CurrentUnitedHealthcarePolicy 2025R8214B

Medicare Advantage reimbursement for cardiovascular biomarker testing (CMS 1500 / UB04)

Defines UnitedHealthcare Medicare Advantage reimbursement stances and coding guidance for various cardiovascular disease biomarker tests (Apo B, Lp(a), CRP, homocysteine, novel biomarkers, and multi-biomarker panels) when billed on CMS 1500 or UB04 forms; applies to providers submitting claims to UnitedHealthcare Medicare Advantage.

Policy Summary

PayerUnitedHealthcare

PolicyMedicare Advantage reimbursement for cardiovascular biomarker testing (CMS 1500 / UB04)

Policy CodePolicy 2025R8214B

Change TypeLanguage and code update

Effective Date

Next Review Date

Key ActionRefer to CMS or your local carrier for billing requirements and prior authorization guidance.

SourceLink

POLICY UPDATE CHANGES

Policy language and code update in Reimbursement Guidelines section.

New Policy established.

Policy published.

1Apo B code(s)

onceLp(a) frequency

multipleNovel biomarkers

multiplePanel codes not covered

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Coverage Criteria for Cardiovascular Biomarkers

Apo B reimbursement criteria

Covered when ALL of the following conditions are met:

Apolipoprotein B (Apo B) reimbursable

Clinical indications (ONE or more of the following)
- Hypertriglyceridemia
- Diabetes mellitus
- Obesity or metabolic syndrome
- Dyslipidemias (such as very low LDL-C)
- On lipid therapy
- Familial dysbetalipoproteinemia or familial combined hyperlipidemia
Apo B procedure code billed: 82172
Not billed for indications other than those listed above (claims for other conditions will not be considered for reimbursement).

Lp(a) coverage

Covered when ALL of the following are met:

ALL of the following

Member age is 19 years or older
Lp(a) procedure code billed: 83695
Reimbursed once per lifetime for the individual

CRP coverage

Not reimbursed for cardiovascular disease risk assessment unless otherwise specified by applicable CMS/local guidance:

ALL of the following

Conventional C-reactive protein testing is being ordered for cardiovascular disease risk assessment
Procedure code: 86140
UnitedHealthcare will not consider reimbursement for this use.

Conventional CRP testing may be subject to other coverage rules outside of cardiovascular risk assessment; follow CMS/local carrier guidance as applicable.

Homocysteine coverage

Not reimbursed when used as a screening study to evaluate cardiovascular disease risk:

ALL of the following

Homocysteine testing is ordered as a screening study to evaluate cardiovascular disease risk
Procedure code: 83090
UnitedHealthcare will not consider reimbursement for this use.

Novel biomarkers exclusion

The following novel lipid and non‑lipid biomarkers are NOT considered medically necessary for cardiovascular disease risk assessment:

ALL of the following

Excluded biomarkers (ONE or more)
- Apolipoprotein AI
- Apolipoprotein E
- B-type natriuretic peptide
- Cystatin C
- Fibrinogen

Panel testing exclusion

Not covered for cardiovascular disease risk assessment:

ALL of the following

Cardiovascular disease panel testing consisting of multiple individual biomarkers is ordered
Procedure codes: 0052U, 0308U, 0309U, 0415U
UnitedHealthcare will not consider reimbursement for panel testing of multiple biomarkers for cardiovascular disease risk assessment.

Coding and Billing Guidance

Apolipoprotein B (Apo B)CPTCovered

82172

Apolipoprotein B

Lipoprotein Lp(a)CPTCovered

83695

Lipoprotein, Lp(a)

Conventional CRPCPTNot Covered

86140

C-reactive protein (conventional)

Homocysteine testingCPTNot Covered

83090

Homocysteine; quantitative

Novel lipid and non-lipid biomarkersmixedNot Covered

82610	Apolipoprotein AI
83700	LDL direct
83701	HDL direct
83704	Triglycerides
83719	Other lipid
83722	Lipoprotein particle testing
83880	Lipoprotein particle quantitation
85384	Cystatin C
85415	B-type natriuretic peptide
0541U	Novel biomarker (proprietary)

Cardiovascular disease multi-biomarker panelsCPTNot Covered

0052U	Cardiovascular disease panel (multiple biomarkers)
0308U	Cardiovascular disease panel
0309U	Cardiovascular disease panel
0415U	Cardiovascular disease panel

Lp(a) age and frequency

Reimbursed frequencyLp(a) (CPT 83695) is reimbursed once per lifetime for individuals age 19 or older.

Age eligibilityApplies to individuals age ≥19 years.

Applicable codeCPT code 83695 (Lipoprotein, Lp(a)).

Billing formsWhen billed on CMS 1500 or UB04 forms to UnitedHealthcare Medicare Advantage.

Provider Actions and Billing Notes

Prior Authorization

Prior authorization and billing guidance — check CMS/local carrier

UnitedHealthcare Medicare Advantage reimbursement policies do not include notations regarding prior authorization requirements; providers should consult CMS or their local carrier for prior authorization and billing rules. Stay current with CMS/local carrier updates for any changes that may affect claim submission or authorization needs.

Providers should refer to CMS or local carrier websites for billing requirements and prior authorization guidance.
Facilities may sign up for CMS/local carrier distributions for policy or regulatory changes.
Contact the member’s customer service (number on back of ID card) for benefit-specific authorization requirements.

Scope and Definitions

Scope of policy

Policy scopeApplies to editing and reimbursement for services associated with cardiovascular disease risk assessment when billed with designated conditions.

Service limitationsCertain services are subject to specific procedure code limitations; see coding section for covered and not‑covered codes.

ApplicabilityApplies to providers submitting claims to UnitedHealthcare Medicare Advantage (CMS 1500 / UB04).

Guidance on updatesUnitedHealthcare Medicare Advantage may modify this policy to comply with changes in CMS policy and national coding guidelines; providers should monitor CMS/local carrier websites for updates.

Prior authorization note

Prior authorization noteUnitedHealthcare Medicare Advantage reimbursement policies do not include notations regarding prior authorization requirements; providers should consult CMS or local carrier sites for billing and authorization guidance.