ModifiedHealthfirstPolicy PO-RE-045v6

Biomarkers for Myocardial Infarction and Chronic Heart Failure Reimbursement Policy

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This reimbursement policy governs coverage of cardiac biomarker testing used to evaluate acute coronary syndrome, myocardial infarction, and chronic heart failure. It applies to providers requesting reimbursement, with criteria dependent on the individual's benefit coverage and the clinical setting.

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ModifiedHealthfirstPolicy PO-RE-045v6

Biomarkers for Myocardial Infarction and Chronic Heart Failure Reimbursement Policy

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Policy Summary

PayerHealthfirst

PolicyBiomarkers for Myocardial Infarction and Chronic Heart Failure Reimbursement Policy

Policy CodePolicy PO-RE-045v6

Change TypeModified

Effective DateNovember 1, 2026

Last ReviewJun 3, 2026

Next Review DateNot scheduled

Key ActionLimit quantitative troponin testing for acute coronary syndrome to no more than four tests within the first 72 hours at an outpatient facility capable of an adequate clinical MI evaluation.

SourceLink

POLICY UPDATE CHANGES

The policy was reviewed and updated on June 3, 2026, including updates to the background, guidelines and recommendations, and evidence-based scientific references, without modifying coverage criteria.

The June 4, 2025 revision reordered coverage criteria so criteria that are met appear before criteria that are not met and renumbered the former third criterion as the second criterion.

CPT code 86141 was added in the June 4, 2025 revision.

Up to 4Quantitative troponin coverage limit after acute coronary syndrome presentation

Up to 4/yearBNP or NT-proBNP chronic heart failure severity-assessment limit

7Listed cardiac biomarkers not covered for acute coronary syndrome MI diagnosis or prognosis

Not coveredOutpatient qualitative troponin measurement

Not coveredOutpatient ST2 or ST2 isoform analysis

Coverage Criteria

Quantitative troponin for myocardial infarction

Covered when all applicable requirements are met.

All requirements: The individual presents with signs and symptoms of acute coronary syndrome; quantitative cardiac troponin T or I is measured for diagnosis of myocardial infarction; testing is performed at an outpatient facility capable of performing an adequate clinical MI evaluation; and testing occurs within the first 72 hours following initial presentation.Up to 4 tests within 72 hours

All listed requirements apply.

BNP or NT-proBNP

Covered when at least one covered clinical indication is met.

ONE of

Diagnosis of heart failure: The individual presents with dyspnea and BNP or NT-proBNP is measured to diagnose heart failure.
Chronic heart failure severity assessment: The individual has chronic heart failure and BNP or NT-proBNP is measured to establish disease severity.Up to 4 times per year in the outpatient setting

AST, CKMB, CK, CK isoenzymes, LD/LDH, and myoglobin

Not covered for acute coronary syndrome myocardial infarction diagnosis or prognosis.

Noncovered biomarkers: For individuals presenting with signs and symptoms of acute coronary syndrome, measurement of AST/SGOT, cardiac CKMB, CK, CK isoenzymes, LD/LDH, or myoglobin for diagnosis or prognosis of myocardial infarction does not meet coverage criteria.

Other biomarkers and ST2

Not covered due to insufficient published evidence or policy exclusion.

Noncovered biomarkers and assays: For individuals presenting with signs and symptoms of acute coronary syndrome, measurement of copeptin, troponin C, C-reactive protein, heart-type fatty acid binding protein (H-FABP), or any other cardiac biomarker not listed above for diagnosis or prognosis of myocardial infarction does not meet coverage criteria; analysis of ST2 or ST2 isoforms, including Presage ST2, does not meet coverage criteria in any outpatient situation.

The policy states that published scientific literature is lacking to confirm that the applicable noncovered tests are required and beneficial for diagnosis and treatment.

For individuals presenting with signs and symptoms of acute coronary syndrome, measurement of AST/SGOT, cardiac CK-MB, CK, CK isoenzymes, LD/LDH, or myoglobin for the diagnosis or prognosis of myocardial infarction does not meet coverage criteria.

Cardiac biomarker measurement for suspected acute coronary syndrome does not meet coverage criteria when performed in an outpatient setting that cannot perform an adequate clinical myocardial infarction evaluation, including an independent laboratory or physician’s office.

In the outpatient setting, qualitative measurement of cardiac troponin T or I does not meet coverage criteria.

For individuals presenting with signs and symptoms of acute coronary syndrome, measurement of copeptin, troponin C, C-reactive protein, heart-type fatty acid binding protein (H-FABP), or any other cardiac biomarker not otherwise listed for the diagnosis or prognosis of myocardial infarction does not meet coverage criteria.

For all outpatient situations, analysis of ST2 or ST2 isoforms, including Presage ST2, does not meet coverage criteria.

The applicable noncovered tests do not meet coverage criteria because the policy identifies a lack of available published scientific literature confirming that the tests are required and beneficial for diagnosing and treating an individual’s illness. The policy also specifically excludes the listed outpatient testing situations and biomarkers from coverage.

Applicable Codes and Coding Details

Applicable CPT CodesCPT

82550	Creatine kinase (CK), (CPK); total.
82552	Creatine kinase (CK), (CPK); isoenzymes.
82553	Creatine kinase (CK), (CPK); MB fraction only.
82554	Creatine kinase (CK), (CPK); isoforms.
82725	Fatty acids, nonesterified.
83006	Growth stimulation expressed gene 2 (ST2, Interleukin 1.
83615	Lactate dehydrogenase (LD), (LDH);
83625	Lactate dehydrogenase (LD), (LDH); isoenzymes, separation and quantitation.
83874	Myoglobin.
83880	Natriuretic peptide.

1–10 of 17

1/2

CPT Code Added in Revision HistoryCPT

86141

CPT code added in the June 4, 2025 revision; code description is not provided in this document window.

Quantitative troponin frequency

TestQuantitative cardiac troponin T or I for myocardial infarction diagnosis

Clinical settingOutpatient facility capable of performing an adequate clinical MI evaluation

Frequency limitUp to four times within the first 72 hours following initial presentation

BNP/NT-proBNP chronic heart failure frequency

Diagnostic indicationDiagnose heart failure in an individual presenting with dyspnea

Chronic heart failure indicationEstablish disease severity in an individual with chronic heart failure

Provider and Billing Actions

Note

Quantitative Troponin: Acute Coronary Syndrome

For individuals presenting with signs and symptoms of acute coronary syndrome, quantitative cardiac troponin T or I measurement for diagnosis of myocardial infarction is covered when performed at an outpatient facility capable of an adequate clinical MI evaluation, subject to frequency limits.

Covered up to four times within the first 72 hours following initial presentation.
The qualifying presentation is signs and symptoms of acute coronary syndrome.

Note

BNP/NT-proBNP: Indications and Limits

BNP or NT-proBNP measurement is covered for qualifying heart failure evaluation and disease-severity assessment, subject to the applicable outpatient frequency limit.

To diagnose heart failure in an individual presenting with dyspnea.
To establish disease severity in an individual with chronic heart failure, up to four times per year in the outpatient setting.

Policy Background

Cardiac biomarkers are biochemical markers released into the blood from injured myocardial tissue during acute and chronic cardiac conditions, including myocardial infarction and heart failure. In acute evaluation, cardiac troponin and CK-MB have been commonly used, with cardiac troponin I and T providing cardiac-specific measurements. Natriuretic peptides, including BNP and NT-proBNP, may support the diagnosis and prognosis of heart failure, while ST2 may reflect myocardial stress and fibrosis. Acute coronary syndromes comprise a continuum ranging from angina and reversible injury to unstable angina and myocardial infarction.

Clinical Definitions

Cardiac biomarkers

DefinitionBiochemical markers released into the blood from injured myocardial tissue

Clinical conditionsReleased during acute and chronic conditions such as myocardial infarction or heart failure

MeasurementBecome elevated in blood after a certain period and can be measured

Acute coronary syndrome/myocardial infarction signs and symptoms

Typical symptomsIschemic chest pain, including pain radiating to the arms, jaw, neck, shoulders, upper abdomen, or back

Associated symptomsShortness of breath, diaphoresis, nausea, vomiting, dizziness, lightheadedness, clamminess, and fatigue

Policy Summary

PayerHealthfirst

PolicyBiomarkers for Myocardial Infarction and Chronic Heart Failure Reimbursement Policy

Policy CodePolicy PO-RE-045v6

Change TypeModified

Effective DateNovember 1, 2026

Last ReviewJun 3, 2026

Next Review DateNot scheduled

Key ActionLimit quantitative troponin testing for acute coronary syndrome to no more than four tests within the first 72 hours at an outpatient facility capable of an adequate clinical MI evaluation.

SourceLink

On This Page

Outpatient frequency limitUp to four times per year for the chronic heart failure disease-severity indication

TriageTrue high-sensitivity troponin I study thresholds

AssayTriageTrue high-sensitivity cardiac troponin I

Rule-out thresholdLess than 3 ng/L

Rule-in thresholdGreater than 60 ng/L

Approximate BNP and NT-proBNP equivalence

BNP referenceGreater than 100 pg/mL

Approximate equivalentNT-proBNP greater than 900 pg/mL

RelationshipNT-proBNP greater than 900 pg/mL is roughly equivalent to BNP greater than 100 pg/mL

sST2 acute aortic dissection study cutoff

BiomarkerSoluble ST2 (sST2)

Study populationPatients evaluated for acute aortic dissection among causes of acute chest pain

Study cutoff34.6 ng/mL

Cardiac troponin myocardial-injury threshold

BiomarkerCardiac troponin

Myocardial-injury thresholdAbove the assay-specific 99th-percentile upper reference limit

Assay considerationThe upper reference limit is assay-specific

Repeat high-sensitivity cardiac troponin testing interval

TestHigh-sensitivity cardiac troponin assay

When to repeatWhen the initial value is nondiagnostic

Repeat interval1–2 hours after the initial test

Repeat conventional cardiac troponin testing interval

TestConventional cardiac troponin assay

When to repeatWhen the initial value is nondiagnostic

Repeat interval3–6 hours after the initial test

Single-value high-sensitivity cardiac troponin pathway

PathwayClinical decision pathway incorporating a single high-sensitivity cardiac troponin value

Timing requirementObtain the sample at least 3 hours after symptom onset

Clinical useSupports more rapid myocardial infarction rule-in or rule-out

Post-PCI or post-CABG CK-MB threshold with normal baseline

ProcedurePCI or CABG

Baseline conditionNormal CK-MB baseline

ThresholdPeak CK-MB within 48 hours greater than 10× the local laboratory ULN, or greater than 5× ULN with new pathologic Q-waves in more than 2 contiguous leads or new persistent LBBB

Post-PCI cardiac troponin threshold when CK-MB is unavailable and baseline cTn is normal

When appliedCK-MB is unavailable and baseline cardiac troponin is normal

TimingCardiac troponin I or T measured within 48 hours of PCI

ThresholdGreater than 70× the local laboratory ULN, or greater than 35× ULN with new pathologic Q-waves in more than 2 contiguous leads or new persistent LBBB

Post-revascularization biomarker threshold with elevated baseline biomarkers

Stable or falling baseline biomarkersThe CK-MB or cardiac troponin rises by an absolute increment equal to the applicable threshold from the most recent pre-procedure level

Unstable baseline biomarkersThe biomarker rises by that absolute increment plus new ST-segment elevation or depression

Additional clinical findingsFor unstable or nonfalling biomarkers, signs consistent with clinically relevant MI are also required, such as new or worsening heart failure or sustained hypotension

High-sensitivity troponin rule-out threshold and assay-specific limit-of-detection guidance

Rule-out approachUse a threshold at or near the assay’s limit of detection

Assay dependenceThe limit of detection varies depending on the assay used

Alternative guidanceUse the assay-specific 99th-percentile threshold or a threshold at or near the limit of detection

Serial high-sensitivity troponin timing

Initial sampleObtain at initial assessment

Second sampleObtain 30 minutes to 3 hours after the initial sample

Serial testing useApply when multiple samples are taken

Denial Risk

Outpatient Setting Must Support Adequate MI Evaluation

For individuals presenting with signs and symptoms of acute coronary syndrome, cardiac biomarker testing for diagnosis or prognosis of myocardial infarction is not covered when performed in an outpatient setting that cannot provide an adequate clinical MI evaluation.

Examples include an independent laboratory or physician's office without adequate MI evaluation capability.

Denial Risk

Qualitative Outpatient Troponin Not Covered

Qualitative measurement of cardiac troponin T or I in the outpatient setting does not meet coverage criteria.

Use of a qualitative outpatient troponin test is not covered.

Denial Risk

Outpatient ST2 Testing Not Covered

Analysis of ST2 or ST2 isoforms does not meet coverage criteria in any outpatient situation, including testing performed with Presage ST2.

Applies to all outpatient settings and indications.

Billing Rule

Compliant Coding and Billing Required

Follow Healthfirst, CMS, NCCI, AMA, CPT, HCPCS, ICD-10, revenue-coding, modifier, and applicable state and federal billing requirements. Noncompliant coding, billing, or reimbursement practices may result in claim denial or recoupment of amounts previously paid.

Apply appropriate modifiers and coding principles.
Account for global surgery, multiple-procedure, medically unlikely, duplicate, and other applicable claim edits.
Claims may be denied, and previously paid amounts may be recouped, for noncompliance.

Atypical presentations

Dyspnea alone, weakness, nausea or vomiting, epigastric discomfort, palpitations, syncope, or cardiac arrest

Acute coronary syndrome definition and clinical continuum

DefinitionA continuum of acute coronary events

ProgressionMay progress from angina and reversible injury to unstable angina and myocardial infarction with extensive tissue necrosis

Common causeAtherosclerotic coronary artery disease with rupture of an atherosclerotic plaque

Myocardial infarction definition and supporting findings

Clinical evidenceTypical clinical symptoms, suggestive ECG changes, or imaging evidence of new myocardial loss or a new regional wall abnormality

Biomarker requirementA rise and/or fall of cardiac biomarkers supports the diagnosis

Disease processMyocardial infarction results in cardiac injury and extensive tissue necrosis

Heart failure definition

DefinitionA complex clinical syndrome resulting from structural or functional impairment of ventricular filling or ejection of blood

Common symptomsDyspnea and fatigue, which may limit exercise tolerance

Other manifestationsFluid retention, edema, dyspnea, or fatigue may occur

Cardiac troponin definition and cardiac-specific isoforms

Cardiac-specific isoformsCardiac troponin I and cardiac troponin T

Clinical roleUsed as biomarkers of cardiac tissue injury

Troponin CHas no role as a cardiac biomarker

ST2 definition and relationship to myocardial stress and fibrosis

FamilyST2 is part of the interleukin-1 receptor family

IsoformsSoluble ST2 (sST2) and ST2L

Clinical relationshipsST2 is associated with myocardial stress and fibrosis

BNP and NT-proBNP definitions and relationship

BNPReleased primarily from the left ventricle after proBNP is cleaved

NT-proBNPThe related N-terminal fragment produced when proBNP is cleaved

Clinical relationshipBoth may assist in heart-failure diagnosis and prognosis

Myocardial injury definition based on cardiac troponin concentration

DefinitionA cardiac troponin concentration above the assay-specific 99th-percentile upper reference limit

Reference limitThe upper reference limit is specific to the assay

InterpretationAn elevated concentration indicates myocardial injury but does not by itself establish acute myocardial infarction

Acute myocardial infarction definition using troponin dynamics and supporting evidence

Troponin patternA rising and/or falling pattern of cardiac troponin values

ThresholdAt least one value is above the 99th-percentile upper reference limit

Supporting evidenceClinical evidence of myocardial ischemia is also required

MINOCA definition and diagnostic criteria

MeaningMyocardial infarction with non-obstructive coronary arteries

Diagnostic frameworkCriteria follow the Fourth Universal Definition of Myocardial Infarction

Troponin criterionA rise or fall in cardiac troponin with at least one value above the 99th-percentile reference limit

High-sensitivity cardiac troponin definition and clinical characteristics

Assay characteristicGreater sensitivity and negative predictive value than conventional troponin assays

Detection capabilityCan detect myocardial injury earlier after symptom onset

Clinical useSupports more rapid myocardial infarction rule-in or rule-out

sST2 definition and association with heart-failure prognosis

Full nameSoluble suppression of tumorigenesis-2

Clinical associationAssociated with heart-failure prognosis

Potential useMay support diagnosis of heart failure with preserved ejection fraction and correlate with left-ventricular end-diastolic pressure