CurrentUnitedHealthcarePolicy N/A

Pancreatic enzyme testing reimbursement (lipase/amylase/trypsin/biomarkers)

Defines UnitedHealthcare Community Plan reimbursement rules for pancreatic enzyme and related biomarker testing (lipase, amylase, trypsin, TAP and listed biomarkers) for Medicaid products and claims filed on UB-04/1500 forms. Affects all network and non-network providers billing these services.

Policy Summary

PayerUnitedHealthcare

PolicyPancreatic enzyme testing reimbursement (lipase/amylase/trypsin/biomarkers)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionReimbursement is considered for serum lipase (83690) for initial determination of acute pancreatitis, limited to no more than once per week per member across all providers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1x/weekmax frequency (lipase)

83690lipase code

82150,83519,83520,83529,84145,86140not reimbursed codes

Community Plan Medicaidapplicability

Coverage Criteria for Pancreatic Enzyme Testing

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Serum lipase coverage

Reimbursable when ALL of the following are met:

All of the following

Member presents with one or more of the listed signs or symptoms: mild to severe epigastric pain (may spread to the back), nausea, vomiting, tender epigastrium, abdominal distention, hypoactive bowel sounds, fever, rapid pulse, tachypnea, hypoxemia, hypotension, anorexia, diarrhea, Cullen sign, or Grey Turner sign.
Procedure code 83690 (serum lipase concentration) is billed.
Service is provided no more than once per week per member across all providers (once per 7-day period).<= 1 per 7 days

UnitedHealthcare will not consider reimbursement of the serum lipase procedure code for any conditions other than those listed above.

Non-covered enzyme/biomarker tests

The following tests are not reimbursable for the assessment, prognosis, or determination of acute pancreatitis:

Any of the following not covered

Serum amylase (82150) is not separately reimbursed when submitted in conjunction with serum lipase on the same date of service.
Urine amylase (82150) is not reimbursed for the initial determination of acute pancreatitis.
Serum or urine trypsin/trypsinogen/TAP (83519) is not reimbursed for assessment, prognosis, or determination of acute pancreatitis.
Biomarker procedure codes (83520, 83529, 84145, 86140) will not be reimbursed for the assessment, prognosis, or determination of acute pancreatitis.

When serum amylase is submitted in conjunction with lipase on the same date of service, separate reimbursement for amylase will not be considered.

Procedure Codes and Frequency Limits

Covered CPT/Procedure CodesmixedCovered

83690

Serum lipase concentration

Not covered CPT/Procedure CodesmixedNot Covered

82150	Amylase, serum or plasma (also listed as not separately reimbursed when submitted with lipase on same date of service; urine amylase not reimbursed)
83519	Trypsin/trypsinogen/TAP, serum or urine
83520	Biomarker procedure code
83529	Biomarker procedure code
84145	Biomarker procedure code
86140	Biomarker procedure code

Coding frequency limit

Frequency limitNo more than once per week per member across all providers

ScopeApplies to serum lipase (procedure code 83690) for the initial determination of acute pancreatitis

Aggregate applicationLimit is applied across all billing and rendering providers (individual providers and facilities) for the same member

Provider Billing Rules and Denial Notices

Prior Authorization

Prior authorization / frequency limit for serum lipase (83690)

UnitedHealthcare will consider reimbursement of serum lipase (83690) for the initial determination of acute pancreatitis, limited to no more than once per week when billed for the listed conditions.

Applies to procedure code 83690 (serum lipase concentration).
Limit: no more than one service per 7-day period (once per week) per member across all providers.

Denial Risk

Denial risk — nonpayable enzyme and biomarker tests

UnitedHealthcare will not consider reimbursement for several pancreatic enzyme and biomarker tests used for assessment, prognosis, or determination of acute pancreatitis, including serum amylase when billed with lipase the same date, urine amylase, trypsin/trypsinogen/TAP, and specified biomarker procedure codes.

Do not submit serum amylase (82150) separately when billed with lipase on the same date of service.
Urine amylase (82150) is not reimbursed for initial determination of acute pancreatitis.
Serum or urine trypsin/trypsinogen/TAP (83519) is not reimbursed for assessment/prognosis/determination of acute pancreatitis.
Biomarker procedure codes (83520, 83529, 84145, 86140) will not be reimbursed for assessment/prognosis/determination of acute pancreatitis.

Scope and Limit Definitions

Once-per-week definition

DefinitionOnce per week limitation applicable across all billing/rendering providers for each member

ClarificationApplies across all billing and/or rendering providers (including any individual provider or any facility) for each individual member for the same date of service

InterpretationThe limitation is not per individual provider; it is a member-level limit aggregated across providers

Application / Scope

Form applicabilityApplies to claims reported on UB-04, CMS-1500 (1500 Health Insurance Claim Form), or electronic equivalents

Product applicabilityApplies to UnitedHealthcare Community Plan Medicaid products

Provider applicabilityApplies to all network and non-network providers, including hospitals, ambulatory surgical centers, physicians, and other qualified health care professionals