CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLABO4Z

Pancreatic Enzyme Testing for Acute Pancreatitis

Defines BCBSNM reimbursement criteria for serum and urine pancreatic enzyme (lipase, amylase, trypsinogen/TAP) and select biomarkers when used to diagnose, assess, or determine severity of acute pancreatitis; applies to providers submitting claims to Blue Cross and Blue Shield of New Mexico.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPancreatic Enzyme Testing for Acute Pancreatitis

Policy CodePolicy CPCPLABO4Z

Change TypeMaterial edits and additions

Effective DateJan 15, 2025

Next Review DateN/A

Key ActionSubmit claims with accurate documentation and valid HIPAA code sets; serum lipase (preferred) or amylase may be reimbursable only for individuals presenting with signs and symptoms of acute pancreatitis.

SourceLink

POLICY UPDATE CHANGES

Edited #2 for clarity on the non-reimbursement of serum lipase or amylase for individuals who have already been diagnosed with acute pancreatitis or chronic pancreatitis.

Added #6 stating that for all other situations not described, measurement of serum lipase and/or amylase is not reimbursable.

Added statement that measurement of urinary amylase concentration for initial diagnosis is not reimbursable for individuals presenting with signs and symptoms of acute pancreatitis (Note 1).

Document updated with literature review; references revised, some added or updated.

1Preferred initial test (serum lipase)

≥3Non-reimbursable biomarker tests

CPCPLABO4ZPolicy identifier

2025-01-15Plan effective

Reimbursement and Coverage Criteria

Reimbursement criteria

Covered when ALL of the following are met:

For individuals presenting with signs and symptoms of acute pancreatitis (see Note 1).

Initial diagnostic testing

Measurement of serum lipase (preferred).
Measurement of serum amylase.

Exclusions (tests NOT reimbursable)

Established diagnosis: Individuals with an established diagnosis of acute or chronic pancreatitis (serum lipase and/or amylase not reimbursable).

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPancreatic Enzyme Testing for Acute Pancreatitis

Policy CodePolicy CPCPLABO4Z

Change TypeMaterial edits and additions

Effective DateJan 15, 2025

Next Review DateN/A

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.

Documentation, Claims, and Authorization

Documentation Required

Documentation and claim submission rules

Providers are responsible for submission of accurate documentation of services performed and must submit claims using valid HIPAA-approved code sets. Claim submissions are subject to review against plan documents, provider contracts, medical and coding policies, and code-edit protocols; upon request providers should submit additional documentation to support the claim.

Submit claims using Health Insurance Portability and Accountability Act (HIPAA) approved code sets (e.g., CPT, HCPCS, ICD-10).
Code claims according to industry-standard coding guidelines and CCI/CMS edits.
Be prepared to provide additional documentation upon request for claim review against plan documents and provider contracts.

Denial Risk

Prior authorization / denial risk: non‑reimbursable scenarios for lipase/amylase

Measurement of serum lipase and/or amylase is not reimbursable for individuals with an established diagnosis of acute or chronic pancreatitis, if billed more than once per visit, for asymptomatic nonpregnant individuals during a general exam without abnormal findings, and in other situations not described; urinary amylase is also not reimbursable for initial diagnosis. Claims in these scenarios are at risk for denial.

Not reimbursable for individuals with an established diagnosis of acute or chronic pancreatitis.
Not reimbursable more than once per visit.
Not reimbursable for asymptomatic nonpregnant individuals during general exam without abnormal findings.
Urinary amylase concentration is not reimbursable for initial diagnosis of acute pancreatitis.
For all other situations or conditions not described, serum lipase and/or amylase measurement is not reimbursable.

Definitions and Plan Documents

Signs and symptoms of acute pancreatitis (Note 1)

Epigastric painMild to severe epigastric pain that begins slowly or suddenly and may spread to the back.

Gastrointestinal symptomsNausea and vomiting.

Abdominal findingsTenderness to palpation of the epigastrium, abdominal distention, and hypoactive bowel sounds.

Systemic signsFever, rapid pulse (tachycardia), hypoxemia, tachypnea, hypotension, and anorexia.

Additional featuresDiarrhea, Cullen sign, and Grey Turner sign.

Plan documents

Definition of plan documentsIncludes, but is not limited to, Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.

Governing authorityIf a conflict arises between this policy and any plan document under which a member is entitled to Covered Services, the plan document will govern.

Interpretation discretionBCBSNM may use reasonable discretion interpreting and applying this policy to services delivered in a particular case, consistent with applicable plan documents.

OpenPayer

Pancreatic Enzyme Testing for Acute Pancreatitis

Reimbursement and Coverage Criteria

Procedure Codes and Frequency

Documentation, Claims, and Authorization

Definitions and Plan Documents