Currentpriority healthPolicy N/A

Cardiovascular Disease Risk Assessment

Defines Priority Health's medical policy and reimbursement guidance for cardiovascular disease (CVD) risk assessment tests and selected CVD risk markers, including coverage, documentation, billing and Medicare-specific pre-service determination instructions; applies to providers submitting claims to Priority Health.

Policy Summary

Payerpriority health

PolicyCardiovascular Disease Risk Assessment

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug. 2025

Next Review DateN/A

Key ActionObtain a Pre‑Service Organization Determination (PSOD) for Medicare when indications do not meet NCD, LCD or specific policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1/yearLp-PLA2 frequency limit

intermediate risk onlyhs-CRP coverage

multipleCode lists included

Coverage criteria for CVD risk markers

Priority Health will consider reimbursement for the following CVD risk markers when documentation supports clinical use; specific limits and documentation requirements apply.

ALL of the following

ALL of the following
- Covered; limited to 1 test per year.
  Frequency limit: one test per 12 months.
ALL of the following
- ALL of the following
  - Patient is at intermediate risk of developing coronary heart disease using a 10-year risk assessment tool.

Policy Summary

Payerpriority health

PolicyCardiovascular Disease Risk Assessment

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug. 2025

Next Review DateN/A

Key ActionObtain a Pre‑Service Organization Determination (PSOD) for Medicare when indications do not meet NCD, LCD or specific policy.

SourceLink

On This Page

Billing codes and coding rules

Screening/Covered codesmixedCovered

80061	Lipid panel. This panel must include the following: Cholesterol, serum, total (82465); Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718); Triglycerides (84478).
81493	Coronary artery disease, mRNA, gene expression profiling by real-time RT-PCR of 23 genes, utilizing whole peripheral blood, algorithm reported as a risk score.
82172	Apolipoprotein, each.
82465	Cholesterol, serum or whole blood, total.
83695	Lipoprotein (a).
83698	Lipoprotein-associated phospholipase A2 (Lp-PLA2).
83718	Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol).
83719	Lipoprotein, direct measurement; VLDL cholesterol.
83721	Lipoprotein, direct measurement; LDL cholesterol.
83722	Lipoprotein, direct measurement; small dense LDL cholesterol.

1–10 of 12

1/2

Not covered codesmixedNot Covered

81240	F2 (prothrombin, coagulation factor II) gene analysis, 20210G>A variant (not covered for screening).
81241	F5 (coagulation factor V) gene analysis, Leiden variant (not covered for screening).
83090	Homocysteine (not covered for screening).
83700	Lipoprotein, blood; electrophoretic separation and quantitation (not covered for screening).
0052U	Lipoprotein, blood, high resolution fractionation and quantitation of lipoproteins, including all five major lipoprotein classes and subclasses by vertical auto profile ultracentrifugation (not covered for any dx).
0308U	Cardiology (CAD), analysis of 3 proteins with 3 clinical parameters, plasma, algorithm reported as a risk score for obstructive CAD (not covered for any dx).
0541U	Cholesterol efflux capacity LC-MS/MS, quantitative measurement of HDL-bound apolipoproteins, algorithm reported as prediction of coronary artery disease (pCAD) score (not covered for any dx).
82777	Galectin-3 (not covered for any dx).

Lp-PLA2 testing limit

Lp-PLA2 (PLAC) frequency limitLimited to 1 test per year.

Pre-service determinations and provider requirements

Prior Authorization

Medicare Pre-Service Organization Determination (PSOD)

For Medicare members, when an indication does not meet the criteria of a National Coverage Determination (NCD), a Local Coverage Determination (LCD), or a specific medical policy, a Pre-Service Organization Determination (PSOD) must be completed. Providers should submit PSOD requests per Priority Health procedures and include all relevant clinical documentation to support medical necessity. See Priority Health PSOD guidance for submission steps, timelines, and contact information.

Medicare PSOD required when NCD/LCD/policy criteria not met
Include complete clinical documentation to support medical necessity
Follow Priority Health PSOD submission process and timelines

Prior Authorization

Place of Service and Authorization

Services must be furnished in an appropriate place of service based on the patient’s medical needs and condition. Prior authorization may be required for certain services and settings; verify member benefits and authorization requirements before scheduling. When authorization is required, submit requests with supporting clinical documentation to avoid delays.

Verify place-of-service appropriateness for the patient
Confirm whether prior authorization is required before service
Provide supporting clinical documentation with authorization requests

OpenPayer

Cardiovascular Disease Risk Assessment

Coverage criteria for CVD risk markers

Billing codes and coding rules

Pre-service determinations and provider requirements

Definitions and risk-stratification summary