ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPLABO2O

Cardiovascular Disease Risk Assessment - Laboratory Testing Reimbursement

Defines Blue Cross Blue Shield of New Mexico's reimbursement stance and lab management criteria for tests used in cardiovascular disease risk assessment for plan members and providers submitting claims.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyCardiovascular Disease Risk Assessment - Laboratory Testing Reimbursement

Policy CodePolicy CPCPLABO2O

Change TypeCoverage and coding revisions (hs-CRP frequencylipid screening intervalcode updates)

Effective DateNov 7, 2025

Next Review DateN/A

Key ActionSubmit claims with accurate documentation and appropriate HIPAA-approved codes; hs-CRP is reimbursable only as an initial test when treatment decisions remain uncertain after ACC/AHA PCEs, with a confirmatory test no sooner than 2 weeks and annual follow-up if confirmed elevated.

SourceLink

POLICY UPDATE CHANGES

Revised frequency of testing in #4a and #4b, and added #4c establishing initial, confirmatory, and annual hs-CRP testing for certain individuals; #5 clarified tests that are not reimbursable (hs-CRP outside described indications and conventional CRP).

Added code 0541U.

Revised screening interval for ages 18–79 to every 4 years and added annual frequency in another provision; added code 84512 and removed 04223T.

Added codes 0415U and 0019M.

every 4 yearslipid screening interval (ages 18–79)

1initial hs-CRP allowed

>=2w

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confirmatory hs-CRP minimum interval

annualannual hs-CRP when confirmed

multiplenon-reimbursable biomarker categories

3recent updates listed

Coverage criteria for CVD laboratory testing

CVD lab testing coverage criteria

Reimbursement positions for common tests used in cardiovascular disease (CVD) risk assessment. Covered or not covered as specified below.

ALL of the following

ALL of the following
- ALL of the following
  - ALL of the following
    Every 4 years for individuals ages 18–79
    Annually for individuals at increased risk of dyslipidemia (examples include obesity/metabolic syndrome, hypothyroidism, nephrotic syndrome, hyperthyroidism, pancreatitis, diabetes, Cushing syndrome, chronic kidney disease, pregnancy, cholestatic liver disease, lipid metabolism disorders)
- ALL of the following
  - To establish baseline levels before initiating statin therapy
  - For individuals beginning or on statin therapy: every 4 to 12 weeks after initiation or change of therapy; annually when no medication changes have occurred
  - For individuals on long-term therapy requiring lipid monitoring (e.g., isotretinoin, antipsychotics): annually
  - For HIV-positive individuals starting or on antiretroviral therapy (ART): every 1 to 3 months after initiation/change; every 6 to 12 months when no medication changes have occurred; baseline before initiating ART

ALL of the following

ALL of the following
- May be reimbursable for any of the following: individuals with diabetes mellitus
- Individuals with hypertriglyceridemia
- Individuals with obesity or metabolic syndrome
- Individuals who are on lipid therapy
- Individuals with other dyslipidemias (such as very low LDL-C)
- Individuals suspected to have familial dysbetalipoproteinemia or familial combined hyperlipidemia

ALL of the following

ANY of the following
- Not reimbursable as an adjunct to LDL cholesterol for routine risk assessment and management of CVD
ANY of the following
- Not reimbursable for CVD risk assessment and stratification in the outpatient setting
ANY of the following
- Not reimbursable for CVD risk assessment (see other policies for non-CVD indications)
ANY of the following
- Not reimbursable for CVD risk assessment (examples include apolipoprotein A1, apolipoprotein E, B-type natriuretic peptide, cystatin C, fibrinogen, leptin, LDL/HDL subclasses)

ALL of the following

A simple lipid panel generally includes total cholesterol, LDL-C, HDL-C, and triglycerides; certain calculated ratios may be reported
Plan documents and product-specific terms determine coverage applicability

hs-CRP and lipid screening reimbursement criteria

Reimbursable hs-CRP testing and related lipid screening guidance when treatment decision remains uncertain after quantitative risk assessment using ACC/AHA PCEs.

ALL of the following

Quantitative risk assessment using 2013 ACC/AHA Pooled Cohort Equations (PCEs) has been performed and a risk-based treatment decision remains uncertain

ALL of the following

ALL of the following
- One hs-CRP test allowed as an initial screen when the treatment decision is uncertain after ACC/AHA PCE calculation of 10-year CVD risk
ALL of the following
- If the initial hs-CRP is abnormal, one confirmatory hs-CRP may be reimbursed no sooner than two weeks after the initial test

Procedure codes, screening intervals, and coding notes

Example procedure codes referencedCPT

80061	Lipid panel
81599	Unlisted laboratory procedure (example listed)
82465	Apolipoprotein B

policy-listed test codes (historic changes)mixed

0541U	Added to policy (unspecified assay/test) per update history
84512	Added to policy (likely CRP/test code) per update history
04223T	Removed from policy per update history
0415U	Added to policy per update history
0019M	Added to policy per update history

Lipid screening interval — adults

Recommended interval (ages 18–79)Every 4 years for individuals ages 18 to 79 years.

Increased-risk frequencyAnnually for individuals at increased risk of dyslipidemia (examples include obesity/metabolic syndrome, diabetes, chronic kidney disease, pregnancy, lipid metabolism disorders, hypothyroidism, nephrotic syndrome, pancreatitis, Cushing syndrome, cholestatic liver disease).

Baseline before therapyBaseline lipid panel to establish levels before initiating statin therapy or antiretroviral therapy (ART).

Monitoring after therapy initiationEvery 4 to 12 weeks after initiation or change of statin therapy; every 1 to 3 months after initiation or change of ART; then periodic monitoring as specified (e.g., every 6–12 months when stable).

hs-CRP confirmatory interval

Documentation, billing, and provider-facing rules

Documentation Required

Documentation and coding requirements

Providers must submit accurate documentation of services performed and bill using HIPAA-approved code sets. Claims are subject to code edit protocols, medical policy review, provider contract terms, and benefit coverage rules. Upon request, providers should supply additional documentation to support medical necessity and coding. Billing must follow industry-standard coding guidelines (e.g., AMA CPT, HCPCS, ICD-10-CM/PCS, NDCs, CMS NCCI edits).

Submit claims with appropriate, valid HIPAA-approved procedure and diagnosis codes.
Claims are subject to claim review including benefit coverage, provider contract language, medical policies, and coding software logic.
Provide additional documentation upon request to support medical necessity and coding.

Billing Rule

Coding updates in policy history

Definitions and abbreviations

Simple lipid panel — definition

DefinitionA simple lipid panel is generally composed of total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides; certain calculated ratios such as total/HDL cholesterol may also be reported.

Excluded componentsTests such as lipoprotein (a), LDL/HDL subclasses, or other novel markers are not considered components of a simple lipid panel.

Use caseUsed for screening and monitoring of cardiovascular disease risk and lipid-lowering therapy per policy criteria.

Pooled Cohort Equations (PCEs)

PurposePooled Cohort Equations (PCEs) are used to calculate 10-year risk of atherosclerotic cardiovascular disease events per the 2013 ACC/AHA guideline and to inform screening and management decisions.

Role in policy

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyCardiovascular Disease Risk Assessment - Laboratory Testing Reimbursement

Policy CodePolicy CPCPLABO2O

Change TypeCoverage and coding revisions (hs-CRP frequencylipid screening intervalcode updates)

Effective DateNov 7, 2025

Next Review DateN/A

SourceLink

On This Page

ANY of the following

Not reimbursable

ANY of the following

Not reimbursable for CVD risk assessment or cardiovascular risk measurement

ANY of the following

Not reimbursable for any CVD risk situations

ALL of the following

If elevated hs-CRP is confirmed, annual hs-CRP screening may be reimbursed

ALL of the following

hs-CRP testing for cardiovascular risk assessments not described above
Conventional (non-high-sensitivity) CRP testing for cardiovascular risk assessment

ALL of the following

Lipid panel screening interval for individuals ages 18–79: every 4 years
Annual screening is allowed for individuals at increased risk (see criteria for increased risk)

ALL of the following

Policy update history revised frequencies and clarified initial, confirmatory, and annual hs-CRP testing; providers should follow plan-specific documentation and coding requirements

Confirmatory test timingIf the initial hs-CRP screen is abnormal, one confirmatory hs-CRP may be reimbursed no sooner than 2 weeks after the initial test.

Initial screenOne hs-CRP test allowed as an initial screen when a risk-based treatment decision remains uncertain after quantitative assessment using ACC/AHA PCEs.

Annual follow-up if confirmedIf elevated hs-CRP is confirmed, annual hs-CRP screening may be reimbursed.

Policy history includes additions and removals of specific CPT/HCPCS/lab test codes across updates. Providers should bill with the codes active on the service date and follow the most recent policy update when applicable.

10/30/2024: Added code 84512; removed 04223T.
03/01/2024: Added codes 0415U and 0019M.
02/04/2025: Added code 0541U.
07/25/2025: Revisions to reimbursement information and testing frequency (see hs-CRP guidance).

Prior Authorization

hs-CRP reimbursement conditions and limits

hs-CRP testing may be reimbursable only when a quantitative 10-year cardiovascular risk assessment using ACC/AHA Pooled Cohort Equations (PCEs) leaves a treatment decision uncertain. Reimbursement limits and frequencies: one test for initial screening; if initial hs-CRP is abnormal, a confirmatory test no sooner than two weeks after the initial test; annual screening thereafter for those with confirmed elevated hs-CRP. hs-CRP testing outside of these indications is not reimbursable.

Reimbursable when: treatment decision remains uncertain after ACC/AHA PCE quantitative 10-year CVD risk assessment.
Frequency: one initial test; confirmatory test ≥2 weeks after an abnormal initial test; annual testing for persistently elevated, confirmed hs-CRP.
Not reimbursable: hs-CRP for cardiovascular risk assessments not fitting the above criteria; conventional (non–high-sensitivity) CRP testing for cardiovascular risk assessment.

Quantitative risk assessment using ACC/AHA PCEs is referenced as the basis for determining the need for additional testing such as hs-CRP when treatment decisions remain uncertain.

Risk factors includedPCEs consider factors including age, sex, race, smoking, hypertension, diabetes, total cholesterol, and HDL cholesterol (per 2013 guideline).

hs-CRP — definition and allowed circumstances

DefinitionHigh-sensitivity C-reactive protein (hs-CRP) refers to C-reactive protein measured with a high-sensitivity assay specifically for cardiovascular risk assessment.

Allowed circumstancesHs-CRP testing may be reimbursable for individuals for whom a risk-based treatment decision is uncertain after quantitative risk assessment using ACC/AHA PCEs (one initial test, confirmatory no sooner than 2 weeks if abnormal, annual if confirmed elevated).

Not reimbursableHs-CRP testing outside the described circumstances and conventional (non–high-sensitivity) CRP testing for cardiovascular risk assessment are not reimbursable.

ACC/AHA PCEs — prerequisite note for hs-CRP

Prerequisite for hs-CRP reimbursementUse of ACC/AHA Pooled Cohort Equations (PCEs) to calculate 10-year CVD risk is a referenced prerequisite for considering hs-CRP testing when treatment decisions remain uncertain.

Policy linkagePolicy update history explicitly ties hs-CRP initial, confirmatory, and annual testing frequency to uncertainty after ACC/AHA PCEs quantitative risk assessment.

Documentation implicationClinician should document quantitative PCE-based risk assessment results to justify hs-CRP reimbursement under the policy conditions.