CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB058

Venous and Arterial Thrombosis Risk Testing

Reimbursement and coding policy governing laboratory testing for venous and arterial thrombosis risk (including protein C, protein S, antithrombin III, Factor V Leiden and prothrombin G20210A) for Blue Cross and Blue Shield of New Mexico members; affects providers submitting claims for these tests.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyVenous and Arterial Thrombosis Risk Testing

Policy CodePolicy CPCPLAB058

Change TypeClarifications and material additions (new indicationsexplicit non-reimbursable assay)

Effective DateAug 8, 2025

Next Review Date

Key ActionSubmit accurate documentation with claims and provide additional documentation upon request to support reimbursement for thrombophilia testing.

SourceLink

POLICY UPDATE CHANGES

Pulmonary embolism added to the eligibility criterion for individuals <50 who have experienced DVT/PE.

New reimbursable indication added for warfarin-induced skin necrosis and neonatal purpura fulminans.

Added explicit non-reimbursement statement for all activated protein C (aPC) resistance assays.

Document updated with literature review and minor clarity revisions to reimbursement information; no change to intent.

7Procedure codes listed

2025-04-28Most recent approval date

08/08/2025Plan effective date

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyVenous and Arterial Thrombosis Risk Testing

Policy CodePolicy CPCPLAB058

Change TypeClarifications and material additions (new indicationsexplicit non-reimbursable assay)

Effective DateAug 8, 2025

Next Review Date

Key ActionSubmit accurate documentation with claims and provide additional documentation upon request to support reimbursement for thrombophilia testing.

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.

Reimbursement Criteria for Thrombophilia Testing

Reimbursement criteria for thrombophilia testing

Plasma testing for protein C, protein S, and antithrombin III deficiency may be reimbursable when clinical criteria are met; genetic testing for Factor V Leiden and Prothrombin G20210A may be included in risk-factor evaluation.

ALL of the following

ANY of the following
- Individuals <50 years who have experienced deep venous thrombosis (DVT) or pulmonary embolism (PE).
- Individuals who have experienced a DVT in unusual sites (e.g., hepatic, mesenteric, or cerebral veins).
- Individuals who have experienced a DVT and have a strong family history of thrombotic disease.
- Individuals who are pregnant or taking oral contraceptives and have experienced a DVT.
- First- and second-degree relatives of individuals who experienced a DVT before age 50.
- Women under 50 who smoke and have suffered a myocardial infarction.
- Targeted testing before administration of oral contraceptives for those with a personal or family history of DVT.
- Pediatric individuals who have suffered a pediatric arterial ischemic stroke.
ANY of the following
- Individuals with warfarin-induced skin necrosis (plasma testing for protein C and protein S may be reimbursable).
- Infants who develop neonatal purpura fulminans (plasma testing for protein C and protein S may be reimbursable).

ALL of the following

Plasma assays for clotting inhibitors (protein C, protein S, antithrombin III) should be performed at least six weeks after the acute thrombotic event and while the patient is not taking anticoagulants.
Assays for clotting inhibitor amount and function should be performed prior to any molecular (genetic) testing.
When hereditary or acquired thrombophilia is suspected, risk-factor testing should include genetic testing for Factor V Leiden and Prothrombin G20210A in addition to plasma testing.

ALL of the following

Venous thrombosis risk testing for superficial venous thrombosis (including superficial thrombophlebitis and varicosities) is not reimbursable.
All activated protein C (aPC) resistance assays are not reimbursable.
DVT risk testing as part of a pre-transplant evaluation is not reimbursable.

Procedure Codes and Timing

Listed laboratory procedure codesCPT

85300
85301
85302
85303
85305
85306
85307

Covered CPT CodesCPTCovered

No codes listed

Timing of plasma testing after acute thrombotic event

Recommended waiting periodPlasma testing for protein C, protein S, and antithrombin III deficiency should be performed at least six weeks after the acute thrombotic event

Anticoagulant statusTesting should be done while the patient is not taking anticoagulants

Sequencing with molecular testingAssays for clotting inhibitor amount and function should be performed prior to any molecular (genetic) testing

Documentation, Claims, and Prior Authorization

Documentation Required

Documentation and claim submission requirements

Providers are responsible for submission of accurate documentation of services performed and are expected to submit claims using valid code combinations from HIPAA‑approved code sets; claims are subject to code edit protocols and review against plan terms, provider contracts, medical policies, clinical payment and coding policies, and coding software logic. Upon request, the provider is urged to submit any additional documentation to support the claim.

Prior Authorization

Prior authorization / coverage conditions and explicit non‑reimbursable tests

Certain plasma and genetic thrombophilia tests are reimbursable only in specified clinical situations described by the policy; specifically, plasma testing for protein C, protein S, and antithrombin III deficiencies may be reimbursable in the listed indications, while all activated protein C (aPC) resistance assays and DVT testing as part of pre‑transplant evaluation are not reimbursable.

Plasma testing may be reimbursable for situations including: individuals <50 with DVT or PE; DVT at unusual sites; DVT with strong family history; pregnancy or oral contraceptive–associated DVT; first‑ and second‑degree relatives of individuals with DVT before age 50; women <50 who smoke with MI; targeted testing before oral contraceptives for those with personal/family DVT history; pediatric arterial ischemic stroke.

Relative Definitions

Definition of first-degree relatives

ParentsIncluded as first-degree relatives

Full siblingsIncluded as first-degree relatives

ChildrenIncluded as first-degree relatives

Definition of second-degree relatives

GrandparentsIncluded as second-degree relatives

Aunts and unclesIncluded as second-degree relatives

Nieces and nephewsIncluded as second-degree relatives