UnitedHealthcare Cardiovascular Risk Tests Coverage Update

Not medically necessary / Unproven tests

Unproven and not medically necessary when used as methods to determine cardiovascular risk or to manage cardiovascular disease (state: Kansas).

Primary exclusion: Arterial compliance testing using waveform analysis for cardiovascular disease risk is unproven and not medically necessary due to insufficient evidence of efficacy.

See supporting evidence summaries.

Primary exclusion: Carotid intima-media thickness (CIMT) measurement as an effective screening tool for management of cardiovascular disease is unproven and not medically necessary.

See supporting evidence summaries.

Primary exclusion: Advanced lipoprotein analyses (including lipoprotein(a), subfractions, particle size, NMR, ultracentrifugation) as methods to determine cardiovascular disease risk are unproven and not medically necessary.

Includes assays and particle-number/size methods referenced in policy.

Primary exclusion: Lipoprotein-associated phospholipase A2 (Lp-PLA2) testing is unproven and not medically necessary as a method to determine cardiovascular disease or ischemic stroke risk.

Insufficient quality evidence and heterogeneous assays limit clinical utility.

Primary exclusion: Endothelial function assessment (e.g., peripheral arterial tonometry [PAT], brachial artery flow-mediated dilation) as a prognostic indicator for cardiovascular disease risk is unproven and not medically necessary.

Conflicting cohort results and lack of demonstrated impact on management or outcomes.

Primary exclusion: Specified multiprotein diagnostic biomarker panels and algorithm-reported risk scores (including listed protein combinations and aptamer-based microarray panels) are unproven and not medically necessary.

See enumerated protein panels in policy (e.g., HDL reverse cholesterol transport CEC panel, 3-protein and 4-protein panels, seven-protein panel).

Coverage rationale (informational)

Coverage stance based on available evidence:

Overall evidence conclusions: Available evidence does not demonstrate that CIMT testing or Lp(a) measurement, when used routinely, clearly alters clinical management or improves patient-centered outcomes; associations with events exist but clinical utility is unestablished.

Multiple large cohort studies, systematic reviews, and analyses show associations but do not establish improved outcomes with routine use.

When testing may be considered: CIMT or Lp(a) measurement may be considered in research settings or selectively when results would meaningfully change management and this rationale is documented; comparative evidence shows coronary artery calcium (CAC) scoring has superior discrimination to CIMT in intermediate-risk individuals.

Documentation should link testing to a specific management change; consider CAC before CIMT for risk discrimination.

Evidence summary for coverage consideration

Summary statements from the evidence:

Lp(a) evidence: Systematic reviews and large cohort analyses report that elevated Lp(a) is associated with increased risk of major adverse cardiovascular events (MACE), myocardial infarction, stroke subtypes, revascularization, and cardiovascular mortality, but heterogeneity in thresholds and populations limits clinical applicability and evidence that measurement changes outcomes is lacking.

See individual-level meta-analyses and systematic reviews.

Lp-PLA2 evidence: Meta-analyses and cohort studies demonstrate associations between higher Lp-PLA2 mass/activity and increased risk of stroke and coronary heart disease, but low-quality evidence, assay heterogeneity, and lack of trials showing management benefit prevent conclusions about clinical utility.

Additional well-designed clinical trials are needed.

Multiprotein risk scores: Multiprotein biomarker panels and algorithm-reported risk scores show statistical associations with cardiovascular outcomes and, in some derivation/validation cohorts, high discrimination; however, these tests provide minimal incremental predictive value beyond established risk factors and there is no evidence that their use improves clinical outcomes.

Endothelial Function Assessment

Endothelial function assessment (PAT, brachial flow-mediated dilation) — summary

Endothelial function testing — coverage stance: Endothelial function assessment (e.g., peripheral arterial tonometry, brachial artery flow-mediated dilation) lacks sufficient evidence of clinical effectiveness or utility to establish cardiovascular risk or to guide management and is not supported for routine use.

Cohort and observational studies show conflicting results and do not demonstrate that routine measurement predicts CVD events or changes clinical outcomes.

CEC and Multiprotein Risk Scores

Cholesterol efflux capacity (CEC) and multiprotein risk scores — summary

CEC association with CAD: Systematic reviews and meta-analyses report that lower cholesterol efflux capacity (CEC) is associated with higher coronary artery disease risk, with some dose–response relationships; associations with cardiovascular mortality are inconsistent and assays/cutoffs are not standardized.

Incremental clinical utility and impact on outcomes have not been demonstrated.

Multiprotein biomarker panels: Some multiprotein models demonstrated high discrimination for obstructive CAD in derivation and limited validation cohorts (AUC ~0.85), but studies did not assess whether using these models improves clinical management or outcomes and external validation is limited.

Panel performance does not equate to proven clinical utility.

When testing may be appropriate

Guidance summaries from multiple professional organizations:

Lp(a) measurement: Measure Lp(a) at least once in adulthood to refine cardiovascular risk; consider measurement for individuals with premature ASCVD, family history of premature CVD, recurrent/progressive ASCVD despite optimal therapy, or calcific aortic valve disease. Elevated Lp(a) (commonly ≥50 mg/dL or ≥125 nmol/L) is viewed as a risk modifier and >180 mg/dL indicates very high inherited risk.see thresholds

ESC/EAS and NLA recommend at least one lifetime measurement and selective use for risk reclassification.

ApoB measurement: Consider apoB measurement for risk assessment, particularly when LDL-C is discordant with the clinical picture or in individuals with high triglycerides, diabetes, obesity/metabolic syndrome, or very low LDL-C.none

NLA supports apoB's use in selected clinical scenarios.

Advanced lipoprotein tests (particle size/number):

The following tests and panels are enumerated as unproven and not medically necessary for determining cardiovascular risk or managing cardiovascular disease due to insufficient evidence of efficacy: arterial compliance testing using waveform analysis; carotid intima-media thickness (CIMT) measurement for screening/management; advanced lipoprotein analyses (including lipoprotein(a), subfractions, and particle size); lipoprotein-associated phospholipase A2 (Lp-PLA2); endothelial function assessment (e.g., peripheral arterial tonometry [PAT], brachial artery ultrasound); and the specified multiprotein diagnostic biomarker panels (including aptamer-based protein arrays, cholesterol efflux capacity algorithms measuring multiple HDL apolipoproteins, and the listed multi-protein algorithmic panels).

CIMT and advanced lipoprotein testing (including Lp(a)) are called out as not appropriate when ordered solely for routine risk assessment without a documented plan showing how results would change management. The policy states evidence is insufficient that measuring CIMT or Lp(a) improves clinical decision-making or patient outcomes, and recommends that testing be limited to situations where the result would meaningfully alter treatment or follow-up.

Multiprotein blood tests and proprietary algorithm-scored panels lack sufficient peer-reviewed evidence of clinical utility. Individual-level analyses and independent evidence reviews identified statistical associations with outcomes but minimal incremental predictive value beyond established risk factors and an absence of studies demonstrating improved clinical outcomes when the tests are used to guide care; specific proprietary assays (for example, the HART CADhs test) currently lack adequate published data to support routine clinical use.

Routine assessment of endothelial function (e.g., PAT, brachial flow-mediated dilation) and ordering of expanded lipid panels (particle sizing or NMR) for asymptomatic individuals are not supported. Peer-reviewed studies show inconsistent associations between endothelial function measures and incident cardiovascular events, and major guideline statements (ACC/AHA, ASCP) do not recommend these tests for routine risk assessment.

Professional society guidance discourages routine ordering of expanded lipid panels and routine screening with additional risk markers (e.g., ABI, CAC, high-sensitivity CRP) in asymptomatic adults. The ASCP specifically recommends against routine expanded lipid panels, the USPSTF found insufficient evidence for ABI screening in asymptomatic adults, and VA/DoD guidance suggests against routine use of extra risk markers; these positions support limiting routine use of additional biomarkers beyond standard lipid testing.

When making coverage determinations, applicable federal, state, or contractual benefit plan requirements take precedence over this policy. In the event of a conflict, those governing terms control, and UnitedHealthcare may modify policies as necessary; providers should check applicable plan terms before relying on this policy for coverage decisions.

Scope: this policy addresses evaluation and medical necessity determinations for tests intended to refine cardiovascular risk assessment, including noninvasive measures of arterial compliance (pulse wave analysis/waveform-derived indices), carotid intima-media thickness (CIMT), and advanced lipoprotein testing (high-resolution fractionation, particle sizing/NMR, and measurements such as Lp(a)), as well as related biomarker tests covered elsewhere in this document.

CIMT and advanced lipoprotein testing are considered not medically necessary when performed solely for routine risk assessment without documentation that the test result will change clinical management. The policy emphasizes that while associations with outcomes exist, the evidence does not demonstrate that these measurements alter treatment to improve clinical outcomes.

The clinical utility of Lp-PLA2, multiprotein biomarker panels, and cholesterol efflux capacity (CEC) is not established. Meta-analyses and cohort studies show associations between higher Lp-PLA2 and stroke/CHD risk, and multiprotein panels correlate with outcomes in some cohorts, but heterogeneity of assays, lack of standardized methods, and absence of data demonstrating improved outcomes when these tests guide care limit support for routine clinical use.

Endothelial function testing (PAT or brachial artery ultrasound) and routine expanded lipid particle testing (particle sizing, NMR) lack sufficient evidence of clinical utility to support routine cardiovascular risk assessment. Cohort analyses report conflicting or weak associations and guideline statements do not endorse routine use; well-designed studies demonstrating impact on management and outcomes are needed.

Routine use of advanced lipoprotein testing (particle sizing/NMR) and routine peripheral arterial disease/CVD risk screening with ABI in asymptomatic adults is discouraged. Specialty statements recommend selective use of apoB and Lp(a) in specific scenarios rather than routine population screening, and USPSTF/VA-DoD guidance do not support routine additional risk-marker screening in asymptomatic populations.

Coding and Diagnostic Thresholds

Denial Risk

Denial risk for unproven tests

Denial risk: Claims for advanced or proprietary cardiovascular biomarker tests, vascular function tests, and specialty lipid assays that lack strong evidence of clinical utility or conflict with the member's benefit plan (e.g., explicitly excluded laboratory services, investigational testing exclusions, or out-of-network benefit limitations) may be denied. Providers should verify member benefits and medical necessity prior to ordering.

Denial triggers: benefit plan exclusions, investigational coding (e.g., unlisted or proprietary U-codes without prior authorization), tests performed for screening in asymptomatic low-risk individuals

Denial Risk

CIMT insufficient evidence

Carotid intima-media thickness (CIMT): ACC/AHA guidance does not recommend routine CIMT for initial CVD risk assessment and considers CIMT not recommended for routine use in asymptomatic adults; some guidance suggests CIMT may be reasonable in select intermediate-risk adults when performed with standardized equipment and trained operators. Given inconsistent evidence of incremental clinical utility over established risk markers, CIMT is considered insufficient evidence for routine coverage of screening.

CIMT (e.g., CPT 93895 for quantitative CIMT) — insufficient evidence for routine use

Denial Risk

Advanced lipoprotein testing insufficient evidence

Advanced lipoprotein testing (including NMR-derived particle analyses, high-resolution fractionation, and proprietary multi-analyte lipoprotein panels) lacks consistent evidence of added clinical benefit beyond a standard fasting lipid profile for routine risk assessment. ACC/AHA guidance advises against routine measurement of lipid parameters beyond a standard lipid panel in asymptomatic adults.

Codes: 0052U, 0377U, 83704 — advanced lipoprotein analyses (NMR, ultracentrifugation)
Provider action: Prefer established risk markers (standard lipid profile, LDL-C, non-HDL-C, apoB when indicated) before ordering advanced tests

Denial Risk

Endothelial function testing — insufficient evidence

Endothelial and arterial function testing (e.g., peripheral flow-mediated dilation, arterial stiffness measures such as cfPWV, arterial pressure waveform analysis) currently have limited or selective recommendations. ACC/AHA advises that peripheral flow-mediated dilation is not recommended for routine risk assessment; arterial stiffness measures are not recommended outside research settings. While some meta-analyses report prognostic associations (cfPWV cutoffs clustered near ~10.7–11.5 m/s in pooled analyses), incremental clinical utility and impact on management remain uncertain.

CPT 93050 — arterial pressure waveform analysis (informational)
cfPWV pooled cutoff points ~10.7–11.5 m/s (reported prognostic thresholds) — not established as routine clinical decision thresholds

Prior Authorization

Provider action: Prefer established risk markers first

Provider action: Prefer established, guideline-recommended risk markers and documented clinical indications prior to ordering advanced biomarker or vascular function tests. Use advanced tests selectively when results would change management and after verifying member coverage. Step therapy: This policy does not specify step-therapy requirements for these tests; however, clinicians should follow payer-specific utilization management processes when applicable.

Preferred initial evaluation: standard fasting lipid profile, assessment of conventional risk factors, and guideline-recommended risk enhancers (e.g., Lp(a) if indicated)
If ordering advanced lipid or vascular tests, document how results will influence treatment decisions and confirm benefit coverage ahead of testing

Provider Actions, Documentation, and Authorization Guidance

Prior Authorization

Prior authorization recommended for CIMT and advanced lipoprotein tests

Prior authorization is recommended when carotid intima-media thickness (CIMT) or advanced lipoprotein testing (including Lp(a), particle size/number, or proprietary multiprotein panels) is requested to ensure documented clinical justification given lack of established clinical utility.

Document how test results would meaningfully change management before approving testing.

Note

Prior authorization not specified for HART CADhs (Hayes review)

No specific prior authorization instructions are provided for the HART CADhs proprietary test; Hayes concluded there is insufficient published, peer-reviewed evidence to fully evaluate HART CADhs, implying likely noncoverage without clinical utility data.

If HART CADhs is requested, expect requests to require supporting peer-reviewed clinical utility evidence.

Prior Authorization

Prior authorization guidance for endothelial function and advanced lipoprotein tests

Endothelial function tests (e.g., PAT, flow‑mediated dilation) and advanced lipoprotein testing beyond standard lipid panels are generally not recommended for routine risk assessment; if prior authorization is requested, justification should reference guideline-supported indications.

Use guideline-supported indications when submitting authorization (e.g., NLA/ACC statements where applicable).

Note

Regulatory clearance does not equal coverage

FDA clearance or device listings (for example, EndoPAT 2000 510(k) clearance) are informational; regulatory status alone is not a basis for coverage decisions.

Devices with 510(k) clearance are not automatically covered; coverage decisions must reference clinical utility and benefit terms.

Note

Use of InterQual and alternate criteria

UnitedHealthcare uses InterQual for primary medical/surgical criteria and may use UnitedHealthcare Medical Policies approved by the Kansas Department of Health and Environment if InterQual lacks applicable criteria.

Check InterQual first; if no applicable criteria exist, consult UnitedHealthcare Medical Policies per Kansas approval.

Note

Provider action: operational details (author to populate)

Operational detail to be provided by policy author — include payer-specific prior authorization codes, contact points, or workflow instructions for submitting clinical rationale and documentation.

Author should populate required submission fields, reviewer contact info, and any form identifiers used for authorization requests.

Step Therapy

Prefer established risk markers (e.g., CAC) before CIMT

Consider established risk markers such as coronary artery calcium (CAC) scoring before ordering CIMT when the clinical goal is improved risk discrimination, since CAC outperformed CIMT in comparative studies of intermediate-risk individuals.

Document why CAC is not appropriate or available if proceeding with CIMT for risk discrimination.

Step Therapy

Step therapy: not specified in this policy

This document does not specify step therapy requirements for advanced biomarkers or diagnostic tests.

If a payer-specific step protocol exists, follow that protocol; none is provided here.

Step Therapy

Step approach: consider BNP/NT‑proBNP first in diabetes

For individuals with diabetes, consider natriuretic peptide screening (BNP or NT‑proBNP) as an initial biomarker approach; abnormal thresholds cited are BNP ≥ 50 pg/mL and NT‑proBNP ≥ 125 pg/mL.

Use natriuretic peptide results to guide further evaluation and targeted therapies before ordering advanced multiprotein panels.

Note

Use advanced lipid tests (apoB, Lp(a)) selectively

Specialty guidance supports selective use of advanced lipid tests: measure apoB and Lp(a) selectively to refine risk assessment (not as routine first-line tests).

Document indication for apoB or Lp(a) (see documentation expectations) when ordering these tests.

Note

Provider action: operational summary (author to populate)

Operational summary placeholder for authors to specify payer submission templates or short summary guidance for case managers and reviewers.

Author to insert brief operational summary (e.g., typical turnaround, required attachments).

Billing Rule

Code listing is informational — inclusion does not imply coverage

The code listings in this policy are provided for informational reference only; listing of a code does not imply that the service described is a covered benefit.

Benefit coverage is determined by applicable federal, state, or contractual plan terms.

Documentation Required

Clinical rationale required linking test to management change

Documentation submitted for CIMT or Lp(a) should clearly link the test result to a specific, documented management change because the literature does not demonstrate that these tests routinely alter management or outcomes.

State the intended management action that would follow from a positive or actionable test result.

Documentation Required

Study measurement reporting — include numeric assay details

Evidence reports include specific study measurement values (e.g., Lp(a) levels, Lp‑PLA2 mass/activity, CEC assay values); when relevant, provide reported numeric results and assay units in documentation to aid review.

Include assay method, units, and reported thresholds from the laboratory when submitting results for review.

Documentation Required

Multiprotein panel documentation required (biomarkers, model details)

When multiprotein biomarker panels are used, documentation should list the biomarkers included, the clinical variables used in the algorithm, cohort characteristics, and validation performance metrics (e.g., AUC).

Provide algorithm description and external validation evidence when available.

Documentation Required

Document indication when ordering apoB or Lp(a)

When ordering apoB or Lp(a), document the clinical indication such as risk stratification, family history of premature CVD, premature ASCVD, recurrent/progressive ASCVD despite therapy, or calcific aortic valve disease.

Note that guidelines recommend at least one lifetime Lp(a) measurement for adults.

Note

Reference governing benefit terms for coverage determinations

When coverage decisions conflict with this policy, reference the governing federal, state, or contractual benefit plan terms, which take precedence over the standard policy.

Verify applicable plan terms before denying or approving services.

Denial Risk

Denial risk for services listed as unproven/not medically necessary

Services explicitly listed as unproven and not medically necessary (arterial compliance/waveform analysis, CIMT for screening/management, advanced lipoprotein analyses, Lp‑PLA2, endothelial function assessment, and listed multiprotein panels) are at risk for denial.

Expect denials when these tests are requested for routine risk assessment without documented plan for management change.

Denial Risk

Denial risk: CIMT lacks sufficient evidence of clinical benefit

Requests for CIMT testing may be denied because clinical evidence does not show added benefit beyond traditional risk assessment and there is inadequate evidence that CIMT alters management or improves outcomes.

Authorization should include clear justification of how CIMT results will change management if requested.

Denial Risk

Denial risk: advanced lipoprotein testing has insufficient evidence

Advanced lipoprotein testing (including Lp(a) and particle/numbers) lacks established clinical utility to change management or improve outcomes; requests without clear management impact or standardized testing methods may be limited or denied.

Provide standardized assay details and clinical action thresholds if available when requesting coverage.

Note

No procedural authorization specified in this policy section

This document portion does not specify explicit authorization, prior authorization, or billing requirements; lack of such procedural instructions may result in denials based on absence of clinical utility evidence.

Follow payer-specific authorization workflows in absence of policy-specified procedures.

Denial Risk

Denial risk: endothelial function testing — insufficient evidence

Endothelial function testing (PAT or brachial artery flow‑mediated dilation) lacks sufficient evidence of clinical utility to establish CVD risk; routine use to predict events or change management is not supported and may be denied.

If requested, document specific clinical circumstances and how results would alter patient management.

Denial Risk

Potential denial triggers: routine expanded lipid panels or routine additional risk marker screening

Ordering expanded lipid panels (particle sizing/NMR) or routine additional risk marker screening (e.g., high‑sensitivity CRP, ABI, CAC) for asymptomatic screening are discouraged by specialty statements and USPSTF positions and may trigger denial.

Provide clinical justification and documentation of how results would change management when requesting these tests.

Denial Risk

Denial triggers: benefit plan conflicts govern coverage

When benefit plan terms (federal, state, or contractual) conflict with this policy, those terms govern coverage decisions and may lead to denial or approval contrary to the policy language.

Confirm applicable plan contract provisions before finalizing coverage decisions.

Definitions and Test Descriptions

Arterial compliance / pulse wave analysis — definition

DefinitionNoninvasive assessment of arterial stiffness using pulse wave velocity, augmentation index, or waveform-derived indices to estimate arterial elasticity and central arterial pressures

Common measurescfPWV (carotid–femoral pulse wave velocity), brachial–ankle PWV, augmentation index, and arterial pressure waveform analysis

Clinical use proposedProposed as early indicators of CVD and for prognostic assessment, but incremental clinical utility is not established

Carotid intima-media thickness (CIMT) — definition and intended use

DefinitionUltrasound measurement of carotid artery wall (intima-media) thickness proposed as a surrogate for atherosclerotic burden and coronary disease risk

Measurement methodHigh-resolution carotid ultrasound images analyzed by software to quantify IMT

Intended useProposed for risk stratification and screening, though evidence is insufficient that CIMT adds clinical benefit beyond traditional risk assessment

Advanced lipoprotein analysis / multiprotein diagnostic panels — summary

DefinitionLaboratory assays including high-resolution lipoprotein fractionation (NMR, ultracentrifugation), Lp(a), Lp-PLA2, and algorithm-scored multiprotein biomarker panels intended to predict cardiovascular risk

ExamplesNMR particle profiling, vertical auto profile ultracentrifugation, Lp(a) immunoassays, Lp-PLA2 mass/activity, and proprietary multiprotein algorithm tests (e.g., HART)

Clinical utilityAlthough associations with outcomes exist, clinical utility to change management and improve outcomes is not established

CCA-IMT context and reported values

CCA-IMT baseline valueMean baseline common carotid artery IMT approximately 0.71 mm in pooled prospective studies

AssociationsHigher baseline CCA-IMT was log-linearly associated with odds of developing incident carotid plaque (adjusted OR per SD ~1.34)

LimitationsHeterogeneity in measurement methods, device generations, and plaque definitions across studies

Lp(a) — definition and genetic determination

DefinitionLipoprotein(a) [Lp(a)] is an atherogenic lipoprotein particle whose circulating levels are largely genetically determined

Clinical associationsElevated Lp(a) is associated with increased ASCVD, MACE, revascularization, and aortic valve stenosis in observational studies and systematic reviews

Measurement variabilityThresholds and units vary across studies (mg/dL and nmol/L); guideline recommendations advise at least one lifetime measurement

Lp(a) — association with MACEs and revascularization

Association with eventsSystematic reviews and cohort analyses report associations between elevated Lp(a) and increased risk of MACE and higher rates of revascularization

Evidence limitationsHeterogeneity in thresholds, outcome definitions, and populations limit pooled estimates and clinical utility conclusions

ImplicationElevated Lp(a) may identify individuals for intensified risk-factor management, but evidence that measurement changes outcomes is not established

Lp-PLA2 — definition and investigational use

DefinitionLipoprotein-associated phospholipase A2 (Lp-PLA2) is a vascular inflammatory enzyme measured as mass or activity and studied as a biomarker for stroke and coronary heart disease

Investigational useInvestigated as an adjunct to conventional risk assessment, but clinical utility to guide treatment or improve outcomes is not established

EvidenceMeta-analyses show modest associations with stroke and ischemic stroke; assay heterogeneity limits interpretation

Cholesterol efflux capacity (CEC) — definition and associations

DefinitionCholesterol efflux capacity (CEC) measures HDL's functional ability to remove cholesterol from macrophages (reverse cholesterol transport)

Association with CADSystematic reviews/meta-analyses found lower CEC associated with higher CAD risk; association with cardiovascular mortality inconsistent

Clinical utilityAssays and cutoffs vary and incremental value to guide management or improve outcomes has not been established

Cholesterol efflux capacity (CEC) — duplicated definitional entry

Duplicate noteCEC defined as HDL functional assay measuring reverse cholesterol transport capacity; associated with CAD risk in observational studies

Reconciliation neededAuthors should reconcile duplicate CEC entries into a single definition noting assay variability and limited clinical utility evidence

Evidence noteMeta-analyses report lower CEC in CAD; association with mortality less consistent

PAT / RHI — peripheral arterial tonometry definition

DefinitionPeripheral arterial tonometry (PAT) is a noninvasive fingertip measurement of pulse amplitude during reactive hyperemia reported as a PAT ratio or Reactive Hyperemia Index (RHI)

Physiologic basisRecords finger arterial pulse amplitude response to ischemia-induced reactive hyperemia as a marker of microvascular endothelial function

Evidence summaryCohort studies show inconsistent associations with composite CVD events; PAT not proven for routine screening

Lp(a) — recommended measurement frequency and notes

Measurement frequencyMeasure Lp(a) at least once in adulthood (ESC/NLA recommendations)

Risk associationElevated Lp(a) associates with increased ASCVD and aortic valve stenosis risk; ~20% population prevalence >50 mg/dL (ESC)

Clinical actionDocument indication when ordering Lp(a) (family history of premature CVD, premature ASCVD, recurrent/progressive ASCVD, or calcific aortic valve disease)

ApoB — definitional note

DefinitionApolipoprotein B (ApoB) is a measure of atherogenic particle number that may better reflect ASCVD risk when discordant with LDL-C

Clinical roleConsider apoB when LDL-C is discordant, in individuals with high triglycerides, diabetes, obesity/metabolic syndrome, or very low LDL-C

Guideline supportNLA 2024 expert consensus endorses apoB's utility for improved risk assessment

Referenced biomarkers and vascular tests

Referenced biomarkers/testsLipoprotein(a) (Lp[a]), pulse wave velocity (cfPWV), peripheral arterial tonometry (PAT), carotid intima-media thickness (CIMT), cholesterol efflux capacity (CEC), Lp-PLA2, apoB, natriuretic peptides (BNP/NT-proBNP), NMR/particle sizing, ABI, coronary artery calcium (CAC), and multiprotein biomarker panels

ContextThese biomarkers and vascular tests are cited throughout the document as measures evaluated for CVD risk stratification, with variable evidence and guideline positions

Coding linkageSeveral proprietary and laboratory CPT/PLA codes for these tests are listed in the policy coding section for reference

OpenPayer

Cardiovascular Disease Risk Tests (for Kansas Only)

Coverage Criteria and Clinical Rationale

Coding and Diagnostic Thresholds

Provider Actions, Documentation, and Authorization Guidance

Background and Scope

Definitions and Test Descriptions

Policy Revision History