DraftBlue Cross Blue Shield - TexasPolicy CPCPLABO46

Biomarkers for Myocardial Infarction and Chronic Heart Failure

Reimbursement and coding policy describing when measurement of cardiac biomarkers (troponins, BNP/NT‑proBNP, and others) is reimbursable in outpatient settings and which biomarker tests are not reimbursable; applies to providers submitting claims to Blue Cross and Blue Shield of Texas.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyBiomarkers for Myocardial Infarction and Chronic Heart Failure

Policy CodePolicy CPCPLABO46

Change TypeRevised — reimbursement info rearrangedcode 86141 added

Effective DateNov 7, 2025

Next Review Date

Key ActionSubmit complete documentation; claims may be reviewed and additional documentation may be requested.

SourceLink

POLICY UPDATE CHANGES

Document updated with literature review and changes to Reimbursement Information including rearranged statements and addition of code 86141.

New policy created on 09/13/2024 with effective date 01/01/2025.

up to fourtroponin reimbursable in first 72 hours for acute coronary syndrome

up to four/yrBNP/NT‑proBNP reimbursable (outpatient)

14+example procedure codes included

1code added (86141)

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Outpatient Biomarker Reimbursement Criteria

Outpatient biomarker reimbursement criteria

Covered when the following specific conditions are met:

Outpatient biomarker reimbursement criteria

Troponin (acute presentation)

Quantitative cardiac troponin (troponin T or I) for diagnosis of myocardial infarction (MI) may be reimbursable when performed at an outpatient facility capable of performing an adequate clinical MI evaluation.<= 4 times within first 72 hours following initial presentation
Applies to individuals presenting with signs and symptoms of acute coronary syndrome (see NOTE 1).
Qualitative measurement of cardiac troponin (troponin T or I) in the outpatient setting is not reimbursable.
Not reimbursable regardless of setting in outpatient claims.

Other troponin-related and setting limitations

Measurement of cardiac biomarkers in an outpatient setting that is not capable of performing adequate clinical MI evaluation (e.g., independent lab or physician's office) is not reimbursable for individuals presenting with signs and symptoms of acute coronary syndrome.
Facility capability must allow adequate clinical MI evaluation.

BNP/NT-proBNP (heart failure)

Measurement of B-type natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP) may be reimbursable to diagnose heart failure in individuals presenting with dyspnea.
Outpatient use for diagnostic evaluation.
Measurement of BNP or NT-proBNP may be reimbursable to establish disease severity in individuals with chronic heart failure.<= 4 times per year in the outpatient setting
Annual outpatient frequency limit applies.

Other cardiac biomarkers not reimbursable

The following biomarkers are not reimbursable for diagnosis and/or prognosis of MI in the outpatient setting: copeptin, troponin C, C-reactive protein, heart-type fatty acid binding protein (H‑FABP), ST2/Presage ST2 and other listed cardiac biomarkers.

Coding and claims note

Procedure code inclusion is illustrative and inclusion does not guarantee coverage; claims remain subject to coding guidelines and plan/contract terms and review.

Reference to symptoms note

Criteria referencing reimbursement for acute coronary syndrome apply when individuals present with signs and symptoms of acute coronary syndrome (see NOTE 1).

Block end: End of outpatient biomarker reimbursement criteria.

Procedure Codes and Quantity Limits

Procedure codes referencedCPT

82550
82552
82553
82554
82725
83006
83615
83625
83874
83880

1–10 of 17

1/2

Added codeCPT

86141

Code added to reimbursement information (document does not provide description)

inv-04: troponin_repeat_limit_72h

Numeric limitUp to 4 quantitative troponin measurements within the first 72 hours following initial presentation

Applicable test typeQuantitative cardiac troponin (T or I)

Setting requirementTest must be performed at an outpatient facility capable of performing an adequate clinical MI evaluation

inv-05: BNP_outpatient_limit_per_year

Numeric limitUp to 4 BNP or NT‑proBNP measurements per year in the outpatient setting

Intended useTo establish disease severity in individuals with chronic heart failure

Documentation, Prior Authorization, and Reimbursement Notices

Documentation Required

Documentation and Claim Review

Providers must submit accurate and complete documentation supporting services and code combinations from HIPAA‑approved code sets. Claims are subject to review and audit; upon request providers should furnish any additional documentation to substantiate medical necessity, coding, and billing. Claim adjudication may also be influenced by benefit terms, provider contract language, clinical payment and coding policies, and code‑editing software logic.

Submit supporting medical records, test results, and clinical justification when requested.
Claims may be audited and are subject to code‑edit protocols and medical policy review.

Prior Authorization

Prior Authorization / Reimbursement Limit for Troponin

Prior authorization is not required universally for troponin testing, but reimbursement for quantitative cardiac troponin (troponin T or I) for individuals presenting with signs and symptoms of acute coronary syndrome is limited to up to four (4) measurements within the first 72 hours following the initial presentation when testing is performed in an outpatient facility capable of providing an adequate clinical MI evaluation. Qualitative troponin testing in the outpatient setting is not reimbursable. Measurement of cardiac biomarkers performed in outpatient settings that are not capable of adequate clinical MI evaluation (e.g., independent labs or physician offices) is not reimbursable.

Definitions, Clinical Context, References, and History

inv-09: Acute Coronary Syndrome/Myocardial Infarction signs and symptoms

Common chest pain descriptorsSqueezing, tightness, pressure, constriction, crushing, burning, heartburn, fullness or band-like sensation in the chest; pain may radiate to jaw, arms, shoulders, back

Associated featuresDiaphoresis, nausea, vomiting, dizziness, lightheadedness, clamminess, fatigue

Atypical presentationsDyspnea alone, weakness, epigastric pain or discomfort, palpitations, syncope, or cardiac arrest

inv-10: BNP/NT‑proBNP

DefinitionMeasurement of B-type natriuretic peptide (BNP) or N-terminal proBNP (NT‑proBNP) in the outpatient setting

Primary outpatient purposeTo establish disease severity in individuals with chronic heart failure (reimbursable up to four times per year)

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyBiomarkers for Myocardial Infarction and Chronic Heart Failure

Policy CodePolicy CPCPLABO46

Change TypeRevised — reimbursement info rearrangedcode 86141 added

Effective DateNov 7, 2025

Next Review Date

Key ActionSubmit complete documentation; claims may be reviewed and additional documentation may be requested.

SourceLink

On This Page

Also reimbursableTo diagnose heart failure in individuals presenting with dyspnea

Quantitative troponin (T or I) reimbursable: up to 4 times within first 72 hours after initial presentation for acute coronary syndrome when performed in an outpatient facility able to provide adequate clinical MI evaluation.
Qualitative troponin assays in outpatient settings: not reimbursable.
Cardiac biomarker testing performed in outpatient settings without adequate clinical MI evaluation capability: not reimbursable.

Billing Rule

Reimbursement Information - Code Addition

Reimbursement information updated — code addition noted. Added CPT code 86141 to the reimbursement information. Providers should include the appropriate code(s) on claims and retain supporting documentation.

Added code: CPT 86141.

Diagnostic useMay be reimbursable to diagnose heart failure in individuals presenting with dyspnea

inv-11: References

ESC guidelinesMultiple ESC guideline references cited, including 2016, 2019, 2021, 2023 and 2024 guideline publications

ACC/AHA statementsACC/AHA focused updates and guideline documents for heart failure and acute coronary syndromes are cited (eg 2017 update; 2025 ACC/AHA guideline for ACS)

NICE guidanceNICE guidance cited for high-sensitivity troponin tests and chest pain/chronic heart failure diagnosis

AHA scientific statements and consensusAmerican Heart Association scientific statements on biomarkers and heart failure are included (eg 2017, 2019)

inv-12: Policy Update History

Most recent update07/25/2025 effective date; document updated with literature review and changes to Reimbursement Information (rearranged statements and added code 86141)

Prior entry09/13/2024 effective date; new policy created (summary of changes effective 01/01/2025)

Nature of changesRearranged reimbursement statements, addition of CPT/HCPCS code 86141, and revision of references