CurrentUnitedHealthcarePolicy N/A

Reimbursement for biomarker testing for autoimmune rheumatic disease

Defines UnitedHealthcare Community Plan Medicaid reimbursement rules for specific biomarker and proprietary algorithm serum tests used in evaluation of autoimmune rheumatic diseases; applies to claims submitted on CMS-1500 or UB-04 forms for Community Plan Medicaid products and all providers.

Policy Summary

PayerUnitedHealthcare

PolicyReimbursement for biomarker testing for autoimmune rheumatic disease

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFeb 2, 2026

Next Review DateN/A

Key ActionProviders must submit accurate claims using CPT/CMS coding guidance for services billed on CMS-1500 or UB-04 forms.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3procedure codes listed as not considered for reimbursement

Community Plan Medicaidproducts to which policy applies

CMS-1500 & UB-04claim forms referenced

exceptions listedstates flagged as exempt from policy

Coverage Criteria for Biomarker and Algorithmic Serum Tests

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

inv-01: ANA/ENA testing

Covered when the following conditions are met:

UnitedHealthcare will not consider reimbursement of antinuclear antibodies (ANA) and extractable nuclear antigen (ENA) testing procedure codes for a general encounter without abnormal findings.

inv-02: Cell-bound complement activation

Coverage stance:

UnitedHealthcare will not consider reimbursement of the following procedure code for the use of cell-bound complement activation products (e.g., Avise Lupus): 0312U.

inv-03: Proprietary biomarker panels

Coverage stance:

UnitedHealthcare will not consider reimbursement of serum biomarker panel testing with proprietary algorithms and index scores for the diagnosis of systemic lupus erythematosus or connective tissue diseases when submitted for those conditions (procedure codes: 0062U, 0446U, 0447U).

Coding and Reimbursement Status

ANA/ENA testing codes not considered for reimbursement for general encounters without abnormal findingsCPTNot Covered

86038	Antinuclear antibodies (ANA) testing
86039	Antinuclear antibodies (ANA) testing
86235	Extractable nuclear antigen (ENA) testing

Cell-bound complement activation testing not considered for reimbursementHCPCSNot Covered

0312U

Cell-bound complement activation product testing (e.g., Avise Lupus)

Proprietary biomarker panel/index tests not considered for diagnosis of SLE or connective tissue diseaseHCPCSNot Covered

0062U	Proprietary serum biomarker panel/index
0446U	Proprietary serum biomarker panel/index
0447U	Proprietary serum biomarker panel/index

Provider Responsibilities and Claim Submission

Billing Rule

Submit accurate claims using CPT/CMS coding guidance

Providers are responsible for submitting accurate claims and must follow CPT/CMS and other coding guidance when billing UnitedHealthcare Community Plan Medicaid. This policy applies to services reported on the CMS-1500 (1500) and UB-04 (UB-04) claim forms (or electronic equivalents).

Ensure claim coding correctly describes the services provided and follows CPT®, CMS, or other coding guidelines referenced by UnitedHealthcare Community Plan.
Be aware that UnitedHealthcare Community Plan may use discretion in interpreting and applying this reimbursement policy and that other factors (regulatory requirements, contracts, benefit design) can affect reimbursement.

Definitions and Test Descriptions

Biomarker testing — definition

DefinitionBiomarker testing associated with autoimmune rheumatic disease: laboratory assays used to detect biological markers relevant to autoimmune rheumatic conditions.

ScopeApplies to testing submitted for evaluation of systemic lupus erythematosus and other autoimmune rheumatic diseases under UnitedHealthcare Community Plan Medicaid.

Claim forms referencedApplies to services billed on CMS-1500 and UB-04 forms for Community Plan Medicaid.

ANA/ENA testing — definition and reimbursement note

DefinitionAntinuclear antibodies (ANA) and extractable nuclear antigen (ENA) testing: immunologic assays to detect autoantibodies against nuclear and extractable nuclear antigens.

Reimbursement ruleUnitedHealthcare will not consider reimbursement of ANA and ENA testing procedure codes for a general encounter without abnormal findings.

Affected codesCPT codes 86038, 86039, 86235 are listed as not considered for reimbursement in this context.

Cell-bound complement activation — definition and example

DefinitionCell-bound complement activation testing: assays that measure complement activation products bound to cellular components (example: Avise Lupus).

Reimbursement ruleUnitedHealthcare will not consider reimbursement of cell-bound complement activation product testing (procedure code 0312U).

Example productAvise Lupus cited as an example of cell-bound complement activation testing.

Proprietary serum biomarker panels — definition

DefinitionProprietary serum biomarker panels: serum tests that use vendor-specific algorithms and index scores to generate diagnostic or risk indices for diseases such as systemic lupus erythematosus or connective tissue diseases.

Reimbursement ruleUnitedHealthcare will not consider reimbursement of serum biomarker panel testing with proprietary algorithms and index scores when submitted for the diagnosis of systemic lupus erythematosus or connective tissue diseases.

Affected codesHCPCS codes 0062U, 0446U, 0447U are identified as proprietary panel/index tests not considered for reimbursement for those diagnoses.