CurrentBlue Cross Blue Shield - TexasPolicy CPCPLABO58

Venous and Arterial Thrombosis Risk Testing

Reimbursement and lab management criteria for thrombophilia (venous and arterial thrombosis) risk testing, specifying when plasma and genetic tests may be reimbursable and when testing is not reimbursable; applies to providers billing Blue Cross Blue Shield - Texas plans.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyVenous and Arterial Thrombosis Risk Testing

Policy CodePolicy CPCPLABO58

Change TypeMaterial update to reimbursement informationreferences revised

Effective DateAug 8, 2025

Next Review Date

Key ActionSubmit accurate documentation and use valid industry-standard codes; claims may be reviewed and require additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

Reimbursement Information updated to specify that for individuals with warfarin-induced skin necrosis and for infants who develop neonatal purpura fulminans, plasma testing for protein C deficiency and protein S deficiency may be reimbursable.

References list was revised.

1.0policy version

2025-08-08plan effective date

6+reimbursable plasma situations

7procedure codes

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyVenous and Arterial Thrombosis Risk Testing

Policy CodePolicy CPCPLABO58

Change TypeMaterial update to reimbursement informationreferences revised

Effective DateAug 8, 2025

Next Review Date

Key ActionSubmit accurate documentation and use valid industry-standard codes; claims may be reviewed and require additional documentation upon request.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Reimbursement criteria and exclusions

Plasma and genetic testing reimbursement criteria and exclusions for thrombophilia risk evaluation.

ALL of the following

ONE of the following clinical situations
- Individuals without recurrent venous thromboembolism/NTE risk factors who have experienced a DVT in unusual sites (hepatic, mesenteric, or cerebral veins).
- Individuals less than 50 years of age who have experienced any deep venous thrombosis (DVT).
- Individuals who have experienced a DVT and who have a strong family history of thrombotic disease.
- First- and second-degree relatives of individuals who have experienced a deep venous thrombosis before 50 years of age.
- Individuals who are pregnant or taking oral contraceptives and who have experienced a DVT.
- Women under the age of 50 who smoke and who have suffered a myocardial infarction (MI).
- Pediatric individuals who have suffered a pediatric arterial ischemic stroke.
- Before the administration of oral contraceptives, targeted testing of individuals with a personal or family history of DVT.
Plasma testing for protein C deficiency, protein S deficiency, and antithrombin III deficiency should be performed at least six weeks after the acute thrombotic event and while the patient is not taking anticoagulants (timing prerequisite).

ALL of the following

For individuals with warfarin-induced skin necrosis, plasma testing for protein C deficiency and protein S deficiency may be reimbursable.
For infants who develop neonatal purpura fulminans, plasma testing for protein C deficiency and protein S deficiency may be reimbursable.

ALL of the following

Venous thrombosis risk testing for superficial venous thrombosis, including superficial thrombophlebitis and varicosities, is not reimbursable.
All activated protein C/protein C resistance assays are not reimbursable in any situation stated.
DVT risk testing performed as part of a pre-transplant evaluation is not reimbursable.

ALL of the following

In addition to plasma testing for protein C, protein S, and antithrombin III deficiencies, risk factor testing for individuals suspected of having hereditary and/or acquired thrombophilia should include genetic testing for Factor V Leiden and Prothrombin G20210A mutations.

Documentation and Claims Submission

Documentation Required

Documentation and claims submission requirements

Providers are responsible for submitting accurate documentation of services performed and must bill using valid industry-standard code sets. Claims are subject to code edit protocols and review against benefit coverage, provider contract language, medical and clinical payment policies, and coding software logic; additional documentation must be provided upon request.

Submit claims using valid code combinations from HIPAA‑approved code sets (e.g., CPT, HCPCS, ICD‑10).
Code claims according to industry standard coding guidelines (Uniform Billing, AMA CPT, CMS NCCI edits, etc.).
Be prepared to provide additional documentation upon request during claim review.

Relationship and Testing Prerequisites

First- and second-degree relatives

First-degree relativesParents, full siblings, and children of the individual

Second-degree relativesGrandparents, aunts, uncles, nieces, nephews, grandchildren, and half-siblings of the individual

Use in guidanceDefined relatives are referenced for reimbursement criteria (e.g., testing of relatives of individuals with DVT before age 50)

Plasma testing timing and prerequisites

Precedence to molecular testingPlasma clotting inhibitor amount and function testing should be performed prior to any molecular testing

Relevant plasma testsProtein C, protein S, and antithrombin III assays

Timing relative to acute event and anticoagulationPerform plasma testing at least six weeks after an acute thrombotic event and while patient is not taking anticoagulants

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85301
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OpenPayer

Venous and Arterial Thrombosis Risk Testing

Reimbursement Criteria and Exclusions

Procedure Codes and Testing Timing

Documentation and Claims Submission

Relationship and Testing Prerequisites