CurrentHumanaPolicy LAB2023043

Laboratory - General Inflammation Testing (CRP and ESR)

Humana Medicare Advantage payment policy governing reimbursement for C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) testing for specified clinical indications and frequencies for Medicare Advantage members.

Policy Summary

PayerHumana

PolicyLaboratory - General Inflammation Testing (CRP and ESR)

Policy CodePolicy LAB2023043

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit claims for CRP or ESR only when medical necessity criteria for the specified conditions and frequencies are met; ESR should not be billed in conjunction with CRP when either test is allowed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Once every 2 daysCRP frequency for osteomyelitis

Listed conditionsESR reimbursable for listed conditions

Not reimbursable with CRPESR restriction when with CRP

DeniedGeneral exam testing

MultipleGuideline sources cited

Claims Payment PolicyPolicy type

Reimbursable and Non-Reimbursable Criteria

Reimbursable and non-reimbursable criteria

Covered when ALL of the following criteria are met:

Medicare Advantage payment policy applies — Commercial Payment Policy criteria apply to Medicare Advantage unless overridden by Original LCDs; claims remain subject to medical necessity and other plan requirements (e.g., referral/authorization).

Context for application

Reimbursable CRP testing

C-reactive protein (CRP) (CPT 86140, 86141) reimbursable for individuals with acute hematogenous osteomyelitis
Frequency: once every two days

Reimbursable ESR testing for specified indications

Erythrocyte sedimentation rate (ESR) (CPT 85651, 85652) reimbursable for acute and chronic urticaria

Policy Summary

PayerHumana

PolicyLaboratory - General Inflammation Testing (CRP and ESR)

Policy CodePolicy LAB2023043

Change TypeNo material changes

Effective Date

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.

Either CRP or ESR reimbursable at specified frequencies

CRP or ESR reimbursable for arthritis
Frequency: one test every month
CRP or ESR reimbursable for giant cell arteritis
Frequency: one test every month
CRP or ESR reimbursable for Takayasu arteritis
Frequency: one test every month
CRP or ESR reimbursable for polymyalgia rheumatica
Frequency: one test every three months
CRP or ESR reimbursable for rheumatoid arthritis
Frequency: one test every month
CRP or ESR reimbursable for systemic lupus erythematosus
Frequency: one test every month

Coverage considerations for inflammation testing

Policy references and evidence summaries informing coverage decisions for general inflammation laboratory testing.

Coverage decisions reference multiple clinical guidance and evidence sources (examples: American College of Rheumatology guidance; ACR/ Spondylitis Association recommendations) as listed in the policy bibliography

Literature notes limitations of inflammatory markers: ESR and CRP levels can be poorly correlated with clinical activity in some conditions and have performance caveats that inform interpretation and coverage rationale

See cited studies summarizing poor correlation and test limitations

CPT Codes, Frequencies, and Test Caveats

Applicable CPT codesCPT

85651	Sedimentation rate, erythrocyte; non-automated
85652	Sedimentation rate, erythrocyte; automated
86140	C-reactive protein
86141	C-reactive protein; high sensitivity (hsCRP)

inflammation tests (examples referenced in evidence)mixed

No codes listed

inv-05: CRP frequency for osteomyelitis

FrequencyCRP reimbursable once every two days for individuals with acute hematogenous osteomyelitis (CPT 86140, 86141)

Applicable codesCPT 86140, 86141

ScopeMedicare Advantage members; subject to plan medical necessity and other claims requirements

inv-06: ESR/CRP frequency for listed conditions

ArthritisCRP or ESR reimbursable one test every month

Giant cell arteritis and Takayasu arteritisCRP or ESR reimbursable one test every month

Polymyalgia rheumaticaCRP or ESR reimbursable one test every three months

Rheumatoid arthritis and Systemic lupus erythematosusCRP or ESR reimbursable one test every month

General ruleFor conditions allowing either test, ESR is not reimbursable when billed with CRP; ESR not reimbursable for conditions not specifically addressed

inv-07: test performance caveats

Correlation limitsLiterature reports CRP and ESR levels are poorly correlated with clinical measures of disease activity in rheumatoid arthritis, systemic lupus erythematosus and osteoarthritis

False-negative ratesRoutine diagnostic tests for periprosthetic joint infection demonstrate a high false-negative rate and are influenced by the infecting organism

Methodologic variabilityRecommendations note modified and alternate methods measuring ESR; inflammatory biomarkers (e.g., fibrinogen) have variable sensitivity/specificity across conditions

Claims, Billing, and Authorization Notes

Documentation Required

Authorization and general claims rules

Prior authorization is not specified in this section; claims for CRP (86140, 86141) and ESR (85651, 85652) remain subject to plan requirements including medical necessity, reasonableness, and any applicable referral or authorization requirements.

Claims are processed in accordance with plan requirements for medical necessity and reasonableness.
Applicable referral or authorization requirements still apply even when specific prior authorization is not listed.

Billing Rule

Claims Payment Policy governs billing (LAB2023043)

This document is the Claims Payment Policy (Policy Number LAB2023043) that governs billing and claims submission for laboratory general inflammation testing.

Refer to Claims Payment Policy LAB2023043 when submitting claims for CRP and ESR testing.

Test Definitions and Biomarkers

inv-10: CRP — C-reactive protein testing (CPT 86140, 86141); includes hsCRP

Test definitionC-reactive protein (CRP) testing, CPT 86140

High-sensitivity CRPCPT 86141 (hsCRP) included

Use noteCRP testing reimbursable per policy criteria (see condition-specific frequencies)

inv-11: ESR — Erythrocyte sedimentation rate testing (CPT 85651, 85652); includes automated and non-automated methods

Test definitionErythrocyte sedimentation rate (ESR) testing, CPT 85651 (non-automated)

Automated ESRCPT 85652 (automated) included

Use noteESR reimbursable only for specified conditions and frequencies; not reimbursable when billed with CRP for conditions allowing either test

inv-12: Inflammatory biomarkers — Markers such as CRP, ESR, fibrinogen and literature limitations

Included markersInflammatory biomarkers referenced include CRP, ESR, and fibrinogen

Clinical limitationsEvidence highlights poor correlation of CRP/ESR with clinical disease activity in several conditions

Test performanceSome diagnostic inflammatory tests show high false-negative rates and methodological variability affecting sensitivity/specificity