CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB028

Immune Cell Function Assay reimbursement

This policy governs BCBSOK reimbursement and coding guidance for immune cell function assays (laboratory tests), including permitted and non-reimbursable indications, and applies to providers submitting claims to Blue Cross Blue Shield of Oklahoma.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyImmune Cell Function Assay reimbursement

Policy CodePolicy CPCPLAB028

Change TypeAdministrative revision

Effective DateNov 1, 2023

Next Review Date

Key ActionSubmit accurate documentation and use valid HIPAA-approved code sets; claims may require additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

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

New policy created on 11/1/22.

3procedure codes listed

11/01/2023plan effective date

7/5/2023committee approval date

Reimbursement and Coverage Criteria

Reimbursement criteria

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May be reimbursable when used to monitor and predict immune function after solid organ transplantation.

Not reimbursable for the following indications (including, but not limited to):

Management of autologous or allogeneic hematopoietic stem cell transplantation.
Management of immunodeficiency disorders including human immunodeficiency virus (HIV) and severe combined immunodeficiency disease (SCID).
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).
Management of inflammatory bowel diseases.
Monitoring immune response following surgery.

Provider Documentation, Billing, and Authorization

Documentation Required

Documentation and claim submission

Providers must submit accurate documentation of services performed and file claims using valid HIPAA‑approved code sets and industry standard coding guidelines. Claims are subject to code edit protocols and claim review and providers may be asked to submit additional documentation upon request.

Submit accurate documentation of services performed.
Use valid code combinations from HIPAA‑approved code sets (e.g., CPT, HCPCS, ICD-10).
Expect claims to be subject to code edit protocols and claim review; provide additional documentation when requested.

Prior Authorization

Prior authorization / reimbursement stance for immune cell function assay

Use of an immune cell function assay to monitor and predict immune function after solid organ transplantation may be reimbursable; use for the listed other indications is not reimbursable.

May be reimbursable when used to monitor and predict immune function after solid organ transplantation.
Not reimbursable for management of autologous or allogeneic hematopoietic stem cell transplantation; immunodeficiency disorders (e.g., HIV, SCID); prediction of infection risk in immune‑mediated disorders (e.g., RA, MS, lupus nephritis); testing for urticaria; diagnosis/management of Lyme disease (e.g., iSpot Lyme); management of inflammatory bowel diseases; or monitoring immune response following surgery.

Key Definitions

Immune Cell Function Assay — definition and attributes

TermImmune Cell Function Assay

DefinitionLaboratory test used to assess immune cell function; BCBSOK has implemented lab management reimbursement criteria and providers should consult plan documents for eligible coverage.

ScopeApplies to providers submitting claims to Blue Cross Blue Shield of Oklahoma; not all requirements apply to each product.

Provider responsibilitiesProviders must submit accurate documentation and use valid HIPAA‑approved code sets; claims are subject to claim review and may require additional documentation upon request.

Policy number and statusCPCPLAB028 — Effective 11/01/2023; Current status; committee approval 7/5/2023.