CurrentHumanaPolicy LAB2023006

Laboratory - Venous and Arterial Thrombosis Testing

Payment and coverage guidance for laboratory testing related to venous and arterial thrombosis for Humana Medicare Advantage products, specifying reimbursable and non-reimbursable tests and situations.

Policy Summary

PayerHumana

PolicyLaboratory - Venous and Arterial Thrombosis Testing

Policy CodePolicy LAB2023006

Change TypeNo material change

Effective Date03/2023

Next Review Date

Key ActionDo not submit claims for APC resistance assay (CPT 85307) or the proprietary multi-gene panel (HCPCS 0278U) as they are not reimbursable; follow plan/LCD guidance for 0278U prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Multiple listedReimbursable clinical situations

3 tests/panelsExplicitly non-reimbursable tests

Medicare AdvantagePlan type governed

MultipleOriginal Medicare LCDs cited

Coverage Criteria — Plasma and Related Testing

inv-01: Covered indications for plasma testing (protein C/S, antithrombin III)

Plasma testing for protein C, protein S, and antithrombin III is reimbursable when any one of the following clinical indications is present:

Reimbursable clinical indications: Plasma testing for protein C deficiency (CPT 85302, 85303), protein S deficiency (CPT 85305, 85306), and antithrombin III deficiency (CPT 85300, 85301) is reimbursable for any of: acute coronary syndromes including myocardial infarction; any deep venous thrombosis; arterial ischemic stroke; deep phlebothrombosis in pregnancy; disseminated intravascular coagulation (defibrination syndrome); pulmonary embolism; relatives of individuals with deep venous thrombosis.

Listed as reimbursable in policy text.

inv-02: Additional reimbursable indications for protein C or S

Reimbursable for protein C/S: Plasma testing for protein C deficiency (CPT 85302, 85303) or protein S deficiency (CPT 85305, 85306) is reimbursable for any of: neonatal purpura fulminans; warfarin-induced skin necrosis.

Explicitly listed in policy.

Policy Summary

PayerHumana

PolicyLaboratory - Venous and Arterial Thrombosis Testing

Policy CodePolicy LAB2023006

Change TypeNo material change

Effective Date03/2023

Next Review Date

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.

Specific Covered Indications for Plasma Assays

inv-19: List of clinical situations where plasma testing is reimbursable (acute coronary syndromes, DVT, stroke, pregnancy DVT, DIC, PE, relatives with DVT)

Plasma testing (CPT 85300-85306) is reimbursable in the following clinical situations when associated with the indicated diagnoses or contexts:

Clinical situations: Acute coronary syndromes including myocardial infarction; any deep venous thrombosis; arterial ischemic stroke; deep phlebothrombosis in pregnancy; disseminated intravascular coagulation (defibrination syndrome); pulmonary embolism; relatives of individuals with deep venous thrombosis.

These indications apply for plasma testing for protein C, protein S, and antithrombin III (CPT 85300-85306).

inv-20: Neonatal purpura fulminans; warfarin-induced skin necrosis — specifically reimbursable for protein C or S assays

Protein C or protein S assays are specifically reimbursable in the following neonatal and medication-related conditions:

Reimbursable specific indications: Neonatal purpura fulminans; warfarin-induced skin necrosis — plasma testing for protein C (CPT 85302, 85303) or protein S (CPT 85305, 85306) is reimbursable.

Explicitly listed as reimbursable for protein C or S assays.

Applicable Codes

Applicable CPT/HCPCS codesmixed

85300	Clotting inhibitors or anticoagulants; antithrombin III, activity
85301	Clotting inhibitors or anticoagulants; antithrombin III, antigen assay
85302	Clotting inhibitors or anticoagulants; protein C, antigen
85303	Clotting inhibitors or anticoagulants; protein C, activity
85305	Clotting inhibitors or anticoagulants; protein S, total
85306	Clotting inhibitors or anticoagulants; protein S, free
85307	Activated Protein C (APC) resistance assay
0278U	Hematology (genetic thrombosis), genomic sequence analysis of 14 genes (Versiti™ Thrombosis Panel)

Coding — Not applicable (placeholder)

Not applicableNot applicable

ContextThis placeholder indicates no coding-specific key/value entries are required for this section.

Policy numberLAB2023006

Code and Test Definitions

Antithrombin III / Protein C / Protein S assays (CPT 85300-85306 mapping)

Codes includedCPT 85300, 85301, 85302, 85303, 85305, 85306 — activity and antigen assays for antithrombin III, protein C, and protein S

85300 descriptionClotting inhibitors or anticoagulants; antithrombin III, activity

85301 descriptionClotting inhibitors or anticoagulants; antithrombin III, antigen assay

85302/85303 descriptionClotting inhibitors or anticoagulants; protein C, antigen (85302) and protein C, activity (85303)

85305/85306 descriptionClotting inhibitors or anticoagulants; protein S, total (85305) and protein S, free (85306)

APC resistance assay (CPT 85307) definition

CodeCPT 85307

DefinitionActivated Protein C (APC) resistance assay

Coverage stanceThe activated protein C resistance assay (CPT 85307) IS NOT REIMBURSABLE under this policy.

Proprietary multi-gene thrombosis panel (HCPCS 0278U) definition

CodeHCPCS 0278U

DefinitionHematology (genetic thrombosis), genomic sequence analysis of 14 genes — Proprietary test: Versiti™ Thrombosis Panel

Specimen typesblood, buccal swab, or amniotic fluid (as described in policy)

Coverage stanceMulti-gene panel testing (0278U) IS NOT REIMBURSABLE under this policy; Original Medicare LCDs referenced for 0278U may apply for prior authorization linkage.

Provider Actions, Billing, and Denial Notices

Prior Authorization

Prior Authorization / LCD Linkage for 0278U

Prior authorization and linkage to Original Medicare LCD/NCDs may apply for molecular/genetic tests such as CPT 0278U. Check and obtain any required authorizations before ordering to avoid claim denials.

Affected code: 0278U (Versiti Thrombosis Panel)
See LCDs: First Coast A58918; Palmetto L35025; Novitas L35062/L39365; Noridian L35160/L36256; CGS L36021/L38288; WPS L36807

Documentation Required

Documentation Expectations for Claims Submission and Medical Necessity

Provide complete clinical documentation with claims to support medical necessity: indication, clinical history, signs/symptoms, relevant prior testing results, relation to diagnosis (e.g., DVT, PE, arterial ischemic stroke, neonatal purpura fulminans), and relationship to current management. Include ordering clinician, specimen source, and test performed (CPT/HCT codes and test name).

General documentation expectations apply to reimbursable plasma testing codes (e.g., CPT 85300–85306)
Document relationship to covered conditions such as DVT, PE, MI, stroke, DIC, pregnancy-related thrombosis

Billing Rule

Provider Billing Action — Ensure Supporting Documentation and Coding

Submiters: review billing rules and ensure correct CPT coding and modifiers. Missing or insufficient documentation, or use of non-reimbursable codes without exception, may result in denial. When applicable, include supporting LCD/NCD references on the claim or in attachments.

Affected codes: CPT 85300–85307; 0278U

Denial Risk

Denial Risk — Superficial Venous Thrombosis Testing

Venous thrombosis risk testing for superficial venous thrombosis (including superficial thrombophlebitis and varicosities) is not reimbursable. Do not submit claims for CPT codes 85300–85303 and 85305–85306 for these indications; such claims will be denied.

Not reimbursable for superficial venous thrombosis: CPT 85300, 85301, 85302, 85303, 85305, 85306

Denial Risk

Denial Notice — APC Resistance Assay (CPT 85307)

The activated protein C resistance assay (CPT 85307) is not reimbursable. Do not order or bill this assay for Medicare Advantage members.

CPT 85307 — Activated Protein C (APC) resistance assay (NOT REIMBURSABLE)

Denial Risk

Denial Notice — Multi-gene Panel (0278U)

Multi-gene thrombosis panels such as CPT 0278U (Versiti Thrombosis Panel, genomic sequence analysis of 14 genes) are not reimbursable under this policy. Prior authorization will not make non‑reimbursable molecular panels payable unless covered by an applicable LCD/NCD.

CPT 0278U — Hematology (genetic thrombosis) genomic sequence analysis of 14 genes (NOT REIMBURSABLE)
Referenced LCDs: First Coast A58918; Palmetto L35025; Novitas L35062/L39365; Noridian L35160/L36256; CGS L36021/L38288; WPS L36807

Background and Clinical Context

Inherited and acquired thrombophilias contribute to venous and arterial thrombotic events. Laboratory evaluation commonly includes assays for antithrombin III, protein C, and protein S, as well as tests such as the activated protein C resistance assay and genetic panels; however, the clinical utility varies by indication and timing relative to acute clotting events. This policy reimburses plasma testing for antithrombin III (CPT 85300-85301), protein C (CPT 85302-85303), and protein S (CPT 85305-85306) for specified clinical situations (for example, acute coronary syndromes, deep venous thrombosis, pulmonary embolism, arterial ischemic stroke, deep phlebothrombosis in pregnancy, disseminated intravascular coagulation, relatives of individuals with DVT, neonatal purpura fulminans, and warfarin‑induced skin necrosis), while noting particular tests and indications that are excluded from coverage.

OpenPayer

Laboratory - Venous and Arterial Thrombosis Testing

Coverage Criteria — Plasma and Related Testing

Specific Covered Indications for Plasma Assays

Applicable Codes

Code and Test Definitions

Provider Actions, Billing, and Denial Notices

Ordering and Prior Authorization Requirements

Not Covered Tests and Situations

Background and Clinical Context

Frequency Limits

Revision History