CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB036

Serum Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases

Defines BCBSNM reimbursement stance and criteria for serum and CSF biomarker testing for MS, NMOSD, and MOG-IgG-associated disease; applies to providers submitting laboratory claims to BCBSNM.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicySerum Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases

Policy CodePolicy CPCPLAB036

Change TypeRevised reimbursement criterionclarifications

Effective DateNov 1, 2023

Next Review Date

Key ActionSubmit accurate documentation and code claims using HIPAA-approved code sets; AQP4-IgG and MOG-IgG serum testing is reimbursable only when all listed clinical and radiologic criteria are met.

SourceLink

POLICY UPDATE CHANGES

Reimbursement criterion #2 was revised to indicate tests for AQP4-IgG and MOG-IgG may be reimbursable when all of the listed criteria are met.

Other changes were made to the Reimbursement Information section for clarity and references were revised.

3primary reimbursement decision categories

10example codes listed

4explicit non-reimbursable statements

7/5/2023committee approval date

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.

Reimbursement Criteria and Exclusions

Biomarker testing reimbursement criteria and exclusions

Reimbursement criteria and exclusions for biomarker testing:

ANY of the following

a. For individuals with atypical clinical, laboratory, or imaging features.
b. For individuals with an atypical clinically isolated syndrome including, but not limited to, primary progressive multiple sclerosis or relapsing-remitting course.
c. For individuals belonging to a population in which MS is less common, including, but not limited to, children, older individuals, or non-Caucasians.
d. For individuals with insufficient clinical or imaging evidence for diagnosis.

ALL of the following

a. The individual has monophasic or relapsing acute optic neuritis, myelitis, brainstem encephalitis, encephalitis, or any combination thereof.
b. The individual has radiological or electrophysiological findings compatible with central nervous system demyelination.
ANY of the following
- i. Belongs to a higher risk population—African American, Latin American, Asian, or pediatric.
- ii. Has an abnormal MRI depicting extensive optic nerve lesion, extensive spinal cord lesion or atrophy, or large confluent T2 brain lesions.
- iii. Has prominent papilledema, papillitis, or optic disc swelling during acute optic neuritis.

In all other situations, serum biomarker tests for multiple sclerosis are not reimbursable.

ELISA, Western blot, immunohistochemistry, or any other serum assays to test for NMOSD or MOG-EM are not reimbursable.

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Procedure and Test Codes

Listed procedure/test codesCPT

83520
83916
84182
86051
86052
86053
86362
86363
88341
88342

Code list completeness and claims guidance

Scope of code listThe listed procedure codes are not an all-encompassing code list; inclusion does not guarantee the code is a covered service or eligible for reimbursement.

Coding guidanceProviders must submit claims using valid code combinations from HIPAA‑approved code sets (e.g., CPT, HCPCS, ICD‑10) and follow industry coding guidelines.

Claim reviewClaims are subject to code edit protocols and review against benefit coverage, provider contracts, medical and clinical payment and coding policies.

Provider responsibilityProviders are responsible for submission of accurate documentation and may be asked to provide additional documentation upon request.

Documentation and Reimbursement Conditions

Documentation Required

Submit accurate documentation and use HIPAA‑approved code sets

Providers must submit accurate documentation of services performed and code claims using valid HIPAA‑approved code sets and industry standard coding guidelines. Claims are subject to code edit protocols and review against benefit coverage, provider contract terms, medical and clinical payment policies, and coding software logic; upon request providers should submit additional documentation.

Use valid code combinations from HIPAA‑approved code sets (e.g., UB, CPT®, HCPCS, ICD‑10, NDC, DRG guidelines).
Code claims appropriately per industry standard coding guidance (AMA CPT®, NCCI, CCI edits, CMS guidance).
Be prepared to provide additional documentation upon request for claim review or coding edits.

Plan Documents and Governing Documents

Plan documents and policy precedence

Definition of plan documentsPlan documents include Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.

Governing precedenceWhen a plan document conflicts with this Clinical Payment and Coding Policy, the plan document will govern.

Provider contractsIf a CPCP conflicts with a provider contract, the provider contract will govern for services under that contract.

Discretion and interpretationBCBSNM may use reasonable discretion in interpreting and applying this policy and retains final discretionary authority to the extent provided under applicable plan documents.