CurrentUnitedHealthcarePolicy 2025R8O07B

Reimbursement for biomarker testing for autoimmune rheumatic disease

Defines UnitedHealthcare's reimbursement stance and coding guidance for biomarker and related laboratory testing billed on CMS 1500/UB04 for Commercial and Individual Exchange plans; applies to network and non-network providers submitting outpatient and facility claims.

Policy Summary

PayerUnitedHealthcare

PolicyReimbursement for biomarker testing for autoimmune rheumatic disease

Policy CodePolicy 2025R8O07B

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit accurate claims using codes that correctly describe services; policy may be applied with discretion and may reference CPT/CMS coding guidelines.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7Listed not-covered procedure codes

Commercial & ExchangeApplies to

CMS-1500/UB04Claim forms

Coverage Criteria

Non-reimbursable biomarker tests

UnitedHealthcare will not consider reimbursement for the following tests under the stated conditions:

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.

ANA and ENA testing (CPT 86038, 86039, 86235) are not reimbursed for a general encounter without abnormal findings.

Cell-bound complement activation testing (0312U) is not reimbursed.

Serum biomarker panels with proprietary algorithms/index scores (0062U, 0446U, 0447U) for the diagnosis of systemic lupus erythematosus or connective tissue diseases are not reimbursed when submitted for those conditions.

Operational note: UnitedHealthcare may apply this policy using discretion and may reference CPT/CMS coding guidelines; contract language, benefit documents, legislative mandates and other policies may affect reimbursement.

Coding Guidance and Examples

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

86038	Antinuclear antibodies (ANA) testing
86039	ANA titer by immunofluorescent technique
86235	ENA (extractable nuclear antigen) panel

Cell-bound complement activationHCPCSNot Covered

0312U

Cell-bound complement activation product testing (example: Avise Lupus)

Proprietary serum biomarker panels with algorithms/index scoresHCPCSNot Covered

0062U	Proprietary serum biomarker panel (index score) for SLE/CTD diagnosis
0446U	Proprietary serum biomarker panel (index score) for SLE/CTD diagnosis
0447U	Proprietary serum biomarker panel (index score) for SLE/CTD diagnosis

Provider Actions and Claim Submission

Billing Rule

Claim submission guidance — submit accurate claims using codes that correctly describe services

Submit accurate claims using the code or codes that correctly describe the health care services provided. UnitedHealthcare may reference Current Procedural Terminology (CPT), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines for definitional purposes only; references do not guarantee reimbursement. This policy is intended as a general reference and does not address every reimbursement scenario. UnitedHealthcare may exercise reasonable discretion in interpreting and applying this policy and other factors (for example: legislative mandates, provider contracts, enrollee benefit documents, other reimbursement/medical/drug policies) may supplement, modify or supersede this policy. Claim processing on different electronic systems may vary due to programming or other constraints.

Use codes that accurately describe the services rendered.
Follow CPT, CMS and other applicable coding guidelines where referenced.
Be aware that UnitedHealthcare may apply discretion in specific cases and that other policies or contractual terms may affect reimbursement.

Note

Scope of applicability — forms, products, network and non‑network applicability for reported services

This reimbursement policy applies to services reported on the CMS-1500 (1500 Health Insurance Claim Form), UB04 claim form or their electronic equivalents and successors. It applies to all UnitedHealthcare products and to both network and non‑network physicians and other qualified health care professionals, outpatient facility claims, Ambulatory Surgical Centers (ASC), Outpatient Surgical Centers (OSC), including but not limited to non‑network authorized and percent-of-charge contract physicians, other qualified health care professionals or facilities.

Forms: CMS-1500, UB04, electronic equivalents or successor forms.
Products: All UnitedHealthcare products.
Providers & Settings: All network and non-network physicians and other qualified health care professionals; outpatient facilities; ASCs; OSCs; non-network authorized and percent-of-charge contract providers.

Definitions

inv-07: Biomarker testing — definition and association with autoimmune rheumatic disease

DefinitionBiomarker testing associated with autoimmune rheumatic disease

PurposeDescribes reimbursement methodology for biomarker testing related to autoimmune rheumatic disease

ScopeIncludes tests used to evaluate autoimmune rheumatic disease; specific non-reimbursable procedures are listed separately in the policy

inv-08: ANA/ENA testing stance — definition and reimbursement stance for general encounter without abnormal findings

DefinitionAntinuclear antibodies (ANA) and extractable nuclear antigen (ENA) testing

Policy stanceUnitedHealthcare will not consider reimbursement of ANA and ENA testing procedure codes for a general encounter without abnormal findings

Example CPT codes listed as not reimbursed in this context86038, 86039, 86235