CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB058

Venous and Arterial Thrombosis Risk Testing

Laboratory reimbursement and coverage criteria for thrombophilia and related venous/arterial thrombosis risk testing for Blue Cross Blue Shield of Oklahoma members and providers.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyVenous and Arterial Thrombosis Risk Testing

Policy CodePolicy CPCPLAB058

Change TypeMaterial update — added explicit non‑reimbursement for aPC resistance assays

Effective DateNovember 1, 2023

Next Review DateN/A

Key ActionReview plan documents for product-level coverage and prior authorization requirements before ordering thrombophilia testing.

SourceLink

POLICY UPDATE CHANGES

For all situations, all activated protein C (aPC) resistance assay is not reimbursable.

Reimbursement information revised for clarity after literature review.

1.0policy version

2023-11-01effective date

1 newaPC exclusion

Created 04/12/2023; updated 08/15/2023history

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Reimbursable plasma thrombophilia testing indications

Covered when ANY ONE of the following are met:

Reimbursable indications list: a) Individuals <50 years with any deep venous thrombosis (DVT); b) Individuals with DVT in unusual sites (hepatic, mesenteric, cerebral veins); c) Individuals with DVT and a strong family history of thrombotic disease; d) Individuals who are pregnant or taking oral contraceptives and have experienced a DVT; e) First- and second-degree relatives of individuals with DVT before age 50; f) Women <50 who smoke and have suffered a myocardial infarction; g) Before administration of oral contraceptives for targeted testing in individuals with personal or family history of DVT; h) Pediatric individuals with pediatric arterial ischemic stroke; i) Individuals with warfarin-induced skin necrosis; j) Infants with Neonatal Purpura Fulminans

See Note 1 and Note 2 for testing timing and genetic test recommendations.

Venous thrombosis risk testing for superficial venous thrombosis (including superficial thrombophlebitis and varicosities) is not reimbursable and claims for these services will be denied.

All activated protein C (aPC) resistance assays are not reimbursable in any situation. Claims for any aPC resistance assay may be denied.

Deep venous thrombosis (DVT) risk testing performed as part of a pre-transplant evaluation is not reimbursable and will not be covered.

Note: The policy explicitly states that all activated protein C (aPC) resistance assays are not reimbursable for any clinical situation; providers should not submit claims for aPC resistance testing.

Covered Indications

Plasma testing for protein C deficiency, protein S deficiency, and antithrombin III deficiency

Covered for the listed indications. Assays should be timed to avoid confounding by acute thrombosis or anticoagulation.

Timing and test-ordering conditions: Plasma testing for protein C deficiency, protein S deficiency, and antithrombin III deficiency should be performed at least six weeks after the acute thrombotic event and while the patient is not taking anticoagulants.

Assay sequencing: Assays for clotting inhibitor amount and function should be performed prior to any molecular (genetic) testing.

Additional recommended testing: Genetic testing for Factor V Leiden and Prothrombin G20210A mutations may be included as part of risk evaluation for individuals suspected of hereditary and/or acquired thrombophilia.

Ordering Requirements and Prior Authorization

Denial Risk

Ordering and Billing Alerts

• Superficial venous thrombosis testing (including standalone assays solely for superficial thrombosis) is not reimbursable. Do not bill for these tests; submit only medically necessary, covered testing per member plan documents. • Activated protein C (aPC) resistance assay is not reimbursable. Do not submit claims for aPC resistance; use alternative approved testing methods if clinically indicated and covered by the member's plan. • Providers must review product-level plan documents for applicability and prior authorization requirements and submit accurate, supporting documentation upon request. Claims are subject to coding edits and contract/plan provisions; failure to follow plan-specific prior authorization or documentation requirements may result in denial or recoupment.

Affected tests: superficial venous thrombosis assays (not covered)
Affected test: aPC resistance assay (not covered)
Action: Verify coverage and prior authorization at the product/plan level before ordering
Action: Submit complete, accurate documentation and use HIPAA-approved code sets

Provider Actions and Billing Guidance

Prior Authorization

Review plan documents for product-level prior authorization

Not all lab management reimbursement criteria apply to every BCBSOK product. Verify the member’s coverage and any product-specific prior authorization requirements before ordering tests.

Review the member’s plan documents for coverage eligibility and product-level prior authorization requirements.

Note

When in doubt, consult the full policy and plan documents

If the policy text does not address a specific situation or you need full policy context, consult the full CPCP and the member’s plan documents for definitive guidance.

Use the complete policy document and plan materials when questions arise or details aren’t found in summaries.

Documentation Required

Provide accurate documentation and follow timing requirements for assays

Submit accurate clinical documentation with claims and be prepared to provide additional records upon request. Time plasma testing for protein C, protein S, and antithrombin III at least six weeks after an acute thrombotic event and while the patient is not anticoagulated; perform clotting inhibitor amount/function assays prior to molecular testing.

Providers must submit accurate documentation of services performed and may be asked to provide additional documentation upon request.
Perform plasma testing at least six weeks after the acute thrombotic event and when the patient is not taking anticoagulants; do inhibitor amount/function assays before molecular testing.

Denial Risk

Do not bill for superficial venous thrombosis risk testing

Do not submit claims for venous thrombosis risk testing intended to evaluate superficial venous thrombosis (including superficial thrombophlebitis and varicosities); such claims will be denied / are not reimbursable.

Venous thrombosis risk testing for superficial venous thrombosis (including superficial thrombophlebitis and varicosities) is not reimbursable.

Denial Risk

aPC resistance assay claims are not reimbursable

Do not submit claims for activated protein C (aPC) resistance assay; all aPC resistance assay claims are not reimbursable and may be denied in all situations.

For all situations, all activated protein C (aPC) resistance assay is not reimbursable.

Denial Risk

Pre-transplant DVT risk testing is not reimbursable

Do not submit claims for DVT risk testing performed solely as part of a pre-transplant evaluation; these tests are not reimbursable.

Deep venous thrombosis (DVT) risk testing as part of a pre-transplant evaluation is not reimbursable.

Definitions

inv-15: Definition — First-degree relatives include parents, full siblings, and children

DefinitionFirst-degree relatives include parents, full siblings, and children

Clinical relevanceUsed when assessing family history for hereditary thrombophilia

Example relationshipsMother, father, full sister, full brother, son, daughter

inv-16: Definition — Second-degree relatives include grandparents, aunts, uncles, nieces, nephews, grandchildren, and half-siblings

DefinitionSecond-degree relatives include grandparents, aunts, uncles, nieces, nephews, grandchildren, and half-siblings

Clinical relevanceIncluded when evaluating extended family history for thrombophilia risk

Example relationshipsGrandparent, aunt, uncle, niece, nephew, grandchild, half-sibling

Background and Rationale

Testing for inherited and acquired thrombophilia can inform management for selected patients with venous thromboembolism (VTE). Plasma assays for protein C, protein S, and antithrombin III have defined reimbursable indications and timing considerations, but certain tests lack clinical utility or have policy exclusions. Specifically, this policy excludes reimbursement for all activated protein C (aPC) resistance assays, for venous thrombosis risk testing when the condition is limited to superficial venous thrombosis, and for DVT risk testing conducted solely as part of a pre-transplant evaluation. For protein C, protein S, and antithrombin III testing, assays should be performed at least six weeks after an acute thrombotic event and when the patient is not anticoagulated (see testing notes and criteria for covered indications).

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyVenous and Arterial Thrombosis Risk Testing

Policy CodePolicy CPCPLAB058

Change TypeMaterial update — added explicit non‑reimbursement for aPC resistance assays

Effective DateNovember 1, 2023

Next Review DateN/A

Key ActionReview plan documents for product-level coverage and prior authorization requirements before ordering thrombophilia testing.

SourceLink

On This Page

OpenPayer

Venous and Arterial Thrombosis Risk Testing

Coverage Criteria for Thrombophilia and Thrombosis Risk Testing

Covered Indications

Coding and Timing Requirements

Ordering Requirements and Prior Authorization

Provider Actions and Billing Guidance

Services Not Covered / Denied

Definitions

Frequency and Timing Limits

Background and Rationale