CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB028

Immune Cell Function Assay

Defines Blue Cross Blue Shield of New Mexico reimbursement stance, coding guidance, and exclusions for immune cell function assays; applies to providers submitting claims to BCBSNM for covered members and products (plan-specific requirements may vary).

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyImmune Cell Function Assay

Policy CodePolicy CPCPLAB028

Change TypeAdministrative updates (no material change)

Effective DateNov 1, 2023

Next Review Date

Key ActionProviders must submit accurate documentation and may be asked to provide additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

Document updated with literature review; reimbursement information unchanged; references revised.

New policy created on 2022-11-01 (policy inception).

1policy version

7/5/2023committee approval

11/1/2023plan effective

3codes listed

Coverage Criteria and Exclusions

Coverage criteria and exclusions

Reimbursement stance and explicit non-reimbursable indications

May be reimbursable to monitor and predict immune function after solid organ transplantation

Not reimbursable for the following indications

Management of autologous or allogeneic hematopoietic stem cell transplantation
Management of immunodeficiency disorders including human immunodeficiency virus (HIV) and severe combined immunodeficiency disease (SCID)
Management of or prediction of infection risk in immune mediated disorders including rheumatoid arthritis (RA), multiple sclerosis, and lupus nephritis

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyImmune Cell Function Assay

Policy CodePolicy CPCPLAB028

Change TypeAdministrative updates (no material change)

Effective DateNov 1, 2023

Next Review Date

Key ActionProviders must submit accurate documentation and may be asked to provide additional documentation upon request.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Procedure Codes and Coding Standards

Listed procedure codes (not exhaustive; inclusion does not guarantee coverage)mixed

81560
86352
0018M

Coding standards requirement

Required code setsClaims must be submitted using valid HIPAA‑approved code sets (e.g., CPT, HCPCS, ICD‑10, NDC, UB, DRG).

Industry coding guidelinesClaims should be coded per industry standard coding guidelines including AMA CPT, CPT Assistant, UB Editor, and CMS NCCI/CCI edits.

Claim edit protocolsClaims are subject to code edit protocols and coding software logic during processing.

Provider responsibilityProviders are responsible for submission of accurate documentation and appropriate coding of services rendered.

Additional documentationUpon request, providers must submit any additional documentation to support the claim.

Documentation, Claim Review, and Reimbursement Overview

Documentation Required

Documentation and claim review requirement

Providers must submit accurate documentation of services performed and are urged to provide additional documentation upon request; claims are subject to code edit protocols and review against benefit coverage, provider contract language, medical policies, CPCPs, and coding software logic.

Submit claims using valid HIPAA-approved code sets and appropriate coding per industry guidelines (CPT, HCPCS, ICD-10, NDC, UB, DRG, CMS NCCI/CCI edits).
Upon request, furnish additional documentation to support the claim.

Prior Authorization

Reimbursement overview and coverage implications

Use of an immune cell function assay to monitor and predict immune function after solid organ transplantation may be reimbursable; other indications listed are not reimbursable.

May be reimbursable: monitoring and predicting immune function after solid organ transplantation.
Not reimbursable for: management of hematopoietic stem cell transplantation (autologous or allogeneic); management of immunodeficiency disorders including HIV and SCID; management or prediction of infection risk in immune-mediated disorders (e.g., RA, MS, lupus nephritis); testing for urticaria; diagnosis and management of Lyme disease (e.g., iSpot Lyme); management of inflammatory bowel diseases; monitoring immune response following surgery.

Plan Documents and Policy Terms

Plan documents

DefinitionPlan documents include Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents that govern member benefits.

Governing authorityIf a conflict exists between a CPCP and a plan document, the plan document will govern coverage for the member.

Product variabilityNot all reimbursement requirements apply to every product; providers should review plan documents for eligible coverage.

Clinical Payment and Coding Policy (CPCP)

Role of CPCPThe Clinical Payment and Coding Policy (CPCP) governs reimbursement and coding unless superseded by plan documents or an applicable provider contract.

Contract precedenceIf a conflict arises between a CPCP and a provider contract, the provider contract will govern.

Discretion and interpretationBCBSNM may use reasonable discretion in interpreting and applying the CPCP and has discretionary authority consistent with applicable plan documents.