk for cardiovascular disease as defined by the 2013 ACC/AHA Pooled Cohort Equations (PCEs) to calculate 10-year risk (note: 10-year ASCVD risk cannot be calculated for individuals 39 years of age or younger).
- Annually for individuals at increased risk of dyslipidemia due to conditions including: obesity/metabolic syndrome; nephrotic syndrome; hypothyroidism; hyperthyroidism; pancreatitis; diabetes; chronic kidney disease; Cushing syndrome; pregnancy; cholestatic liver disease; adult lipid metabolism disorders (e.g., Gaucher disease); being on long-term drug therapy that requires lipid monitoring (e.g., isotretinoin, antipsychotics); family history of elevated lipids; premature heart disease; history of stroke.
ALL of the following
- Obtain baseline lipid levels before initiating statin therapy.
- Repeat testing every 4 to 12 weeks after initiation or change of therapy.
- Subsequent monitoring every 3 to 12 months as clinically indicated.
ALL of the following
- Obtain baseline lipid levels before initiating ART.
- Repeat testing every 1 to 3 months after initiation or change of therapy.
- If stable with no medication changes, repeat testing every 6 to 12 months.
ALL of the following
- Measurement of apoB may be reimbursable for selected indications including hypertriglyceridemia, diabetes, obesity/metabolic syndrome, other dyslipidemias (e.g., very low LDL-C), individuals on lipid therapy, or those suspected of familial Dysbetalipoproteinemia or familial combined hyperlipidemia.
- Frequency limit: no more than once every four weeks.
ALL of the following
- Measurement of Lp(a) may be reimbursable once per lifetime when performed at age 18 years or older.
ALL of the following
- Conventional CRP testing is not reimbursable for CVD risk assessment.
- High-sensitivity CRP (hs-CRP) is not reimbursable for general CVD risk assessment.
ALL of the following
- High-sensitivity cardiac troponin (hs-cTnT) is not reimbursable for CVD risk assessment in the outpatient setting.
- Homocysteine testing is not reimbursable for CVD risk assessment.
- Novel lipid and non-lipid biomarkers (e.g., apoAI, apoE, B-type natriuretic peptide, cystatin C, fibrinogen, leptin, LDL/HDL subclasses, myeloperoxidase) are not reimbursable for CVD risk assessment.
- CVD risk panels consisting of multiple individual biomarkers (other than a simple lipid panel) are not reimbursable.
- Lipoprotein-associated phospholipase A2 (Lp-PLA2) and secretory type II phospholipase A2 (SPLA2-IIA) are not reimbursable.
- Serum intermediate density lipoproteins, long-chain omega-3 fatty acids in red blood cell membranes, and all other tests for assessing CVD risk not explicitly allowed are not reimbursable.
ALL of the following
- A simple lipid panel is generally composed of total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides; calculated ratios may be reported. Other tests (e.g., apolipoproteins, particle number/size, Lp(a)) are not components of a simple lipid panel.
- Procedure codes listed in policy are examples; inclusion of a code does not guarantee coverage. Providers must follow Plan documents and contracts governing coverage and submission requirements.
ALL of the following
- Not all requirements apply to every product; providers should review specific Plan documents for eligible coverage.
- If there is a conflict between this reimbursement policy and a Plan document or provider contract, the Plan document or contract governs, and BCBSNM may use discretion in interpretation.
Reference evidence nodes
References and guideline sources informing coverage determinations include systematic reviews, meta-analyses, guideline statements, and public health resources.
ALL of the following
- Systematic reviews, meta-analyses, and primary studies addressing biomarkers and their associations with cardiovascular disease (examples cited in references numbered ~37–127).
- Evidence from Mendelian randomization and large observational cohorts informing biomarker causality and association with CVD outcomes.
ALL of the following
- Key guideline citations include: 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease; 2013 and 2018 ACC/AHA cholesterol guidelines; ESC/EAS dyslipidemia guidelines (2021/2025 updates referenced); and ADA Standards of Care.
- Guidelines were used to inform screening intervals, definitions of increased risk, and selective use of biomarkers (e.g., Lp(a), apoB).
ALL of the following
- CDC cardiovascular biomarker standardization and Lipids Standardization Program documents are cited for laboratory standardization considerations.
- CMS lipid testing national coverage documentation is referenced for coverage context.
ALL of the following
- References address apolipoprotein B clinical management, Lp(a) scientific statements, associations of inflammatory markers (e.g., fibrinogen, CRP), troponin, and other biomarkers with CVD risk.
- Evidence on lipid-lowering therapies, statin benefits, and the implications for testing frequency and monitoring are included among cited sources.
ALL of the following
- References include peer-reviewed journals, society guideline documents, and public health agency resources (CDC, CMS) used to support policy positions on reimbursable tests and testing intervals.
Reimbursement criteria for CVD risk laboratory testing
Coverage and frequency rules as stated in policy history and reimbursement information updates.
ALL of the following
- Routine lipid screening interval was updated from every 4 years to every 5 years for individuals ages 18–79 (policy history revision).
- Lipid panel screening reimbursable annually for individuals with increased risk of dyslipidemia; this annual recommendation was added/clarified in policy history.
ALL of the following
- Policy revised to allow measurement of Lp(a) once per lifetime when performed at age ≥18 years.
ALL of the following
- General reimbursement for hs-CRP was removed; however, for individuals for whom a risk-based treatment decision is uncertain after quantitative risk assessment, hs-CRP testing may be reimbursable with these limits: one initial test for screening; if initial screen is abnormal, confirmatory testing no sooner than two weeks after the initial test; annual screening thereafter for those with confirmed elevated hs-CRP.
- Conventional (non–high-sensitivity) CRP testing remains not reimbursable for CVD risk assessment.
ALL of the following
- Policy history specifies that Lp-PLA2 is not reimbursable for any indication; additional tests (e.g., myeloperoxidase) are listed as not reimbursable in updates.
ALL of the following
- Policy history entries document that changes were made based on guideline updates (e.g., NLA, VA/DoD, USPSTF) and literature reviews; providers should consult current policy history for effective dates of these changes.
Procedure and Billing Codes
Provider Actions, Documentation & Billing Guidance
Documentation and claims submission — submit accurate coded claims and retain supporting records
Providers must submit accurate documentation of services rendered and use valid code combinations from HIPAA‑approved code sets; claims are subject to code edits, review, and may require additional documentation upon request. Code selection should follow industry coding guidance (e.g., CPT, HCPCS, ICD‑10‑CM, CMS NCCI) and providers should be prepared to supply supporting records if the claim is audited.
- Submit claims using valid HIPAA‑approved code sets and appropriate code combinations per industry standards (CPT, HCPCS, ICD‑10‑CM, Uniform Billing rules).
- Claims are subject to code edit protocols, plan and contract terms, and may require submission of additional documentation upon request.
- Provider contract or Plan documents govern in case of conflict with this reimbursement policy.
Guideline references provided for clinical decision‑making (informational)
This policy cites major clinical practice guidelines and consensus statements (e.g., ACC/AHA primary prevention and cholesterol guidelines) and other society guidance as informational resources to guide clinical decision‑making; these citations do not constitute prior authorization requirements.
- Key cited guidelines include the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease and ACC/AHA cholesterol guidance (2013, 2018).
- The references list includes multiple professional society and consensus statements used to inform coverage determinations.
Public health and coverage‑related references (CDC, CMS) — informational
Public health and coverage resources (CDC biomarker/lipid standardization programs and CMS lipid testing guidance) are cited as supporting evidence; the references section does not establish a separate prior authorization process or explicit billing actions.
- CDC resources cited include the Cardiovascular Disease Biomarker Standardization Programs and Lipids Standardization Program documents.
- CMS lipid testing NCD is referenced; policy history documents reflect coding and reimbursement updates but do not create a prior authorization requirement.
Billing code updates and conditional reimbursement — code additions and applicable conditions
Policy history documents additions and revisions of CPT/HCPCS and other billing codes to align reimbursement for CVD risk laboratory tests and specify conditional reimbursement rules (e.g., for hs‑CRP and one‑time Lp(a)).
- Policy history shows addition of codes such as 83876, 0541U, 0415U, 0019M, and 84512 across updates to support covered tests.
- Conditional reimbursement is specified for hs‑CRP (limited to uncertain risk‑based treatment decisions with initial, confirmatory ≥2 weeks, and annual if confirmed) and Lp(a) (one lifetime measurement ≥18 years).
Definitions and Key Terms
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