CurrentColorado Rocky Mountain Health PlansPolicy 2025R8214B

Cardiovascular Risk Biomarker Testing — Medicare Advantage Reimbursement

Defines UnitedHealthcare Medicare Advantage reimbursement stance for cardiovascular disease risk assessment tests billed on CMS 1500 and UB04 forms, and applies to UnitedHealthcare Medicare Advantage plans and network providers.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCardiovascular Risk Biomarker Testing — Medicare Advantage Reimbursement

Policy CodePolicy 2025R8214B

Change TypeNo material change

Effective Date

Next Review Date

Key ActionDo not bill or expect reimbursement for cardiovascular disease panel testing that includes multiple individual biomarkers; follow fee-for-service coding on CMS 1500 or UB04 forms and refer to benefit documents for prior authorization requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Apo B covered

1Lp(a) lifetime

1CRP excluded

0Novel biomarkers

0%Panel testing reimbursed

6Procedure codes listed

Coverage Criteria and Exclusions

Apolipoprotein B coverage

Apolipoprotein B (Apo B) coverage — Covered when ANY of the following conditions are present:

ANY of the following

Hypertriglyceridemia
Diabetes mellitus
Obesity or metabolic syndrome
Dyslipidemias (such as very low LDL-C)
On lipid therapy
Familial dysbetalipoproteinemia or familial combined hyperlipidemia

Homocysteine exclusion

Homocysteine testing — Exclusion

ALL of the following

Homocysteine testing is not considered reimbursable when performed as a screening study to evaluate cardiovascular disease risk.

Novel biomarkers exclusion

Novel lipid and non-lipid biomarkers — Exclusion

ALL of the following

UnitedHealthcare will not consider reimbursement of novel lipid and non-lipid biomarker testing for cardiovascular disease risk assessment.
Examples include but are not limited to: apolipoprotein AI, apolipoprotein E, B-type natriuretic peptide, cystatin C, fibrinogen, leptin, LDL subclass, HDL subclass.

Procedure Codes and Frequency Limits

Referenced procedure codes and descriptionsCPT

82172	Apolipoprotein B
83695	Lipoprotein Lp(a)
86140	Conventional C-Reactive Protein (CRP)
83090	Homocysteine
82610 / 83700 etc.	Various novel biomarker codes listed (see policy for mapping)
0052U	Cardiovascular disease panel testing

Referenced procedure codes and descriptions (expanded novel biomarkers)CPT

82610	(see mapping to 83700, 83701, 83704, 83719, 83722)
83880	(see mapping to 85384, 85415, 0541U, etc.)

Cardiovascular panel codeCPTNot Covered

0052U

Cardiovascular disease panel testing (multiple individual biomarkers) — as listed in policy

Lp(a) frequency

FrequencyOnce per lifetime for individuals age 19 or older

Applicable testLipoprotein Lp(a) — procedure code 83695

Age restrictionApplies to individuals age 19 and older

Policy source noteCoverage limited to once-per-lifetime per UnitedHealthcare Medicare Advantage reimbursement policy

Provider Billing, Documentation, and Denial Notices

Documentation Required

Form applicability and prior authorization note

This reimbursement policy applies to services billed on UB04 (CMS 1450) and CMS 1500 forms or their electronic equivalents. UnitedHealthcare Medicare Advantage reimbursement policies do not include prior authorization notations; providers must refer to the enrollee's benefit coverage documents or contact customer service for prior authorization requirements and are responsible for submission of accurate claims using the codes that correctly describe the services provided.

Policy applies to all Medicare Advantage products and network provider services reported using UB04 and CMS 1500 forms or electronic equivalents.
UnitedHealthcare Medicare Advantage reimbursement policies do not include notations regarding prior authorization requirements; check benefit documents or call customer service for prior auth details.
Providers are responsible for accurate claim submission and using codes that correctly describe services.

Scope, Definitions, and Coding Notes

Applicability

Plan applicabilityApplies to UnitedHealthcare Medicare Advantage Plans

Form typesApplies to services billed on UB04 (CMS 1450) and CMS 1500 forms or electronic equivalents

ScopePolicy governs editing and reimbursement for cardiovascular disease risk assessment services; may be interpreted with discretion

Procedure code note

Purpose of listed codesProcedure codes appearing in policy documents are included only as a general reference tool

CompletenessCodes may not be all‑inclusive

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCardiovascular Risk Biomarker Testing — Medicare Advantage Reimbursement

Policy CodePolicy 2025R8214B

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

On This Page

Denial Risk

Cardiovascular disease panel testing — denial of reimbursement

UnitedHealthcare will not consider reimbursement for cardiovascular disease panel testing that consists of multiple individual biomarkers for cardiovascular disease risk assessment.

Procedure code example listed in policy: 0052U (cardiovascular disease panel testing).
Claims for multi-analyte cardiovascular risk panels are at high risk for denial and should not be billed for reimbursement.

References to CPT or other sources are for definitional purposes and do not imply a right to reimbursement

Cardiovascular disease panel testing (multiple individual biomarkers)

DefinitionCardiovascular disease panel testing consisting of multiple individual biomarkers: multi‑analyte panels used for cardiovascular disease risk assessment

Coverage stanceUnitedHealthcare will not consider reimbursement for these panels

Example procedure code0052U (cardiovascular disease panel testing) listed in policy