ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLAB020

Cardiovascular Disease Risk Assessment

BCBSOK Clinical Payment and Coding Policy governing reimbursement criteria for laboratory testing related to cardiovascular disease (CVD) risk assessment for members and providers.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyCardiovascular Disease Risk Assessment

Policy CodePolicy CPCPLAB020

Change TypeRevised — reimbursement clarity and frequency updates

Effective DateNovember 1, 2023

Next Review Date

Key ActionProviders must submit accurate documentation and may be asked to provide additional documentation upon request; claims are subject to review.

SourceLink

POLICY UPDATE CHANGES

Reimbursement information revised for clarity and frequency added allowing annual lipid panel screening for those with increased risk of dyslipidemia and frequency added for hs-CRP measurement.

Addition of frequency to 1b, now allowing lipid panel screening on an annual basis for those with increased risk of dyslipidemia.

Addition of frequency to #4 for hs-CRP measurement.

2023-11-01plan effective date

1.0policy version

2023-07-17committee approval

22+procedure codes referenced

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annualallowed lipid frequency (increased risk)

Coverage Criteria for CVD Risk Assessment Laboratory Testing

CVD laboratory reimbursement criteria

Reimbursable and non-reimbursable laboratory tests for CVD risk assessment and the conditions and frequencies that apply.

ALL of the following

Screening frequency for ages 18–79: every 4–6 years; annually for individuals at increased risk for cardiovascular disease as defined by 2013 ACC/AHA Pooled Cohort Equations (PCEs).
Annual testing for individuals at increased risk of dyslipidemia due to: obesity or metabolic syndrome; nephrotic syndrome; hypothyroidism; hyperthyroidism; pancreatitis; diabetes; chronic kidney disease; Cushing syndrome; pregnancy; cholestatic liver disease; lipid metabolism disorders (e.g., Gaucher disease in adults).
Monitoring for statin therapy: baseline before initiating statin therapy; every 4–12 weeks after initiation or change of therapy; annually when no medication changes have occurred.
Monitoring for long-term drug therapies requiring lipid monitoring (e.g., isotretinoin, certain antipsychotics): reimbursable at intervals appropriate to the drug per clinical judgment.
HIV-positive individuals on or about to begin antiretroviral therapy (ART): baseline before ART; every 1–3 months after initiation/change; every 6–12 months when no medication changes have occurred.

ALL of the following

Indications: hypertriglyceridemia; diabetes mellitus; obesity or metabolic syndrome; other dyslipidemias (such as very low LDL-C); individuals on lipid therapy; suspected familial dysbetalipoproteinemia or familial combined hyperlipidemia.

ALL of the following

Not reimbursable as an adjunct to LDL-C in the risk assessment and management of cardiovascular disease.

ALL of the following

May be reimbursable when a risk-based treatment decision remains uncertain after quantitative risk assessment using ACC/AHA PCEs.
Recommended frequency: initial screening requires two measurements at least 2 weeks apart; if initial screen is abnormal, follow-up screening is allowed up to once per year.

ALL of the following

Not reimbursable for CVD risk assessment and stratification in the outpatient setting.

ALL of the following

Not reimbursable for CVD risk assessment; see other policies for non-CVD indications.

ALL of the following

Examples include apolipoprotein AI, apolipoprotein E, B-type natriuretic peptide, cystatin C, fibrinogen, leptin, LDL/HDL subclasses, Lp-PLA2, SPLA2-IIA, secretory type II phospholipase A2 (SPLA2-IIA), long-chain omega-3 fatty acids in RBC membranes, serum intermediate density lipoproteins, CVD risk panels, and other novel biomarkers.

ALL of the following

All other tests for assessing CVD risk that are not explicitly described as reimbursable (other than simple lipid panels) are not reimbursable.

Reference-only — no coverage criteria

Reference list supporting clinical content elsewhere in the policy; no explicit coverage criteria in these chunks.

Content summary: Chunks 18–20 (and nearby reference chunks) list clinical guidelines, systematic reviews, and studies relevant to lipid management and biomarkers (e.g., ACC/AHA guidelines, studies of lipoprotein-associated phospholipase A2, troponin literature, and other cited sources). These references support the clinical rationale but do not themselves establish coverage rules.

Coverage frequency updates

Policy update indicates coverage-related changes to testing frequency.

ALL of the following

Change: Addition of frequency to allow lipid panel screening on an annual basis for those with increased risk of dyslipidemia (effective per Policy Update History).
Source support: Policy Update History documents the addition of annual frequency for increased-risk individuals (7/17/2023).

ALL of the following

Change: Frequency for hs-CRP measurement was added — initial screening requires two measurements at least 2 weeks apart; if abnormal, follow-up allowed up to once per year.
Source support: Reimbursement information specifies the hs-CRP initial and follow-up frequency; Policy Update History confirms addition of frequency.

Procedure Codes and Frequency Notes

Example procedure codes referencedmixed

80061	Lipid panel
81599
82172
82465	Apolipoprotein B
82610
83090
83695
83698
83700	Triglycerides
83701

1–10 of 28

1/3

No codes in referencesmixed

No billing or procedure codes provided in these reference-only chunks.

Lipid panel frequency (age 18-79)

Screening interval (age 18–79)Every 4 to 6 years for routine CVD risk screening

Increased CVD risk intervalAnnually for individuals at increased CVD risk as defined by 2013 ACC/AHA Pooled Cohort Equations (PCEs)

Annual for dyslipidemia risk conditionsAnnually for individuals with obesity/metabolic syndrome, nephrotic syndrome, thyroid disease, pancreatitis, diabetes, chronic kidney disease, Cushing syndrome, pregnancy, cholestatic liver disease, or lipid metabolism disorders

Statin therapy monitoringBaseline before initiating statin, every 4–12 weeks after initiation/change, then annually if no medication changes

ART and other drug monitoringFor HIV on ART: baseline, every 1–3 months after initiation/change, then every 6–12 months when stable; long-term drug therapies requiring lipid monitoring follow similar clinical intervals

Provider Responsibilities and Reimbursement Notes

Documentation Required

Documentation and claims review

Providers are responsible for submission of accurate documentation of services performed. Providers must submit claims using valid HIPAA-approved code sets and appropriate coding guidelines (e.g., UB, AMA CPT®, CPT® Assistant, HCPCS, ICD-10-CM/PCS, NDC, DRG, CMS NCCI policy and edits). Claims are subject to code edit protocols and clinical review against benefit terms, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers should supply any additional documentation to support the claim.

Submit claims with HIPAA-approved code sets and industry-standard coding guidance
Claims may be reviewed and requested for additional documentation

Note

References

References cited in this policy are informational only and do not imply prior authorization requirements. Providers should consult these sources for clinical context and supporting evidence.

Garber AJ et al. (2020) - AACE/ACE consensus on type 2 diabetes management algorithm

Definitions and Terminology

Simple lipid panel — definition

DefinitionSimple lipid panel generally includes total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides; certain calculated ratios (e.g., total/HDL) may also be reported

ExclusionsApolipoproteins, lipid particle number/size, and lipoprotein(a) are not considered components of a simple lipid profile

UseUsed for routine CVD risk screening and monitoring per specified intervals

PCEs — definition and role

PCEs definition2013 ACC/AHA Pooled Cohort Equations (PCEs) calculate 10-year risk of atherosclerotic cardiovascular disease events

Role in policyPCEs are used to define individuals at increased CVD risk who may receive annual lipid panel screening

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyCardiovascular Disease Risk Assessment

Policy CodePolicy CPCPLAB020

Change TypeRevised — reimbursement clarity and frequency updates

Effective DateNovember 1, 2023

Next Review Date

Key ActionProviders must submit accurate documentation and may be asked to provide additional documentation upon request; claims are subject to review.

SourceLink

On This Page

Example procedure codes referencedIncludes CPT codes such as 80061 (Lipid panel), 82465 (Apolipoprotein B), 84478 (hs-CRP), 83700 (Triglycerides), 86140 (Lipoprotein(a)), and 0423T (novel biomarker example)

Code list scopeCode list is illustrative and not all-encompassing; inclusion does not guarantee coverage

Coding guidanceProviders should use HIPAA-approved code sets and follow coding guidelines; claims may be edited or reviewed per contract

Garg PK et al. (2015) - Lp-PLA2 and cardiovascular disease risk

Genova Diagnostics (2023) - Cardio Check sample report

Gibson M, Morrow D (2022) - Elevated cardiac troponin without ACS

Billing Rule

Reimbursement and frequency updates

Reimbursement information has been revised for clarity. Frequency allowances were added: annual lipid panel screening is permitted for individuals with increased risk of dyslipidemia; frequency for hs-CRP measurement was also added. Providers should bill according to the updated reimbursement and frequency guidance and retain documentation supporting medical necessity.

Annual lipid panel screening allowed for increased-risk individuals (frequency added)
Frequency specification added for hs-CRP measurement
Reimbursement language clarified

LimitationsPCE is a powerful population tool but has limitations when applied to individuals; clinician-patient discussion may include additional risk-enhancing factors

References — selected citation types

Key guidelines and reviewsIncludes clinical practice guidelines and reviews such as management of blood cholesterol (ACC/AHA), Endocrine Society guideline on lipid management, and USPSTF statements

Systematic reviews and primary studiesReferences include remnant cholesterol studies, lipoprotein(a) meta-analyses, and clinical outcome studies informing biomarker utility

Practice statementsNational Lipid Association scientific statements and Society-specific prevention guidelines are cited to support testing and interpretation

Reference sources — guideline and literature citations

USPSTFUS Preventive Services Task Force recommendations on CVD risk assessment and related screening topics are cited

ESC/EAS and ESC prevention guidelinesEuropean Society of Cardiology prevention and related guidelines (e.g., 2021 ESC) are cited

ACC/AHA2013 ACC/AHA Pooled Cohort Equations and subsequent ACC/AHA guideline documents are cited

National Lipid AssociationNational Lipid Association scientific statements on lipid measurements and Lp(a) are included among references

Other sourcesAdditional sources include NICE guidance, Endocrine Society guideline, VA/DoD synopsis, and recent clinical studies and reviews (see full reference list)