CurrentHumanaPolicy LAB2023011

Laboratory - Immune Cell Function Assay

Humana's Medicare Advantage payment policy that governs reimbursement for immune cell function assays (proprietary tests such as Pleximmune/Pleximark and codes including 81560, 86352, 0018M) for providers submitting claims for Humana Medicare Advantage members.

Policy Summary

PayerHumana

PolicyLaboratory - Immune Cell Function Assay

Policy CodePolicy LAB2023011

Change TypeNo material changes

Effective Date04/2023

Next Review Date07/2025

Key ActionDo not bill for immune cell function assays (codes 81560, 86352, 0018M) for Humana Medicare Advantage members as they are not reimbursable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3CPT/HCPCS/proprietary procedures explicitly listed

Not reimbursableCoverage stance for listed assay codes

Medicare AdvantageProducts this policy applies to

Novitas L34914Original Medicare LCD referenced

Coverage Determination

Reimbursement criteria

Humana Medicare Advantage policy position on immune cell function assays and related procedural codes:

Immune cell function assays represented by CPT 81560, CPT 86352, and CPT 0018M are not reimbursable under Medicare Advantage plans.

Proprietary tests called out include Pleximmune (81560) and Pleximark (0018M) manufactured by Plexision, Inc.; these are included in the not reimbursable stance.

Claims remain subject to other plan requirements including medical necessity, reasonableness, referral/authorization requirements and any applicable Original Medicare Local Coverage Determinations (Novitas L34914 referenced for CPT 86352).

This policy is a claims payment guideline and does not alone determine coverage for a specific member; providers should verify plan-specific terms and requirements.

Codes and Billing

Policy Summary

PayerHumana

PolicyLaboratory - Immune Cell Function Assay

Policy CodePolicy LAB2023011

Change TypeNo material changes

Effective Date04/2023

Next Review Date07/2025

Key ActionDo not bill for immune cell function assays (codes 81560, 86352, 0018M) for Humana Medicare Advantage members as they are not reimbursable.

SourceLink

On This Page

Tests addressedmixedNot Covered

81560	Transplantation medicine (allograft rejection, pediatric liver and small bowel), measurement of donor and third-party-induced CD154+T-cytotoxic memory cells, utilizing whole peripheral blood, algorithm reported as a rejection risk score; Proprietary test: Pleximmune (Plexision, Inc.)
86352	Cellular function assay involving stimulation (eg, mitogen or antigen) and detection of biomarker (eg, ATP)
0018M	Transplantation medicine (allograft rejection, renal), measurement of donor and third-party-induced CD154+T-cytotoxic memory cells, utilizing whole peripheral blood, algorithm reported as a rejection risk score; Proprietary test: Pleximark (Plexision, Inc.)

Provider Billing and Authorization Actions

Prior Authorization

Prior authorization / reimbursement rule — Immune cell function assays not reimbursable

An immune cell function assay represented by CPT codes 81560, 86352, and 0018M is not reimbursable for Humana Medicare Advantage plans. Claims for these codes will be denied under this payment policy and remain subject to other plan requirements (e.g., medical necessity, reasonableness, referral/authorization rules) and any applicable Original Medicare LCDs.

Codes affected: 81560, 86352, 0018M
Claims remain subject to medical necessity, reasonableness, referral/authorization requirements, and applicable Original Medicare LCDs

Key Definitions

Pleximmune / Pleximark (definition)

TermPleximmune / Pleximark

DefinitionProprietary laboratory tests from Plexision, Inc. that measure donor and third-party–induced CD154+ T‑cytotoxic memory cells using whole peripheral blood and report an algorithm as a rejection risk score.

ManufacturerPlexision, Inc.

Use caseReported as a rejection risk score for allograft (transplant) rejection assessment.

Cellular function assay (86352)

CodeCPT 86352

DefinitionCellular function assay involving stimulation (e.g., mitogen or antigen) and detection of a biomarker (e.g., ATP).

ContextListed among applicable procedures for Medicare Advantage plans addressing immune cell function assays.