Serum Testing for Evidence of Mild Traumatic Brain Injury
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This policy governs coverage for laboratory testing of blood, saliva, or CSF biomarkers (e.g., S100B, GFAP, UCH-L1) and panels intended to aid evaluation of mild traumatic brain injury (concussion) for BlueCross BlueShield of Tennessee members.
Panel testing moved from CC1 into new CC2 for clarity; new CC2 states panels designed to measure biomarkers of TBI do not meet coverage criteria.
Added CPT code 0570U (effective date 7/1/2025).
Background, guidelines and evidence-based scientific references were updated; literature review did not necessitate modifications to coverage criteria.
Coverage Criteria
Not covered for evaluation of mild TBI
The following do not meet coverage criteria:
Applies to individual biomarkers measured in any of these fluids.
Applies to proprietary panel tests and lab-based assays intended for TBI biomarker panels.
If there is a conflict between this policy and any applicable government policy (for example, Medicare Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), or state Medicaid rules), the government policy controls coverage determinations for the affected member.
Measurement of concussion biomarkers (including but not limited to S100B, GFAP, and UCH-L1) in blood, saliva, or cerebrospinal fluid, and panels designed to measure biomarkers of traumatic brain injury (for example, i-STAT TBI Plasma and Alinity® i TBI) do not meet coverage criteria and are considered not medically necessary for the evaluation of mild traumatic brain injury (concussion).
Applicable CPT / HCPCS Procedure Codes
| 83516 | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method. |
| 84999 | Unlisted chemistry procedure. |
| 0570U | Neurology (traumatic brain injury), analysis of glial fibrillary acidic protein (GFAP) and ubiquitin carboxylterminal hydrolase L1 (UCHL1), immunoassay, whole blood or plasma, individual components reported with the overall result of elevated or non-elevated based on threshold comparison (Proprietary test: i-STAT TBI; Lab/Manufacturer: Abbott Point of Care). |
Provider Actions and Billing Guidance
Denial triggers for concussion/biomarker testing
Requests for measurement of concussion biomarkers (e.g., S100B, GFAP, UCH-L1) in blood, saliva, or cerebrospinal fluid (CSF), and requests for panels designed to measure such biomarkers are not covered and will be denied.
- Affected tests include but are not limited to: S100B, GFAP, UCH-L1
- Panels such as i-STAT TBI Plasma and Alinity® i TBI are not covered
Provider action
If submitting claims for concussion biomarker testing, do not expect coverage; document clinical rationale and provide prior authorization only if required by benefit — however, the policy states these tests do not meet coverage criteria.
- There is no specified prior authorization exception for these tests under this policy
- Maintain clinical documentation in the medical record if testing is performed despite expected denial
Government policy precedence
If there is a conflict between this policy and any applicable government policy (e.g., CMS Local Coverage Determinations or National Coverage Determinations, or state Medicaid rules), the government policy takes precedence and will be used to make the coverage determination.
- Check current Medicare (LCD/NCD) and state Medicaid policies for members covered under those programs
Billing and coding note
Procedure codes referenced in this policy are provided for billing reference. Coverage/denial applies per the policy statements; inclusion here does not imply coverage. CPT code 0570U and related chemistry codes are listed for reference and will be denied when used for tests that do not meet coverage criteria.
Background and Rationale
Traumatic brain injury (TBI) encompasses a spectrum of brain injuries caused by external force. Concussion describes a trauma‑induced alteration in mental status that may occur with or without loss of consciousness and represents the mild end of the TBI spectrum.
Measurement of blood or other fluid biomarkers has been proposed as an adjunct to evaluate mild TBI, but current evidence is insufficient to demonstrate that routine measurement of individual concussion markers (e.g., S100B, GFAP, UCH‑L1) or proprietary panels improves diagnosis or management in a way that meets BlueCross BlueShield of Tennessee coverage criteria. Where government policies (LCD/NCD or state Medicaid) conflict with this policy, the applicable government policy will govern determinations.
Definitions
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