CurrentHumanaPolicy LAB2O23001

Laboratory Biomarkers for Myocardial Infarction and Chronic Heart Failure

This Medicare Advantage claims payment policy describes Humana's reimbursement stance for laboratory biomarkers used in the diagnosis and management of myocardial infarction (MI) and chronic heart failure, and lists applicable CPT codes and limits for Medicare Advantage members/providers.

Policy Summary

PayerHumana

PolicyLaboratory Biomarkers for Myocardial Infarction and Chronic Heart Failure

Policy CodePolicy LAB2O23001

Change TypeNo material change

Effective Date06/2023

Next Review Date

Key ActionOrder up to four serial quantitative troponin tests (CPT 84484) in the first three days for patients presenting with ischemic chest pain or listed ischemic symptoms.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4max serial troponin tests (first 3 days)

4natriuretic peptide limit (per 365 days)

Medicare Advantageproduct

84484troponin reimbursable code

83880natriuretic peptide code

Coverage Criteria — Laboratory Biomarkers for MI and Heart Failure

Main coverage rules

Reimbursement determinations for listed biomarkers and scenario-specific limits.

Quantitative cardiac troponin (CPT 84484) is reimbursable for the diagnosis of myocardial infarction (MI) for individuals presenting with ischemic chest pain or listed ischemic symptoms.

A maximum of four serial quantitative troponin tests (CPT 84484) is reimbursable in the first three days after presentation.

Natriuretic peptide testing (BNP, NT-proBNP) (CPT 83880) is reimbursable for individuals presenting with dyspnea or shortness of breath.

Natriuretic peptide testing (CPT 83880) is reimbursable up to four times every 365 days for individuals with any of the following: chronic heart failure (systolic, diastolic, or combined), acute on chronic combined systolic and diastolic heart failure, or chronic right heart failure.

Policy Summary

PayerHumana

PolicyLaboratory Biomarkers for Myocardial Infarction and Chronic Heart Failure

Policy CodePolicy LAB2O23001

Change TypeNo material change

Effective Date06/2023

Next Review Date

Key ActionOrder up to four serial quantitative troponin tests (CPT 84484) in the first three days for patients presenting with ischemic chest pain or listed ischemic symptoms.

SourceLink

On This Page

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Coding and Frequency Limits

Listed biomarker CPT codesCPT

84484	Troponin, quantitative
83880	Natriuretic peptide
82553	Creatine kinase (CK) (CPK); MB fraction only
82554	Creatine kinase (CK) (CPK); isoforms
82550	Creatine kinase (CK)
82552	Creatine kinase isoenzymes
83874	Myoglobin
83625	Lactate dehydrogenase (LDH)
82725	Heart-type fatty acid binding protein (H-FABP)
86140	C-reactive protein

1–10 of 13

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No billing codes listed in this excerptmixed

No codes listed

inv-05: Troponin serial limit

LimitMaximum of four quantitative troponin tests reimbursable in the first 3 days after presentation.

Applies toQuantitative cardiac troponin (troponin T or I) testing (CPT 84484) for diagnosis of myocardial infarction when presenting with ischemic chest pain or listed ischemic symptoms.

Time windowFirst three days after presentation (serial testing).

CodeCPT 84484 (quantitative troponin).

inv-06: Natriuretic peptide frequency

Frequency limitNatriuretic peptide testing reimbursable up to four times every 365 days.

IndicationsIndividuals presenting with dyspnea or shortness of breath; chronic heart failure (systolic, diastolic, combined), acute-on-chronic heart failure, chronic right heart failure.

CodeCPT 83880 (BNP, NT-proBNP).

Measurement examplesBNP, NT-proBNP assays as noted in policy text.

inv-07: (unnamed key_value item)

Placeholder(No threshold or value provided in brief/source for this item.)

NoteThis entry corresponds to an empty/unnamed threshold in the brief.

SourcePolicy references bibliography and clinical sources but provides no numeric threshold for this item.

Provider Actions and Authorization Notes

Prior Authorization

Prior authorization / reimbursement rule for quantitative troponin (CPT 84484)

Quantitative cardiac troponin (CPT 84484) is reimbursable for the diagnosis of myocardial infarction when the individual presents with ischemic chest pain or listed ischemic symptoms; a maximum of four serial quantitative troponin tests (CPT 84484) are reimbursable in the first three days after presentation.

Reimbursable presenting symptoms include ischemic chest pain and listed symptoms such as squeezing, tightness, pressure, radiation to jaw, back pain, shortness of breath, nausea, diaphoresis, dizziness, and fatigue.
Limit: up to four serial quantitative troponin measurements in the first three days after presentation.

Note

Authorization summary — headers present; no prior authorization stated

The policy header names laboratory biomarkers for myocardial infarction and chronic heart failure but the provided excerpt does not specify any prior authorization or explicit authorization actions.

Document subject: Laboratory Biomarkers for Myocardial Infarction and Chronic Heart Failure (Policy LAB2O23001).
No authorization requirements or prior authorization procedures are stated in the excerpted text.

Definitions — Biomarkers and Test Codes

inv-10: Quantitative troponin

Test descriptionQuantitative measurement of cardiac troponin (troponin T or I).

CPT code84484

Clinical useReimbursable for diagnosis of myocardial infarction in individuals presenting with ischemic chest pain or listed ischemic symptoms.

LimitMaximum of four serial quantitative troponin tests reimbursable in the first three days after presentation.

inv-11: Natriuretic peptides

Test descriptionTesting for natriuretic peptides (BNP, NT-proBNP).

CPT code83880

Clinical useReimbursable for individuals presenting with dyspnea or shortness of breath and for specified heart failure diagnoses.

Frequency limitReimbursable up to four times every 365 days.

inv-12: Laboratory biomarkers (myocardial infarction and heart failure)

Guideline and evidence citationsPolicy cites multiple clinical and guideline references related to biomarkers, including Van der Vusse & Glatz (1995), Kempf et al. (2012), and WHO (1979).

Natriuretic peptide evidenceIncludes citations on natriuretic peptide measurement and management of heart failure (e.g., UpToDate, Wijk et al. 2014, Yancy et al. 2013/2017).

Other biomarkers literatureReferences concerning MB isoenzyme, myoglobin, soluble ST2, and novel biomarkers for cardiovascular stress.