CurrentColorado Rocky Mountain Health PlansPolicy N/A

Pancreatic enzyme testing reimbursement

Governs reimbursement methodology for pancreatic enzyme and related biomarker testing (lipase, amylase, trypsin, biomarkers) for Medicaid products; applies to claims submitted on UB-04 and CMS-1500 forms and affects all network and non-network providers serving plan members.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPancreatic enzyme testing reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionReimbursement considered for serum lipase (83690) for initial determination of acute pancreatitis no more than once per week across all providers for each member.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

83690lipase authorized

82150,83519,83520,83529,84145,86140not reimbursed codes

once/weekfrequency limit

Medicaidplan applicability

Coverage Criteria for Pancreatic Enzyme Testing

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Reimbursement criteria for pancreatic enzyme testing

Covered when ALL of the following are met:

Serum lipase (CPT 83690) billed for the initial determination of acute pancreatitis and no more than once per week per member across all providers.

ONE OR MORE of the following clinical signs/symptoms must be present

Mild to severe epigastric pain that begins slowly or suddenly (may spread to the back).
Nausea.
Vomiting.
Tenderness to palpation of the epigastrium.
Abdominal distention.
Hypoactive bowel sounds.
Fever.
Rapid pulse (tachycardia).
Tachypnea.
Hypoxemia.
Hypotension.
Anorexia.
Diarrhea.
Cullen sign (periumbilical ecchymosis).
Grey Turner sign (flank ecchymosis).

Once-per-week limit applies across all billing/rendering providers for each member (see definitions).

Procedure Codes and Frequency Limits

Covered CPT/Procedure CodesmixedCovered

83690

Serum lipase concentration

Not reimbursed / Excluded Procedure CodesmixedNot Covered

82150	Amylase; serum or plasma (also listed for urine amylase exclusion)
83519	Trypsin/trypsinogen assays
83520	Pancreatic elastase or related biomarker
83529	Other protease tests / biomarkers
84145	Lipase (alternate biomarker code)
86140	Immunoassay (listed biomarker)

Frequency Limitation (applies to covered code)mixed

83690

Reimbursed no more than once per week across all providers for each member

Frequency limit — lipase (83690)

Procedure code83690 (Serum lipase concentration)

Frequency limitReimbursed no more than once per week for the initial determination of acute pancreatitis

Scope of applicationLimit applies across all billing and rendering providers for each member (not per individual provider)

When reimbursedWhen billed for listed clinical conditions/signs/symptoms for initial determination of acute pancreatitis

Provider Billing Actions and Denial Risks

Prior Authorization

Prior authorization / frequency limitation for serum lipase (83690)

UnitedHealthcare will consider reimbursement of serum lipase (CPT 83690) for the initial determination of acute pancreatitis no more than once per week when billed with the listed conditions; the once‑per‑week limit applies across all billing and rendering providers for each member.

Code: 83690
Frequency limit: no more than once per week across all providers for each member

Denial Risk

Not reimbursed: amylase, trypsin/TAP, and biomarker tests

UnitedHealthcare will not consider separate reimbursement of serum amylase when submitted with lipase on the same date of service. Urinary amylase, serum or urine trypsin/trypsinogen/TAP, and the listed biomarker procedure codes are also not reimbursed for assessment, prognosis, or determination of acute pancreatitis.

Do not separately reimburse serum amylase when billed with lipase on same date (serum amylase).
Urinary amylase is not reimbursed for initial determination of acute pancreatitis.
Serum or urine trypsin/trypsinogen/TAP is not reimbursed for assessment/prognosis/determination of acute pancreatitis.
Listed biomarker procedure codes are not reimbursed for assessment/prognosis/determination of acute pancreatitis.

Definitions and Limits

Once per week limitation — definition

DefinitionOnce per week: limitation on reimbursement frequency for the specified procedure code

ApplicabilityThe once-per-week limitation is applicable across all billing and/or rendering providers (including individual providers and facilities) for each individual member

Same date of serviceSame date of service is applied across all billing and/or rendering providers for each member