Currentblue cross blue shield - tennesseePolicy N/A

Cardiovascular_Disease_Risk_Assessment_Fep_G2050

Defines coverage criteria and exclusions for laboratory tests and panels used to assess cardiovascular disease (CVD) risk in adults, specifying which tests meet coverage criteria, frequencies, and conditions (e.g., lipid panels, apoB, Lp(a), hs-CRP) and listing applicable CPT/HCPCS codes and references. This part covers policy description, indications/limitations, regulations, procedure code lists, and evidence references (PART 1 of 2).

Policy Summary

Payerblue cross blue shield - tennessee

PolicyCardiovascular_Disease_Risk_Assessment_Fep_G2050

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument quantitative risk assessment using 2013 ACC/AHA Pooled Cohort Equations (PCEs) when determining need for annual lipid screening in individuals at increased CVD risk.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes identified.

AnnualLipid panel frequency (general population 18-79)

CoveredapoB coverage

1Lp(a) lifetime test

Not coveredNovel biomarkers & CVD panels

30+

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References in Part 2

Coverage Summary

Coverage stance is mixed: simple lipid panels (total cholesterol, HDL, LDL, triglycerides) and certain targeted tests (apoB in specified indications; Lp(a) once per lifetime; hs-CRP in select uncertain risk cases) are generally covered, while many advanced multi-marker panels and novel biomarkers are not covered.

Policy intent is to allow routine lipid panel screening and guideline-aligned adjunctive testing for CVD risk assessment while excluding broad multianalyte or novel biomarker panels that are not considered components of a simple lipid panel.

Key thresholds & quick facts

Lp(a) lifetime test1

Lipid panel frequencyAnnual (ages 18-79)

apoBCovered for listed indications (eg, hypertriglyceridemia, diabetes, obesity/metabolic syndrome, other dyslipidemias, on lipid therapy, suspected familial dysbetalipoproteinemia/combined hyperlipidemia)

Novel biomarkers & panelsNot covered (novel lipid/non-lipid biomarkers and multi-biomarker CVD panels do not meet coverage criteria)

References30+

Medical Necessity Criteria (by test)

Lipid Panel Coverage (Individuals ≥18 years)

Lipid panel testing MEETS COVERAGE CRITERIA when ANY of the following conditions are met:

ANY of the following

To screen for cardiovascular disease (CVD): Annually for individuals ages 18 to 79 years.
To screen for cardiovascular disease (CVD): Annually for individuals at increased risk for cardiovascular disease as defined by 2013 ACC/AHA Pooled Cohort Equations (PCEs) to calculate 10-year risk of CVD events.
Document quantitative risk assessment using PCEs when determining need for annual lipid screening.
At increased risk of dyslipidemia due to:
- Obesity or metabolic syndrome

Tests Not Meeting Coverage Criteria

The following tests DO NOT MEET COVERAGE CRITERIA for CVD risk assessment:

ANY of the following

CRP (non-high-sensitivity) for CVD risk assessment.
High-sensitivity cardiac troponin T (hs-cTnT) for CVD risk assessment and stratification in the outpatient setting.
Homocysteine testing for CVD risk assessment, screening, evaluation, and management.
Novel lipid and non-lipid biomarkers (e.g., apolipoprotein AI, apolipoprotein E, B-type natriuretic peptide, cystatin C, fibrinogen, leptin, LDL subclass, HDL subclass).

Procedure Codes (policy reference list)

Covered / referenced procedure codes (general reference list in policy)mixed

80061	Lipid panel.
81599	Unlisted multianalyte assay with algorithmic analysis.
82172	Apolipoprotein, each.
82465	Cholesterol, serum or whole blood, total.
82610	Cystatin C.
83090	Homocysteine.
83695	Lipoprotein (a).
83698	Lipoprotein-associated phospholipase A2 (Lp-PLA2).
83700	Lipoprotein, blood; electrophoretic separation and quantitation.
83701	Lipoprotein, blood; high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed.

1–10 of 28

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Provider Actions & Requirements

Documentation Required

Use of Pooled Cohort Equations (PCEs)

Document quantitative cardiovascular risk assessment using the 2013 ACC/AHA Pooled Cohort Equations (PCEs) when determining the need for annual lipid screening in individuals at increased CVD risk. The policy requires noting that the PCE estimates 10-year ASCVD risk using factors such as age, sex, race, smoking, blood pressure, diabetes, and cholesterol values, and that clinicians may supplement the PCE with additional risk-enhancing factors during clinician–patient risk discussion.

Use the 2013 ACC/AHA Pooled Cohort Equations (PCEs) ASCVD Risk Estimator (2013 ACC/AHA guideline).

Prior Authorization

Lifetime Lp(a) testing frequency constraint

Lipoprotein(a) testing (Lp[a]) is covered once per lifetime for individuals age ≥18. Providers should document the patient's prior Lp(a) testing history in the medical record to support coverage of a lifetime Lp(a) measurement.

Affected code: 83695

Background & Definitions

Cardiovascular risk assessment uses lipid profiles, biomarkers, and risk calculators (for example, the 2013 ACC/AHA Pooled Cohort Equations) to estimate 10-year risk of CVD events and guide management.

A simple lipid panel is defined as total cholesterol, HDL cholesterol, LDL cholesterol, and triglycerides; certain calculated ratios (eg, total/HDL) may also be reported. The policy context specifies that advanced lipid testing (eg, apolipoproteins, particle number/size, Lp(a) beyond its limited coverage) and multi-marker CVD panels are generally not part of a simple lipid panel and are typically not covered unless explicitly listed in the coverage criteria.

Definitions

Evidence / References summary

Revision History

Policy Summary

Payerblue cross blue shield - tennessee

PolicyCardiovascular_Disease_Risk_Assessment_Fep_G2050

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument quantitative risk assessment using 2013 ACC/AHA Pooled Cohort Equations (PCEs) when determining need for annual lipid screening in individuals at increased CVD risk.

SourceLink

On This Page

Chronic kidney disease

Cholestatic liver disease

Lipid metabolism disorders, such as Gaucher disease in adults

Individuals about to begin or currently receiving statin therapy:

To establish baseline levels before initiating statin therapy.
Every four to twelve weeks after initiation or change of therapy.
Annually when no medication changes have occurred.

Individuals on long-term drug therapy requiring lipid monitoring:

Annually for individuals on long-term drug therapy that requires lipid monitoring (e.g., Accutane, anti-psychotics).

HIV-positive individuals about to begin or receiving antiretroviral therapy (ART):

To establish baseline levels before initiating ART.
Every one to three months after initiation or change of therapy.
Every six to twelve months when no medication changes have occurred.

Apolipoprotein B (apoB)

Measurement of apoB MEETS COVERAGE CRITERIA for ANY of the following:

ANY of the following

Individuals with hypertriglyceridemia.
Individuals with diabetes mellitus.
Individuals with obesity or metabolic syndrome.
Individuals with other dyslipidemias (such as very low LDL-C).
Individuals who are on lipid therapy.
Individuals suspected to have familial dysbetalipoproteinemia or familial combined hyperlipidemia.

Lipoprotein(a) (Lp(a))

Measurement of Lp(a) MEETS COVERAGE CRITERIA:

ALL of the following

For individuals 18 years of age or older.
Once per lifetime.
Providers should document prior Lp(a) testing history to support coverage.

High-sensitivity C-reactive protein (hs-CRP)

hs-CRP MEETS COVERAGE CRITERIA when used to clarify risk in specific situations:

ALL of the following

For individuals for whom a risk-based treatment decision is uncertain after quantitative risk assessment using ACC/AHA PCEs.
Document that hs-CRP was used as an adjunctive test and that initial screening included two measurements at least two weeks apart; if abnormal, document follow-up testing frequency (up to annually).
ANY of the following
- Initial screening cadence: Initial screening: two measurements at least two weeks apart.
- Follow-up frequency: If initial screen abnormal: follow-up screening allowed up to once per year.
  hs-CRP abnormal threshold: ≥2.0 mg/L (risk-enhancing factor).

CVD risk panels consisting of multiple individual biomarkers (other than simple lipid panels).

Serum intermediate density lipoproteins measurement.

Lipoprotein-associated phospholipase A2 (LpPLA2) measurement.

Measurement of long-chain omega-3 fatty acids in red blood cell membranes.

All other tests for assessing CVD risk not described as covered above.

Advanced lipid testing and multi-marker CVD panels are explicitly distinguished from a simple lipid panel and are generally not considered components of it; as a result, such tests and panels are frequently excluded from coverage.

The policy notes that a simple lipid panel is generally composed of total cholesterol, HDL cholesterol, LDL cholesterol, and triglycerides, and states that other types of lipid testing (eg, apolipoproteins, particle number/size, Lp(a) or multianalyte panels) are not components of a simple lipid profile and, except as specifically listed, do not meet coverage criteria.

Documentation Required

hs-CRP testing for uncertain risk-based decisions

High-sensitivity C-reactive protein (hs-CRP) may be used to clarify a risk-based treatment decision when uncertainty remains after quantitative risk assessment with the ACC/AHA PCEs. Document that hs-CRP was used as an adjunct, that initial screening included two measurements at least two weeks apart, and if the initial screen was abnormal, document that follow-up screening will occur no more than once per year.

Affected code: 86141

Billing Rule

Lipid panel coverage intervals

Simple lipid panel testing is allowed at the policy-specified intervals: annually for routine screening (ages 18–79 and for individuals at increased risk per PCEs); to establish baseline before initiating statin therapy; every 4–12 weeks after starting or changing statin therapy, then annually when stable; annually for individuals on long-term drugs requiring lipid monitoring; and specified intervals for ART monitoring (baseline, every 1–3 months after initiation/change, then every 6–12 months if stable).

Affected codes: 80061
82465
84478
83721
83718