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    v1.0.30
    OpenPayerPolicy UpdatesLaboratory/PathologyHealthfirst TBI Biomarker Coverage | OpenPayer
    Ask Trek AI about this page
    ModifiedHealthfirstPolicy PO-RE-125v3

    Serum Testing for Evidence of Mild Traumatic Brain Injury

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    This policy governs reimbursement for blood, saliva, cerebrospinal fluid, and biomarker panel testing used to evaluate mild traumatic brain injury, subject to the member's applicable benefit coverage.

    Policy Summary
    PayerHealthfirst
    PolicySerum Testing for Evidence of Mild Traumatic Brain Injury
    Policy CodePolicy PO-RE-125v3
    Change TypeModified
    Effective DateNovember 1, 2026
    Next Review DateNot specified
    Key ActionDo not submit claims for concussion-marker testing or TBI biomarker panels because they do not meet coverage criteria.
    SourceLink
    POLICY UPDATE CHANGES

    The June 3, 2026 revision updated the background, guidelines, recommendations, and evidence-based scientific references without modifying coverage criteria.

    The June 4, 2025 revision moved panel testing from coverage criterion 1 into a new coverage criterion 2, which states that panels designed to measure traumatic brain injury biomarkers do not meet coverage criteria.

    CPT code 0570U was added effective July 1, 2025.

    Not coveredConcussion-marker testing
    Not coveredTBI biomarker panels
    3Applicable procedure codes

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    0570UAdded CPT code

    Coverage Criteria

    Concussion-marker testing

    The following does not meet coverage criteria due to a lack of available published scientific literature confirming that the test(s) is/are required and beneficial for the diagnosis and treatment of an individual's illness.

    For the evaluation of mild traumatic brain injury (TBI), measurement of concussion markers (e.g., S100B, GFAP, and UCH-L1) in the blood, saliva, and/or cerebrospinal fluid (CSF) DOES NOT MEET COVERAGE CRITERIA.

    TBI biomarker panels

    Panels designed to measure biomarkers of TBI (e.g., i-STAT TBI Plasma, Alinity® i TBI) DO NOT MEET COVERAGE CRITERIA.

    Not covered biomarker panels

    Not covered: panels designed to measure traumatic brain injury (TBI) biomarkers, including i-STAT TBI Plasma and Alinity® i TBI.

    For the evaluation of mild traumatic brain injury (TBI), measurement of concussion markers (e.g., S100B, GFAP, and UCH-L1) in the blood, saliva, and/or cerebrospinal fluid (CSF) DOES NOT MEET COVERAGE CRITERIA.

    Panels designed to measure biomarkers of TBI (e.g., i-STAT TBI Plasma, Alinity® i TBI) DO NOT MEET COVERAGE CRITERIA.

    Panels designed to measure traumatic brain injury biomarkers, including i-STAT TBI Plasma and Alinity® i TBI, DO NOT MEET COVERAGE CRITERIA.

    The testing does not meet coverage criteria because available published scientific literature does not confirm that the testing is required and beneficial for the diagnosis and treatment of an individual's illness.

    Applicable Codes

    Applicable CPT CodesCPT
    83516Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method.
    84999Unlisted chemistry procedure.
    0570UNeurology (traumatic brain injury), analysis of glial fibrillary acidic protein (GFAP) and ubiquitin carboxylterminal hydrolase L1 (UCHL1), immunoassay, whole blood or plasma, individual components reported with the overall result of elevated or non-elevated based on threshold comparison. Proprietary test: i-STAT TBI Lab/Manufacturer: Abbott Point of Care.
    Added CPT CodeCPT
    0570UAdded effective July 1, 2025.

    Provider Actions and Billing Guidance

    Denial Risk

    Mild TBI Concussion-Marker Testing

    For evaluation of mild traumatic brain injury (TBI), concussion-marker testing in blood, saliva, and/or cerebrospinal fluid (CSF) does not meet coverage criteria because published scientific literature is insufficient to confirm that these tests are required and beneficial for diagnosing or treating an individual's illness.

    • Affected markers include S100B, GFAP, and UCH-L1, as well as related concussion markers.
    • Do not submit these tests as covered services for mild TBI; claims may be denied.
    Denial Risk

    TBI Biomarker Panels

    Panels designed to measure TBI biomarkers do not meet coverage criteria because available published scientific literature does not establish that the testing is required and beneficial for diagnosis or treatment.

    • Examples include i-STAT TBI Plasma and Alinity® i TBI.
    • Other TBI biomarker panels are subject to the same coverage limitation.

    Clinical Background

    Traumatic brain injury results from external forces applied to the brain and may produce contusions, hematomas, diffuse axonal injury, edema, and other molecular injury processes. Concussion is a trauma-induced alteration in mental status associated with mild traumatic brain injury and may occur with or without loss of consciousness. Biomarkers such as S100B, GFAP, and UCH-L1 have been investigated as diagnostic or prognostic adjuncts, but concerns remain regarding their specificity and clinical usefulness.

    Definitions

    Traumatic brain injury (TBI)
    DefinitionPathologic injury to the brain resulting from external forces or trauma.
    Concussion
    DefinitionTrauma-induced alteration in mental status after mild traumatic brain injury; loss of consciousness may or may not occur.

    Covered Indications and Clinical Context

    FDA-Described Use of TBI Biomarker Testing

    Covered for the following clinical use when all criteria are met:

    All of the following

    • The patient is 18 years of age or older.>= 18 years
    • The patient has suspected mild traumatic brain injury.
    • The Glasgow Coma Scale score is 13-15.GCS 13-15
    • Testing is performed within 12 hours of the injury.Within 12 hours of injury

    Not Covered Services

    Testing for S100B, GFAP, and UCH-L1 concussion markers in blood, saliva, and/or cerebrospinal fluid for evaluation of mild traumatic brain injury is not covered.

    TBI biomarker panels, including i-STAT TBI Plasma and Alinity i TBI, are not covered.

    Panels designed to measure traumatic brain injury biomarkers, including i-STAT TBI Plasma and Alinity® i TBI, do not meet coverage criteria and are not covered.

    Policy Summary
    PayerHealthfirst
    PolicySerum Testing for Evidence of Mild Traumatic Brain Injury
    Policy CodePolicy PO-RE-125v3
    Change TypeModified
    Effective DateNovember 1, 2026
    Next Review DateNot specified
    Key ActionDo not submit claims for concussion-marker testing or TBI biomarker panels because they do not meet coverage criteria.
    SourceLink
    On This Page
    Coverage CriteriaApplicable CodesProvider Actions and Billing GuidanceClinical BackgroundDefinitionsCovered Indications and Clinical ContextNot Covered Services
    Denial Risk

    Noncompliant Coding or Billing

    Failure to follow applicable coding, billing, reimbursement, modifier, and national guidelines may result in denial and/or recoupment of claim payment. Providers should apply Healthfirst claim edits and applicable benefit, regulatory, and participation-agreement requirements when submitting professional and institutional claims.

    • Follow CMS-aligned National Correct Coding Initiative (NCCI), National and Local Coverage Determination (NCD/LCD), appropriate modifier, global surgery, multiple procedure reduction, medically unlikely edit, and duplicate-claim rules.
    • Apply AMA and CMS CPT, HCPCS, and ICD-10 principles; National Uniform Billing Editor revenue-coding guidance; CPT Assistant guidance; New York State coding, billing, and payment policies; and applicable national physician specialty academy coding and clinical guidelines.
    • Reimbursement is not guaranteed by this policy; determinations also depend on the applicable evidence of coverage, state and federal requirements or mandates, and the provider's participation agreement.
  1. The test is used with other clinical information to assist in assessing the need for radiologic imaging, such as CT or MRI.

    2. Blood-Based Biomarker Use When Brain CT Risk Is Low but Nonzero

    Covered for suspected traumatic brain injury when all of the following clinical conditions are met:

    All of the following

    • The patient has suspected traumatic brain injury.
    • The Glasgow Coma Scale score is 13-15.GCS 13-15
    • The patient meets clinical criteria for brain CT imaging under applicable brain CT imaging decision rules.
    • The clinician assesses a low but nonzero risk for traumatic intracranial hemorrhage.

      Blood-based biomarkers may be used to help rule out the need for brain CT imaging.