CurrentHumanaPolicy LAB2023028

Laboratory Cardiovascular Disease Risk Assessment in Adults

Humana's Medicare Advantage payment policy describing which laboratory tests for cardiovascular disease risk assessment are reimbursable or not reimbursable for adult members and referencing applicable Original Medicare LCD/NCD considerations affecting payment.

Policy Summary

PayerHumana

PolicyLaboratory Cardiovascular Disease Risk Assessment in Adults

Policy CodePolicy LAB2023028

Change TypeNo material changes

Effective DateJun 1, 2023

Next Review Date

Key ActionSubmit claims that meet medical necessity and applicable referral or authorization requirements; reimbursement follows specified criteria for ApoB and Lp(a) and excludes several biomarkers and proprietary panels.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

ApoBApoB reimbursable

Lp(a)Lp(a) once-per-lifetime

MultipleMultiple codes not reimbursable

Small dense LDLSmall dense LDL restricted

Lp-PLA2Lp-PLA2 not reimbursable

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Coverage Criteria

Coverage criteria for specified laboratory tests

Humana's payment positions for specific laboratory tests (by CPT/HCPCS) used in cardiovascular risk assessment:

Measurement of apolipoprotein B (ApoB) (CPT 82172) is reimbursable when the individual has ONE OR MORE of the following: Hypertriglyceridemia; Diabetes mellitus; Obesity or metabolic syndrome; Disorder of galactose, lipoprotein, or amino acid transport metabolism; History of circulatory system disorders; Presence of coronary angioplasty implant.

Measurement of lipoprotein (a) (Lp(a)) (CPT 83695) is reimbursable once per lifetime after the individual turns 18 years of age.

Direct measurement of small dense LDL (CPT 83722) is not reimbursable except when performed for one of the following diagnoses: Cushing's disease; Chronic kidney disease (CKD); Obstruction of the bile duct; Pregnancy.

Measurement of lipoprotein-associated phospholipase A2 (Lp-PLA2) (CPT 83698) is not reimbursable.

Measurement of various novel lipid and non-lipid biomarkers and proprietary multi-marker cardiovascular risk panels is not reimbursable as an adjunct to direct LDL-C. Examples listed include CPT codes 82610, 83700, 83701, 83704, 83719, 83880, 85384, 85415 and proprietary panel codes 0052U, 0308U, 0309U, 0415U; see policy for the full list and details.

Components of a lipid panel (e.g., CPT 82465, 83718, 84478) are not reimbursable on the same date of service as a lipid panel (CPT 80061).

Payment criteria and applicability for specific CPT codes may vary by Medicare contractor/jurisdiction; exceptions and jurisdictional notes are listed in the policy (see contractor-specific exceptions for listed CPTs).

Operational: Verify contractor/jurisdictional exceptions when submitting claims.

Coverage — not stated in provided text

No explicit coverage criteria appear in these chunks. The content is bibliographic and guideline references only.

This portion of the policy contains bibliographic citations and guideline references (for example, literature on natriuretic peptide measurement, C-reactive protein, cardiac troponin, Lp-PLA2, and major lipid/apolipoprotein studies) and does not state additional coverage determinations.

Coding and Billing

Selected CPT/HCPCS/proprietary codes mentionedmixed

82172	Apolipoprotein B
83695	Lipoprotein (a)
83722	Direct measurement; small dense LDL cholesterol
83698	Lipoprotein-associated phospholipase A2 (Lp-PLA2)
82610	Cystatin C
83880	Natriuretic peptide (BNP/NT-proBNP)
80061	Lipid panel
0052U	VAP proprietary lipoprotein panel
0308U	HART CAD (Prevencio) proprietary test
0309U	HART CVE (Prevencio) proprietary test

1–10 of 11

1/2

No billing codes provided in this portionmixed

No codes listed

Lp(a) frequency — once per lifetime after age 18

FrequencyOnce per lifetime after the individual turns 18 years of age.

Applicable CPTCPT 83695 (Lipoprotein[a]).

Policy contextReimbursable as a single lifetime measurement for cardiovascular risk assessment in adults.

inv-06:

Content availableNo explicit coverage criteria are provided in this bibliographic portion of the policy; contains guideline and literature references.

Examples of referencesNatriuretic peptide measurement in heart failure; C-reactive protein in cardiovascular disease; studies on omega-3 fatty acids and CVD.

Provider Actions and Billing Rules

Note

Provider Action: No Prior Authorization or Additional Documentation

No prior authorization, documentation, step therapy, denial risk, or special billing-rule instructions are required for these laboratory cardiovascular disease risk assessment services. Claims are subject to standard plan payment policies, including requirements of medical necessity, reasonableness, and any applicable referral or authorization rules under the member's benefit plan.

Billing Rule

Claims Processing Reminder

Payments remain subject to the plan's general claims processing requirements. Providers should ensure claims reflect medical necessity and comply with applicable coding, referral, and authorization rules of the member's plan; absence of a policy-specific prior authorization does not override those standard requirements.

Definitions and Test Descriptions

inv-09: ApoB (CPT 82172) — a measured apolipoprotein used as a marker of atherogenic lipoproteins; reimbursable for listed indications.

DefinitionApolipoprotein B (ApoB) — measured apolipoprotein used as a marker of atherogenic lipoproteins.

Applicable CPTCPT 82172.

Reimbursement stanceReimbursable for individuals with hypertriglyceridemia, diabetes mellitus, obesity or metabolic syndrome, disorders of galactose/lipoprotein/amino acid transport metabolism, history of circulatory system disorders, or presence of coronary angioplasty implant.

inv-10: Lp(a) (CPT 83695) — an atherogenic lipoprotein particle; reimbursable once in a lifetime after age 18.

DefinitionLipoprotein(a) [Lp(a)] — an atherogenic lipoprotein particle and genetic risk factor for atherosclerotic cardiovascular disease.

Applicable CPT