Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyHumana CRP ESR Coverage Policy Update | OpenPayer
    Ask Trek AI about this page
    CurrentHumanaPolicy LAB2023043

    Laboratory General Inflammation Testing (CRP and ESR)

    Customize your policy alerts

    Sign up for Humana Policy LAB2023043 alerts

    Get alerted when Policy LAB2023043 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Defines Humana Medicare Advantage payment and reimbursement criteria for C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) laboratory testing, including allowed frequencies and clinical indications for reimbursement.

    Policy Summary
    PayerHumana
    PolicyLaboratory General Inflammation Testing (CRP and ESR)
    Policy CodePolicy LAB2023043
    Change TypeNo material changes
    Effective Date07/2023
    Last ReviewJul 1, 2025
    Next Review Date07/2025
    Key ActionReimburse CRP and ESR only for specified clinical indications and at defined frequencies; ESR is not reimbursable when billed with CRP for allowed conditions.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    once every 2 daysCRP frequency for acute hematogenous osteomyelitis

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    specific conditions
    ESR reimbursable for listed conditions
    monthlyMonthly testing allowed
    disallowedESR disallowed with CRP
    not reimbursableGeneral exam testing
    multipleGuideline references

    Coverage Criteria for CRP and ESR

    Codes, Frequencies, and Coding Notes

    ESR and CRP CPT codes referencedCPT
    85651Sedimentation rate, erythrocyte; non-automated
    85652Sedimentation rate, erythrocyte; automated
    86140C-reactive protein
    86141C-reactive protein; high sensitivity (hsCRP)
    Examples of tests referenced in literaturemixed
    No codes listed
    Testing frequency rules
    CRP frequency for acute hematogenous osteomyelitisC-reactive protein (CPT 86140, 86141) is reimbursable once every 2 days.
    ESR reimbursable conditions (as-needed or interval-based)Erythrocyte sedimentation rate (CPT 85651, 85652) reimbursable for acute/chronic urticaria, ankylosing spondylitis, nonradiographic axial spondyloarthritis, periprosthetic joint infection, T‑cell lymphoma, large vessel vasculitis signs/symptoms, and select IBS symptoms (as needed); Hodgkin lymphoma every 3 months.
    Monthly testing allowanceCRP or ESR reimbursable one test every month for arthritis, giant cell arteritis, Takayasu arteritis, rheumatoid arthritis, and systemic lupus erythematosus.
    Quarterly testing allowancePolymyalgia rheumatica: one test every three months.
    ESR billing restriction with CRPFor conditions where either CRP or ESR testing is allowed, measurement of ESR is not reimbursable when billed in conjunction with CRP.
    WHO essential diagnostics consideration
    WHO guidance referencedPolicy references the WHO Model List of Essential In Vitro Diagnostics to inform selection and use of in vitro diagnostic tests.
    WHO documents citedSecond WHO Model List of Essential In Vitro Diagnostics (2019) and subsequent WHO reports on selection and use of essential in vitro diagnostics.
    Use in test selectionWHO EDL is cited as contextual guidance to inform which diagnostic tests may be essential for clinical care and policy consideration.

    Provider Actions and Billing Guidance

    Billing Rule

    Reimbursement Criteria and Frequencies (No Prior Authorization Specified)

    No prior authorization is specified for the laboratory tests described below. Reimbursement and frequency rules apply as listed for the associated CPT codes; ensure documentation in the medical record supports the clinical indication and testing frequency to avoid payment denial.

    • CPT 86140, 86141 (C-reactive protein): Reimbursable for individuals with acute hematogenous osteomyelitis at a frequency of once every two days.
    • CPT 85651, 85652 (erythrocyte sedimentation rate): Reimbursable for the listed conditions and symptoms at the frequencies noted — examples include Hodgkin lymphoma (one test every three months) and as-needed testing for conditions such as acute and chronic urticaria, ankylosing spondylitis, nonradiographic axial spondyloarthritis, periprosthetic joint infections, T‑cell lymphoma, inflammatory bowel disease signs/symptoms, and large vessel vasculitis signs/symptoms.
    • Billing note: Submit the appropriate CPT code (86140, 86141, 85651, or 85652) with supporting clinical documentation of the indication and frequency. Frequency limits above are plan payment rules and may be reviewed on claims for medical necessity.

    Definitions and Test Descriptions

    86141 — C-reactive protein; high sensitivity (hsCRP)
    Code 86141 definitionC-reactive protein; high sensitivity (hsCRP).
    Associated code grouping86141 is listed alongside 86140 as CRP procedures referenced in the policy.
    Medicare applicability notePayment criteria for 86141 apply to most Medicare jurisdictions, with specific exceptions noted in the policy.
    85651 / 85652 — Erythrocyte sedimentation rate (ESR)
    Code 85651 definitionSedimentation rate, erythrocyte; non-automated (CPT 85651).
    Code 85652 definitionSedimentation rate, erythrocyte; automated (CPT 85652).
    Policy Summary
    PayerHumana
    PolicyLaboratory General Inflammation Testing (CRP and ESR)
    Policy CodePolicy LAB2023043
    Change TypeNo material changes
    Effective Date07/2023
    Last ReviewJul 1, 2025
    Next Review Date07/2025
    Key ActionReimburse CRP and ESR only for specified clinical indications and at defined frequencies; ESR is not reimbursable when billed with CRP for allowed conditions.
    SourceLink
    On This Page
    Coverage Criteria for CRP and ESRCodes, Frequencies, and Coding NotesProvider Actions and Billing GuidanceDefinitions and Test Descriptions
    Note

    Guideline-Informed Review

    Clinical guidelines and peer-reviewed literature are referenced to inform claims and payment decisions. Providers should ensure testing aligns with accepted guideline recommendations and document rationale when testing frequency or indications deviate from routine practice.

    • Guideline-aligned review: Claims for ESR and CRP testing may be evaluated against specialty society guidelines (e.g., ACR, EULAR, NCCN) cited in the policy when determining medical necessity.
    • Documentation expectation: Include diagnosis, clinical signs/symptoms, and justification for test frequency in the medical record to support reimbursement.
    Policy grouping
    85651 and 85652 are referenced together as ESR procedures covered under Medicare Advantage payment criteria.
    Inflammation laboratory tests
    Core inflammation tests includedPolicy references C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and platelet count as commonly used laboratory tests to evaluate inflammatory and infectious conditions.
    Literature supportCited studies include evaluations of platelet count, ESR, and CRP in pediatric inflammatory and infectious disease to support the role of these tests.
    Clinical contextsTests are referenced across rheumatologic, infectious disease, and pediatric inflammatory conditions in the supporting literature and guidelines.