Sierra Health and Life cardiovascular risk tests Coverage

Coverage Criteria and Clinical Rationale

Not Medically Necessary / Unproven

The following tests are considered unproven and not medically necessary due to insufficient evidence of efficacy:

Unproven/Not Medically Necessary Tests: Arterial compliance testing using waveform analysis; carotid intima-media thickness (CIMT) measurement for screening or management; advanced lipoprotein analysis (including lipoprotein(a), subfractions, or particle size); lipoprotein-associated phospholipase A2 (Lp-PLA2) enzyme testing; endothelial function assessment using peripheral arterial tonometry (PAT) or brachial artery ultrasound; and the listed multiprotein diagnostic biomarker panels (specified protein combinations with algorithm-reported risk scores) are considered unproven and not medically necessary due to insufficient evidence that they alter management or improve clinical outcomes.

See policy list for the specific multiprotein combinations and proprietary codes.

CIMT: clinical utility

Evidence summary and implied coverage considerations

CIMT evidence summary: Clinical evidence is insufficient to show an added benefit of carotid intima-media thickness (CIMT) testing beyond traditional risk assessment; there is inadequate prospective evidence that use of CIMT changes management or improves clinical outcomes.

Systematic reviews and cohort studies indicate heterogeneity in CIMT measurement and that coronary artery calcium scoring provides superior discrimination to CIMT for asymptomatic low-to-intermediate risk individuals (see Azcui Aparicio et al. 2021 and Geisel et al. 2017).

Lp(a): clinical utility

Evidence summary and implied coverage considerations

Lp(a) evidence summary: Lp(a) is consistently associated with increased cardiovascular risk and provides risk information that is independent and additive to LDL-C; however, the clinical utility of routine measurement to change management or improve outcomes has not been established and study thresholds are heterogeneous across populations.variable (examples include ≥50 mg/dL in some studies and percentile-based cutoffs in cohorts)

Multiple cohort studies, individual-level meta-analyses, and systematic reviews report associations with MACEs and coronary outcomes but do not demonstrate that measuring Lp(a) improves patient-centered outcomes.

Comparative risk markers

Comparative performance of subclinical atherosclerosis tests

Comparative findings: Coronary artery calcium (CAC) scoring generally provides superior risk discrimination compared with CIMT and carotid plaque identification in asymptomatic low-to-intermediate risk individuals; CIMT shows greater heterogeneity and lower net reclassification performance in systematic comparisons.CAC ≥ 11.2% (net reclassification) > carotid plaque ≥ 2% > CIMT 3% (reported ranking)

These conclusions are based on systematic reviews and cohort comparisons that highlight methodologic heterogeneity for ultrasound markers (CIMT).

Evidence associations (informational)

Summary of evidence-based associations (no explicit coverage decision in this segment):

Lp(a) associations: Elevated Lp(a) levels are associated with increased risks of major adverse cardiovascular events, myocardial infarction, stroke, and need for revascularization across multiple cohorts and meta-analyses; magnitude and thresholds vary by study and population.examples include ≥50 mg/dL or high percentiles in cohort analyses

Evidence demonstrates association but not that routine measurement improves outcomes.

Lp-PLA2 associations: Higher Lp-PLA2 mass or activity has been associated with increased risks of coronary heart disease and ischemic stroke in meta-analyses, with pooled relative risks indicating modestly increased risk across studies.not standardized across studies

Assay heterogeneity and limited data on how measurement guides treatment limit clinical applicability.

Multiprotein risk scores:

Endothelial function assessment

Not supported for routine cardiovascular risk assessment due to insufficient evidence of clinical utility.

Endothelial function assessment: Peripheral arterial tonometry (PAT) and brachial artery flow-mediated dilation (FMD) have not demonstrated consistent, clinically relevant associations with incident CVD or mortality sufficient to support routine use for risk stratification; evidence does not show that these tests change management or improve outcomes.

Large community and cohort studies report conflicting or non-significant associations (see Schnabel et al. 2021, Cooper 2021, Venuraju 2019).

Cholesterol efflux capacity (CEC) testing

Associations with CAD and adverse cardiovascular events have been observed but clinical utility is unproven.

Cholesterol efflux capacity (CEC) testing: Meta-analyses and observational studies report that lower CEC is associated with presence of coronary artery disease and with higher rates of adverse cardiovascular events; for example, each 0.1-unit increase in CEC was associated with approximately a 5% reduced risk of adverse cardiovascular events in one meta-analysis.no standardized cutoff

Assay heterogeneity and lack of a gold-standard assay, plus absence of evidence that measuring CEC alters management or improves outcomes, limit clinical utility.

Multiprotein/biomarker risk scores for obstructive CAD or MACE

Models show good discrimination in derivation and some external validation but lack evidence of clinical impact.

Model performance and limitations: Multiprotein and biomarker-based risk scores for obstructive coronary artery disease or major adverse cardiac events have achieved AUCs in the range of ~0.85–0.88 in derivation and some external cohorts; however, studies are observational or retrospective with small event counts and do not demonstrate that use of these scores changes patient management or improves outcomes.

Clinical implementation requires evidence that score-guided care leads to better outcomes; current evidence is insufficient.

Guideline positions on advanced lipid and biomarker testing

Professional society statements vary; many recommend selective use of Lp(a), apoB, and natriuretic peptides in specific contexts and do not support routine advanced lipoprotein testing.

Guideline summary—Lp(a) and apoB: Multiple professional organizations recognize Lp(a) and apoB as risk-enhancing factors in selected individuals (family history of premature ASCVD, unexplained or recurrent ASCVD, certain ancestries, or discordant LDL-C); several societies recommend measuring Lp(a) at least once in adults or in targeted circumstances and endorse apoB measurement to refine risk when LDL-C is discordant.Examples: Lp(a) ≥50 mg/dL often cited as risk-enhancing; apoB ≥130 mg/dL noted as risk-enhancing

Guidelines disagree on routine population screening; ASCP advises against routine expanded lipid panels. ADA and others provide context-specific recommendations (e.g., natriuretic peptide thresholds for diabetes).

Guideline summary—other markers: ACC/AHA and other guideline documents generally do not recommend arterial compliance measures or expanded lipoprotein testing for routine risk assessment outside of select research or specific clinical circumstances; brachial/peripheral FMD and routine particle-number assays lack endorsement for routine screening.

Recommendations vary by society and by clinical context; see respective guideline citations for details.

Lp(a) testing — targeted use

Covered when used for risk stratification in specific clinical contexts

Indications for Lp(a) measurement: Measure Lp(a) at least once in adults for risk stratification or when used in individuals with a family history of premature CVD, unexplained or recurrent ASCVD despite therapy, calcific aortic valve disease, or other circumstances where reclassification would alter management.Lp(a) risk thresholds per society guidance (e.g., low <30 mg/dL; intermediate 30–50 mg/dL; high ≥50 mg/dL)

Document the clinical indication and how results will influence management (e.g., more intensive LDL-C lowering or cascade testing).

ApoB testing — targeted use

Covered when used to resolve discordance or refine risk

Indications for apoB measurement: ApoB measurement may be used to refine cardiovascular risk assessment when LDL-C is discordant with clinical risk (for example, in individuals with high triglycerides, diabetes, obesity/metabolic syndrome, or very low LDL-C), and to assist in diagnosing lipoprotein phenotypes and family cascade screening.Consider apoB thresholds (e.g., ≥130 mg/dL as risk-enhancing; target goals vary by risk category)

Consider apoB or non-HDL-C prior to ordering specialized particle-number assays; document how results will change management.

Advanced particle testing — limited utility

Not routinely covered for screening

Advanced lipoprotein particle testing and unstandardized assays: Routine ordering of expanded lipid panels (particle sizing or nuclear magnetic resonance [NMR]–based assays) and other specialized particle-number/size assays for CVD screening is discouraged because these tests lack standardization and have not demonstrated sufficient incremental predictive value to justify routine use.

Consider only in select cases where results will change management and after standard lipid testing and apoB/non–HDL-C assessment as appropriate.

ABI and other vascular markers — restricted use

Vascular function and ABI testing

ABI and other additional risk markers: Screening for peripheral artery disease with the ankle–brachial index (ABI) in asymptomatic adults lacks sufficient evidence per USPSTF and is not recommended for routine population screening; routine use of additional nontraditional risk markers (e.g., hs-CRP, ABI, CAC) in some guideline sets is discouraged for general use.ABI < 0.9 is a recognized abnormal value

If ordering ABI or other vascular tests, document a specific clinical indication; routine screening in asymptomatic individuals is not supported.

The policy designates several tests as not medically necessary because current evidence does not demonstrate they change clinical management or improve outcomes. Explicit exclusions include: arterial compliance testing (waveform analysis), carotid intima-media thickness (CIMT) measurement when used for screening/management, advanced lipoprotein analysis (including particle size/subfractions and some proprietary assays), lipoprotein-associated phospholipase A2 (Lp-PLA2), endothelial function assessment (e.g., peripheral arterial tonometry or brachial artery ultrasound), and the specified multiprotein diagnostic biomarker panels reported with algorithmic risk scores.

Evidence summaries note limited generalizability and heterogeneity across populations and studies. For example, CIMT literature does not demonstrate added benefit beyond traditional risk assessment and many Lp(a) studies vary by race/ethnicity, comorbidities, thresholds, and outcome definitions. As a result, the policy does not specify population-level exceptions and emphasizes that applicability to non-White or otherwise diverse populations may be constrained by available data.

Multiprotein blood tests and proprietary panels reported as algorithmic risk scores lack sufficient high-quality, peer-reviewed evidence of clinical utility. Systematic reviews and evidence briefs (e.g., Hayes on HART CADhs) found limited published studies and no convincing data that use of these scores changes management or improves outcomes; therefore such tests are considered unsupported for routine clinical use.

Routine measurement of endothelial function tests such as peripheral arterial tonometry (PAT) or brachial artery flow-mediated dilation for community screening or routine cardiovascular risk stratification is discouraged. The peer-reviewed literature shows conflicting associations and no demonstration that routine use of PAT or flow-mediated dilation meaningfully predicts events or alters management.

Routine ordering of expanded lipid panels (particle sizing or NMR) and ankle–brachial index (ABI) screening in asymptomatic adults is discouraged. The American Society for Clinical Pathology recommends against routine expanded lipid panels for screening, and the USPSTF finds insufficient evidence to support ABI screening in asymptomatic adults, supporting limited use only when a specific clinical indication exists.

Summary of tests designated not medically necessary: arterial compliance/waveform analysis; CIMT for routine screening/management; advanced lipoprotein analyses (including many particle-size and proprietary assays); Lp-PLA2 enzyme testing; endothelial function assessments (PAT or brachial artery ultrasound); and multiprotein diagnostic biomarker panels reported with algorithmic risk scores. These determinations reflect insufficient evidence that these tests change clinical management or improve outcomes.

The evidence base for carotid intima-media thickness (CIMT) does not establish that CIMT measurement provides added clinical benefit over traditional risk assessment. Systematic reviews and meta-analyses report variable definitions and modest diagnostic performance, and prospective data are inadequate to show that CIMT-guided care improves outcomes.

Use of Lp-PLA2 assays or multiprotein blood tests solely for general population screening is discouraged. Meta-analyses and evidence reviews identify low-quality or limited evidence for Lp-PLA2 and note inadequate peer-reviewed literature for multiprotein tests (for example, the HART CADhs evidence brief), with no demonstrated link between testing and improved patient outcomes.

Endothelial function testing (PAT, brachial flow-mediated dilation) and routine expanded lipid panel testing (particle sizing, NMR) are not supported for routine use in asymptomatic adults. Studies show inconsistent associations with cardiovascular events and professional guidance advises against routine advanced lipid testing without a clear clinical indication.

Ordering advanced lipoprotein assays (particle-number/size or other specialized particle tests) as routine screening is not recommended without a documented clinical rationale. Professional guidance acknowledges potential roles in select cases but emphasizes lack of standardization and insufficient evidence for routine primary prevention screening.

Procedural and Billing Codes

Listed proprietary and lab codesCPT

0019M	Cardiovascular disease, plasma, analysis of protein biomarkers by aptamer-based microarray and algorithm reported as 4-year likelihood of coronary event in high-risk populations.
0052U	Lipoprotein, blood, high resolution fractionation and quantitation of lipoproteins, including all five major lipoprotein classes and subclasses of HDL, LDL, and VLDL by vertical auto profile ultracentrifugation.
0308U	Cardiology (coronary artery disease [CAD]), analysis of 3 proteins (high sensitivity [hs] troponin, adiponectin, and kidney injury molecule-1 [KIM-1]) with 3 clinical parameters (age, sex, history of cardiac intervention), plasma, algorithm reported as a risk score for obstructive CAD.
0309U	Cardiology (cardiovascular disease), analysis of 4 proteins (NT-proBNP, osteopontin, tissue inhibitor of metalloproteinase-1 [TIMP-1], and kidney injury molecule-1 [KIM-1]), plasma, algorithm reported as a risk score for major adverse cardiac event.
0377U	Cardiovascular disease, quantification of advanced serum or plasma lipoprotein profile, by nuclear magnetic resonance (NMR) spectrometry with report of a lipoprotein profile (including 23 variables).
0415U	Cardiovascular disease (acute coronary syndrome [ACS]), IL-16, FAS, FASLigand, HGF, CTACK, EOTAXIN, and MCP-3 by immunoassay combined with age, sex, family history, and personal history of diabetes, blood, algorithm reported as a 5-year (deleted risk) score for ACS.
0541U	Cardiovascular disease (HDL reverse cholesterol transport), cholesterol efflux capacity, LC-MS/MS, quantitative measurement of 5 distinct HDL-bound apolipoproteins (apolipoproteins A1, C1, C2, C3, and C4), serum, algorithm reported as prediction of coronary artery disease (pCAD) score.
83695	Lipoprotein (a).
83698

Applicable CPT/HCPCS and unlisted codesmixed

0377U	Cardiovascular disease, quantification of advanced serum or plasma lipoprotein profile, by NMR spectrometry with report of a lipoprotein profile (including 23 variables).
0415U	Cardiovascular disease (ACS), IL-16, FAS, FASLigand, HGF, CTACK, EOTAXIN, MCP-3 by immunoassay combined with age/sex/family history/personal diabetes history, blood, algorithm reported as a 5-year (deleted risk) score for ACS.
0541U	Cholesterol efflux capacity, LC-MS/MS, quantitative measurement of 5 HDL-bound apolipoproteins, serum, algorithm reported as prediction of coronary artery disease (pCAD) score.
83695	Lipoprotein (a).
83698	Lipoprotein-associated phospholipase A2 (Lp-PLA2).
83701	Lipoprotein, blood; high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed (e.g., electrophoresis, ultracentrifugation).
83704	Lipoprotein, blood; quantitation of lipoprotein particle number(s) (e.g., by nuclear magnetic resonance spectroscopy), includes lipoprotein particle subclass(es), when performed.
93050	Arterial pressure waveform analysis for assessment of central arterial pressures, includes obtaining waveform(s), digitization and application of nonlinear mathematical transformations to determine central arterial pressures and augmentation index, with interpretation and report, upper extremity artery, non-invasive.
93799	Unlisted cardiovascular service or procedure.
93895	Quantitative carotid intima media thickness and carotid atheroma evaluation, bilateral.

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No codes listed in excerptmixed

No codes listed

inv-27: cfPWV cutoff — reported cutoff points

cfPWV cutoff pointsClosest cutoff points reported were 10.7 and 11.5 m/s (Sequí-Domínguez et al., systematic review/meta-analysis).

inv-28: ePWV risk increment — per 1 m/s increase associated risk estimates

ePWV per 1 m/s risk incrementEach 1 m/s increase in estimated pulse wave velocity (ePWV) was associated with ~36%–41% increased risk for cardiovascular events and mortality (Li et al., meta-analysis of 20 studies).

inv-29: IMT cutoff — 1 mm association from meta-analysis

IMT diagnostic cutoffA pooled meta-analysis identified an IMT cutoff of 1.0 mm as a more accurate diagnostic criterion for coronary artery disease (improved sensitivity/specificity/AUC).

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Applicable codes and prior authorization note

The following codes are provided for reference only; listing does not imply coverage or payment. Providers must verify member-specific benefit plan terms and applicable mandates before billing. Prior authorization requirements are not specified in the excerpted material; however, some tests (especially multiprotein risk panels and other advanced assays) may require prior authorization based on insufficient evidence of clinical utility and plan-specific rules. UnitedHealthcare (and related plans) may use external tools (e.g., InterQual) to assist coverage decisions.

Applicable codes are illustrative only — inclusion does not guarantee coverage or reimbursement.
Prior authorization: not explicitly specified in the excerpt; check member-specific plan for PA requirements.
Multiprotein and other advanced risk tests may be subject to prior authorization or denial due to insufficient evidence of clinical utility.
Third-party decision-support tools (e.g., InterQual) may be used to support coverage determinations.

Prior Authorization

Prior authorization expectation for multiprotein and other advanced tests

Clinical Background and Scope

Background: Cardiovascular diseases including coronary artery disease, stroke, and hypertension are major causes of morbidity and mortality. A range of proposed tests — arterial compliance (pulse wave velocity/waveform analysis), CIMT, advanced lipoprotein profiling, Lp-PLA2 measurement, endothelial function testing, and multiprotein biomarker panels — have been investigated to improve early identification or risk stratification. Current evidence, however, does not conclusively show these tests alter management or improve clinical outcomes in asymptomatic screening contexts.

Definitions and Test Descriptions

inv-61: Arterial compliance / pulse wave analysis definition

Definition — arterial compliance / pulse wave analysisNoninvasive assessment of arterial elasticity using measures such as pulse wave velocity and augmentation index; central arterial pressures and waveform analysis derived from peripheral waveforms to estimate arterial compliance.

inv-62: Carotid intima-media thickness (CIMT) definition

Definition — CIMTCarotid intima‑media thickness (CIMT) is an ultrasound‑based measurement of carotid artery wall thickness (common or segmental) used as a marker of subclinical atherosclerosis.

inv-63: Lp-PLA2 definition

Definition — Lp-PLA2Lipoprotein‑associated phospholipase A2 (Lp‑PLA2) is a vascular inflammatory enzyme measured as mass or activity and investigated as a biomarker for plaque stability, ischemic stroke, and coronary heart disease.

Policy Revision History

2026-04-01policy_revisionLatest

Updated Clinical Evidence and References sections; archived previous policy version 2026T0389DD.

OpenPayer

Cardiovascular Disease Risk Tests (Coverage Criteria)