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Currentsierra health and lifePolicy 2026T0389EE

Cardiovascular Disease Risk Tests (Coverage Criteria)

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Defines UnitedHealthcare policy stance on a range of cardiovascular risk tests (arterial compliance/waveform analysis, carotid intima-media thickness, advanced lipoprotein and multiprotein biomarker assays, Lp-PLA2) for Commercial and Individual Exchange plans.

Policy Summary

Payersierra health and life

PolicyCardiovascular Disease Risk Tests (Coverage Criteria)

Policy CodePolicy 2026T0389EE

Change TypeClarified clinical evidence and references

Effective DateApr 1, 2026

Last ReviewApr 1, 2026

Next Review DateN/A

Key ActionDocument the clinical indication and how test results will change management when ordering Lp(a) or apoB, and reference the member-specific benefit plan before requesting coverage.

SourceLink

POLICY UPDATE CHANGES

Updated Clinical Evidence and References sections to reflect the most current information

multipleUnproven test types

≥9Proprietary/temporary codes listed

Commercial & ExchangeApplies to lines of business

0.85-0.88AUC reported for multi-biomarker models

Do not routinely orderASCP stance

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.

Policy Summary

Payersierra health and life

PolicyCardiovascular Disease Risk Tests (Coverage Criteria)

Policy CodePolicy 2026T0389EE

Change TypeClarified clinical evidence and references

Effective DateApr 1, 2026

Last ReviewApr 1, 2026

Next Review DateN/A

Key ActionDocument the clinical indication and how test results will change management when ordering Lp(a) or apoB, and reference the member-specific benefit plan before requesting coverage.

SourceLink

On This Page

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: Multiprotein biomarker panels are associated with cardiovascular outcomes in observational studies and can achieve high discriminatory metrics in derivation/validation cohorts, but they add limited incremental predictive value over established risk factors and lack evidence that their use changes management or improves outcomes.not applicable

Quality and quantity of peer-reviewed evidence are insufficient for broad clinical adoption (e.g., HART CADhs lacks adequate published validation).

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.

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.

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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1/2

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).

inv-30: Net reclassification index ranking — CAC > carotid plaque > CIMT

Net reclassification index rankingSystematic review reported net reclassification: CAC ≥11.2% > carotid plaque ≥2% > CIMT 3%.

inv-31: Lp(a) thresholds - heterogeneity — variable cutoffs across studies

Heterogeneity of Lp(a) thresholdsStudies use variable cutoffs and percentiles for elevated Lp(a); no single uniform threshold is broadly applicable across populations.

inv-32: Lp(a) abnormal threshold example (ATTICA cohort)

Example abnormal Lp(a) threshold (ATTICA cohort)ATTICA study used ≥50 mg/dL to define abnormal Lp(a) and observed higher 10-year CVD event rates (24% vs 14% for <50 mg/dL).

inv-33: BNP/NT-proBNP abnormal threshold — thresholds cited for risk detection

BNP abnormal thresholdBNP ≥ 50 pg/mL is cited as an abnormal threshold for screening in people with diabetes (ADA).

NT-proBNP abnormal thresholdNT‑proBNP ≥ 125 pg/mL is cited as an abnormal threshold for screening in people with diabetes (ADA).

inv-34: Lp(a) and apoB thresholds cited as risk-enhancing — multiple thresholds referenced

Lp(a) risk-enhancing thresholdLp(a) ≥ 50 mg/dL (or ≥125 nmol/L) is identified as a risk‑enhancing factor in guideline statements (ACC/AHA, ESC/EAS, NLA).

ApoB risk-enhancing thresholdApoB ≥130 mg/dL is identified as a risk‑enhancing factor; guideline documents provide context for apoB use.

inv-35: Lp(a) risk thresholds — low/intermediate/high/very high categories

Lp(a) risk categoriesDefinitions used in guidance: low risk <30 mg/dL (<75 nmol/L); intermediate 30–50 mg/dL (75–125 nmol/L); high risk ≥50 mg/dL (≥125 nmol/L); very high inherited risk >180 mg/dL (>430 nmol/L).

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

Requests for multiprotein diagnostic biomarker panels, advanced lipoprotein analyses, Lp-PLA2, endothelial function testing, arterial compliance/waveform analysis, and carotid intima-media thickness are identified in the policy as having insufficient evidence of clinical utility. Expect these services to be reviewed closely and potentially denied or require prior authorization. Document clinical indication and how test results will change management when ordering.

Multiprotein panels (e.g., 0019M, 0308U, 0309U, 0415U, 0541U) — evidence insufficient to demonstrate clinical utility; prior authorization may be required.
Advanced lipoprotein testing (e.g., 0377U, 83701, 83704) — inconsistent evidence; PA may be required.
Lp-PLA2 (e.g., 83698) and Lp(a) (83695) — use per guideline-based indications; broader use may be subject to review.
Endothelial function testing (PAT, brachial ultrasound) and arterial compliance (e.g., 93050, SphygmoCor/EndoPAT devices) — unsupported for routine risk stratification; expect denials without strong justification.
Carotid IMT (93895) — not supported for routine screening; document why testing is expected to change management.

Documentation Required

Laboratory and device compliance

Laboratories and device vendors must comply with applicable regulatory and quality standards. Advanced lipoprotein analysis and similar assays should be performed in CLIA-certified laboratories and in accordance with any stated FDA clearances or 510(k) summaries for devices used. FDA clearance alone does not establish coverage.

Advanced lipoprotein analysis must meet Clinical Laboratory Improvement Amendments (CLIA) quality standards.
Device-specific 510(k) clearances (e.g., Endo PAT 2000, SphygmoCor systems) are informational; they do not imply routine screening coverage.
Providers should ensure tests are performed by appropriately accredited labs and that device use aligns with intended FDA indications.

Documentation Required

Measurement, evidence sufficiency, and outcome/utility documentation

Documentation expectations: the policy emphasizes the heterogeneity of measurement techniques and limited evidence. When ordering tests with limited evidence, document the specific clinical indication, the intended management change based on results, and any thresholds or decision points that will be used to act on results.

Document measurement method and laboratory performing the assay (to address heterogeneity in techniques).
State how results will alter clinical management (e.g., medication change, further testing, referral).
Provide any relevant prior test results, family history, or guideline-based indications supporting testing.

Note

Therapy sequencing and reference to member-specific plan

Therapy sequencing and other procedural requirements are not specified in this segment. Lp(a) is discussed as an independent risk marker; there are guideline recommendations for when to measure it. Always refer to member-specific benefit plans for coverage decisions and to determine whether step-therapy or other utilization management applies.

No explicit step-therapy or sequencing rules are provided in the excerpt; Lp(a) is independent of LDL-C and may be measured once per lifetime per some guidelines.
Providers must reference the member-specific benefit plan for any PA, step therapy, or coverage restrictions.
In event of conflict, the member-specific benefit plan governs.

Documentation Required

Biomarker thresholds for diabetes screening

Specific biomarker thresholds referenced by external guidance should be used when applicable and documented. For diabetes patients, the American Diabetes Association notes BNP ≥ 50 pg/mL and NT-proBNP ≥ 125 pg/mL as abnormal thresholds; interpret these values in clinical context.

BNP threshold: ≥ 50 pg/mL identified as abnormal for consideration in diabetes screening context.
NT-proBNP threshold: ≥ 125 pg/mL identified as abnormal for consideration in diabetes screening context.
Document comorbidities that may affect natriuretic peptide levels when using thresholds to guide care.

Denial Risk

Endothelial function testing and routine screening — denial risk

Endothelial function testing (e.g., PAT, flow-mediated dilation) and routine use of expanded lipid panels, CIMT, arterial compliance testing, and similar assays for population screening are considered unsupported or unproven for routine risk stratification. Anticipate denials unless strong, individualized justification is provided and documented.

Endothelial function assessment lacks sufficient evidence to establish clinical utility — avoid routine screening use.
Expanded lipid panels and ABI screening in asymptomatic adults are discouraged by guideline bodies and may be denied.
Requests for arterial compliance testing, CIMT, and similar procedures may be subject to denial.

Note

Reference member-specific plan

When coverage is uncertain or evidence is limited, providers should explicitly reference the member-specific benefit plan and any applicable federal/state mandates. The policy excerpt is informational and may be superseded by member plan terms.

Verify member-specific benefits and state/federal mandates prior to ordering.
In the event of conflict, member-specific benefit plan language governs coverage decisions.

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.

inv-64: Multiprotein diagnostic biomarker panels definition

Definition — Multiprotein diagnostic biomarker panelsAssays combining concentrations of multiple proteins (eg, hs‑troponin, adiponectin, KIM‑1, NT‑proBNP, osteopontin, TIMP‑1, IL‑16) with an algorithm to report a risk score for obstructive CAD or MACE (proprietary examples include HART CADhs and HART CVE).

inv-65: CIMT (alternate entry) — definition and context

CIMT — alternate contextCIMT measures common carotid artery IMT; large meta-analyses and trials have associated CIMT progression with CVD endpoints but heterogeneity in measurement techniques and uncertain impact on management limits routine use.

inv-66: Lp(a) definition — genetic atherogenic lipoprotein and thresholds

Definition — Lp(a)Lipoprotein(a) is an atherogenic, genetically determined lipoprotein with plasma levels associated with increased ASCVD and aortic valve stenosis risk; thresholds vary by guidance and population.

inv-67: Abnormal Lp(a) — ATTICA cohort threshold example

ATTICA cohort abnormal Lp(a) thresholdIn the ATTICA prospective cohort, an Lp(a) threshold of ≥50 mg/dL was used to define abnormal status and was associated with approximately doubled 10‑year CVD risk.

inv-68: Lp-PLA2 (alternate) — biomarker context for plaque stability

Lp-PLA2 — alternate contextMeta-analysis across diverse vascular territories found Lp‑PLA2 mass/activity had diagnostic accuracy for plaque stability, but substantial heterogeneity and lack of standardized thresholds limit clinical utility.

inv-69: Cholesterol efflux capacity (CEC) — definition and measurement context

Definition — Cholesterol efflux capacity (CEC)CEC measures HDL functional capacity to remove cholesterol from macrophages (reverse cholesterol transport); observational meta-analyses report lower CEC in CAD and an association with reduced adverse events, but assays and cutoffs are heterogeneous.

inv-70: PAT / RHI — peripheral arterial tonometry definition

Definition — Peripheral arterial tonometry (PAT) / RHIFingertip pulse amplitude–based, noninvasive test of digital microvascular reactivity (PAT ratio or reactive hyperemia index [RHI]); studies show inconsistent associations with composite CVD events and limited utility for routine screening.

inv-71: Lp(a) — additional definition and clinical associations

Lp(a) — additional clinical associationsLp(a) is largely genetically determined; elevated levels are causal for ASCVD and associated with aortic valve stenosis; several societies recommend at‑least‑once measurement in adults to refine risk.

inv-72: ApoB — definition and clinical role

Definition — ApoBApolipoprotein B (apoB) reflects atherogenic particle number and may better align with ASCVD risk than LDL‑C when discordant; guidelines recommend apoB measurement in select contexts (eg, high TG, diabetes).

inv-73: Advanced lipoprotein testing (particle size/number, NMR) — definition and current recommendations

Advanced lipoprotein testing (NMR/particle size) — definitionSpecialized assays for lipoprotein particle size/number (eg, NMR) that report particle characteristics; tests are not standardized and are not routinely recommended for screening due to limited added predictive value.

Cardiovascular Disease Risk Tests (Coverage Criteria)

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Coverage Criteria and Clinical Rationale

Procedural and Billing Codes

Provider Requirements, Prior Authorization, and Documentation

Clinical Background and Scope

Definitions and Test Descriptions

Policy Revision History