CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLABO28

Immune Cell Function Assay reimbursement

This Blue Cross Blue Shield Oklahoma policy describes reimbursement and coding considerations for immune cell function assays (laboratory tests) and defines indications where reimbursement may or may not be provided; it applies to providers submitting claims to BCBSOK for covered members.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyImmune Cell Function Assay reimbursement

Policy CodePolicy CPCPLABO28

Change TypeReferences updated; no material coverage changes

Effective DateFeb 1, 2024

Next Review Date

Key ActionSubmit accurate documentation and use valid HIPAA-approved code sets; be prepared to provide additional documentation on request.

SourceLink

POLICY UPDATE CHANGES

Document updated with literature review; reimbursement information unchanged; references revised.

Document updated with literature review prior to 02/01/2024 and 11/01/2023 with reimbursement information unchanged.

Initial policy created on 11/1/22.

Feb 1, 2024Plan effective date

1policy number present

severalexcluded indications listed

multiplereferences cited

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyImmune Cell Function Assay reimbursement

Policy CodePolicy CPCPLABO28

Change TypeReferences updated; no material coverage changes

Effective DateFeb 1, 2024

Next Review Date

Key ActionSubmit accurate documentation and use valid HIPAA-approved code sets; be prepared to provide additional documentation on request.

SourceLink

On This Page

Coverage criteria and exclusions

Reimbursement information and scope

ALL of the following

Use of an immune cell function assay to monitor and predict immune function after solid organ transplantation may be reimbursable

Not reimbursable for the following indications (includes but is not limited to)

Management of immunodeficiency disorders including human immunodeficiency virus (HIV) and severe combined immunodeficiency disease (SCID)
Management of autologous or allogeneic hematopoietic stem cell transplantation
Management of or prediction of infection risk in immune-mediated disorders including rheumatoid arthritis (RA), multiple sclerosis (MS), and lupus nephritis
Testing for urticaria
Diagnosis and management of Lyme disease (for example, iSpot Lyme Test)
Monitoring immune response following surgery
Management of inflammatory bowel diseases

Procedure codes and coding standards

Procedure codesmixed

The policy states procedure codes may apply but provides no exhaustive code list; inclusion does not guarantee coverage.

Coding standards required

Required coding systemsClaims must be coded using industry-standard code sets including UB, AMA CPT, CPT Assistant, HCPCS, ICD-10 CM/PCS, NDC, DRG, and CMS NCCI/CCI guidelines.

Claims submission expectationsProviders are expected to submit claims using valid HIPAA-approved code combinations and appropriate coding per the listed guidelines.

Claim review and editsClaims are subject to code edit protocols and claim review including plan benefits, provider contracts, medical policies, CPCPs, and coding software logic.

Documentation upon requestProviders may be asked to submit additional documentation upon request to support billed services.

Provider submission and documentation responsibilities

Documentation Required

Provider submission, coding, and documentation responsibilities

Providers must submit accurate documentation and use valid HIPAA‑approved code sets when filing claims; claims will be reviewed against benefit coverage, provider contract terms, medical and coding policies, and code‑edit protocols. BCBSOK may request additional documentation and plan documents or provider contracts govern in case of conflict with this policy.

Submit claims using valid code combinations from HIPAA‑approved code sets (e.g., UB, AMA CPT, HCPCS, ICD-10, NDC, DRG).
Code claims per industry standard coding guidelines, including CMS NCCI/CCI edits and other CMS guidance.
Claims are subject to claim review and code‑edit protocols; BCBSOK may request additional supporting documentation.
If a conflict exists, the applicable plan document or provider contract governs over this CPCP.

Definitions and plan documents

Immune Cell Function Assay

TermImmune Cell Function Assay

Brief descriptionLaboratory assay used to assess immune cell function; BCBSOK has implemented lab management reimbursement criteria for these assays and reimbursement may be provided for specific uses such as monitoring and predicting immune function after solid organ transplantation.

Policy applicabilityNot all requirements apply to every product; providers should review plan documents for coverage eligibility.

Plan documents / governing hierarchy

Primary governing documentsCertificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.

Hierarchy in conflicts