032 Form

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Medical Policy High-Sensitivity C-Reactive Protein Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History
• Endnotes
Policy Number: 032

BCBSA Reference Number: N/A
Related Policies
None Policy1 Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

Measurement of high sensitivity C-reactive protein (hsCRP) for assessment of coronary artery disease risk may be MEDICALLY NECESSARY in individuals who meet all the following criteria:

• The individuals must have undergone previous traditional risk assessment* and been found to have a 10-year risk of cardiovascular heart disease (CHD) between 10-20% (intermediate risk), AND • The test is performed in individuals considered to be metabolically stable and without obvious inflammatory or infectious conditions, AND • When the test is performed twice in a twelve-month period.

• Traditional cardiac risk assessment should consider: Individual gender, age, total cholesterol, HDL cholesterol, systolic blood pressure, smoking status, and personal and family medical history.

  Measurement of high sensitivity C-reactive protein (hsCRP) for assessment of coronary artery disease risk is considered NOT MEDICALLY NECESSARY in all other situations including, but not limited to:

  • Individuals already identified as high risk, OR • Individuals with established coronary artery disease, OR • Serial testing to monitor therapy; OR • Screening asymptomatic individuals among the general population.

  Prior Authorization Information
  Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
  Outpatient

2 • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required.

CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity:

CPT Codes CPT codes:

Code Description 86141 C-reactive protein; high sensitivity (hsCRP) The following ICD Diagnosis Codes are considered medically necessary when submitted with the CPT code above if medical necessity criteria are met: ICD-10 Diagnosis Codes ICD-10-CM- codes: Code Description E10.10 Type 1 diabetes mellitus with ketoacidosis without coma E10.11 Type 1 diabetes mellitus with ketoacidosis with coma E10.21 Type 1 diabetes mellitus with diabetic nephropathy E10.22 Type 1 diabetes mellitus with diabetic chronic kidney disease E10.29 Type 1 diabetes mellitus with other diabetic kidney complication E10.311 Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema E10.319 Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema E10.321 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E10.3211 Type 1 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy With Macular Edema, Right Eye E10.3212 Type 1 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy With Macular Edema, Left Eye E10.3213 Type 1 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy With Macular Edema, Bilateral E10.3219 Type 1 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy With Macular Edema, Unspecified Eye E10.329 Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E10.3291 Type 1 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy Without Macular Edema, Right Eye

3 E10.3292 Type 1 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy Without Macular Edema, Left Eye E10.3293 Type 1 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy Without Macular Edema, Bilateral E10.3299 Type 1 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy Without Macular Edema, Unspecified Eye E10.331 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E10.3311 Type 1 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy With Macular Edema, Right Eye E10.3312 Type 1 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy With Macular Edema, Left Eye E10.3313 Type 1 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy With Macular Edema, Bilateral E10.3319 Type 1 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy With Macular Edema, Unspecified Eye E10.339 Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E10.3391 Type 1 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy Without Macular Edema, Right Eye E10.3392 Type 1 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy Without Macular Edema, Left Eye E10.3393 Type 1 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy Without Macular Edema, Bilateral E10.3399 Type 1 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy Without Macular Edema, Unspecified Eye E10.341 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E10.3411 Type 1 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy With Macular Edema, Right Eye E10.3412 Type 1 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy With Macular Edema, Left Eye E10.3413 Type 1 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy With Macular Edema, Bilateral E10.3419 Type 1 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy With Macular Edema, Unspecified Eye E10.349 Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E10.3491 Type 1 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy Without Macular Edema, Right Eye E10.3492 Type 1 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy Without Macular Edema, Left Eye E10.3493 Type 1 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy Without Macular Edema, Bilateral E10.3499 Type 1 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy Without Macular Edema, Unspecified Eye E10.351 Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema E10.3511 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Macular Edema, Right Eye E10.3512 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Macular Edema, Left Eye E10.3513 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Macular Edema, Bilateral E10.3519 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Macular Edema, Unspecified Eye

4 E10.3521 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Involving The Macula, Right Eye E10.3522 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Involving The Macula, Left Eye E10.3523 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Involving The Macula, Bilateral E10.3529 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Involving The Macula, Unspecified Eye E10.3531 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Not Involving The Macula, Right Eye E10.3532 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Not Involving The Macula, Left Eye E10.3533 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Not Involving The Macula, Bilateral E10.3539 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Not Involving The Macula, Unspecified Eye E10.3541 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Combined Traction Retinal Detachment And Rhegmatogenous Retinal Detachment, Right Eye E10.3542 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Combined Traction Retinal Detachment And Rhegmatogenous Retinal Detachment, Left Eye E10.3543 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Combined Traction Retinal Detachment And Rhegmatogenous Retinal Detachment, Bilateral E10.3549 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Combined Traction Retinal Detachment And Rhegmatogenous Retinal Detachment, Unspecified Eye E10.3551 Type 1 Diabetes Mellitus With Stable Proliferative Diabetic Retinopathy, Right Eye E10.3552 Type 1 Diabetes Mellitus With Stable Proliferative Diabetic Retinopathy, Left Eye E10.3553 Type 1 Diabetes Mellitus With Stable Proliferative Diabetic Retinopathy, Bilateral E10.3559 Type 1 Diabetes Mellitus With Stable Proliferative Diabetic Retinopathy, Unspecified Eye E10.359 Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema E10.3591 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy Without Macular Edema, Right Eye E10.3592 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy Without Macular Edema, Left Eye E10.3593 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy Without Macular Edema, Bilateral E10.3599 Type 1 Diabetes Mellitus With Proliferative Diabetic Retinopathy Without Macular Edema, Unspecified Eye E10.36 Type 1 diabetes mellitus with diabetic cataract E10.37X1 Type 1 Diabetes Mellitus With Diabetic Macular Edema, Resolved Following Treatment, Right Eye E10.37X2 Type 1 Diabetes Mellitus With Diabetic Macular Edema, Resolved Following Treatment, Left Eye E10.37X3 Type 1 Diabetes Mellitus With Diabetic Macular Edema, Resolved Following Treatment, Bilateral E10.37X9 Type 1 Diabetes Mellitus With Diabetic Macular Edema, Resolved Following Treatment, Unspecified Eye E10.39 Type 1 diabetes mellitus with other diabetic ophthalmic complication E10.40 Type 1 diabetes mellitus with diabetic neuropathy, unspecified E10.41 Type 1 diabetes mellitus with diabetic mononeuropathy E10.42 Type 1 diabetes mellitus with diabetic polyneuropathy E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy

5 E10.44 Type 1 diabetes mellitus with diabetic amyotrophy E10.49 Type 1 diabetes mellitus with other diabetic neurological complication E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.59 Type 1 diabetes mellitus with other circulatory complications E10.610 Type 1 diabetes mellitus with diabetic neuropathic arthropathy E10.618 Type 1 diabetes mellitus with other diabetic arthropathy E10.620 Type 1 diabetes mellitus with diabetic dermatitis E10.621 Type 1 diabetes mellitus with foot ulcer E10.622 Type 1 diabetes mellitus with other skin ulcer E10.628 Type 1 diabetes mellitus with other skin complications E10.630 Type 1 diabetes mellitus with periodontal disease E10.638 Type 1 diabetes mellitus with other oral complications E10.641 Type 1 diabetes mellitus with hypoglycemia with coma E10.649 Type 1 diabetes mellitus with hypoglycemia without coma E10.65 Type 1 diabetes mellitus with hyperglycemia E10.69 Type 1 diabetes mellitus with other specified complication E10.8 Type 1 diabetes mellitus with unspecified complications E10.9 Type 1 diabetes mellitus without complications E11.00 Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic- hyperosmolar coma (NKHHC) E11.01 Type 2 diabetes mellitus with hyperosmolarity with coma E11.10 Type 2 diabetes mellitus with ketoacidosis without coma E11.11 Type 2 diabetes mellitus with ketoacidosis with coma E11.21 Type 2 diabetes mellitus with diabetic nephropathy E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease E11.29 Type 2 diabetes mellitus with other diabetic kidney complication E11.311 Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema E11.321 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema E11.3211 Type 2 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy With Macular Edema, Right Eye E11.3212 Type 2 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy With Macular Edema, Left Eye E11.3213 Type 2 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy With Macular Edema, Bilateral E11.3219 Type 2 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy With Macular Edema, Unspecified Eye E11.329 Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema E11.3291 Type 2 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy Without Macular Edema, Right Eye E11.3292 Type 2 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy Without Macular Edema, Left Eye E11.3293 Type 2 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy Without Macular Edema, Bilateral E11.3299 Type 2 Diabetes Mellitus With Mild Nonproliferative Diabetic Retinopathy Without Macular Edema, Unspecified Eye E11.331 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema E11.3311 Type 2 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy With Macular Edema, Right Eye

6 E11.3312 Type 2 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy With Macular Edema, Left Eye E11.3313 Type 2 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy With Macular Edema, Bilateral E11.3319 Type 2 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy With Macular Edema, Unspecified Eye E11.339 Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema E11.3391 Type 2 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy Without Macular Edema, Right Eye E11.3392 Type 2 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy Without Macular Edema, Left Eye E11.3393 Type 2 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy Without Macular Edema, Bilateral E11.3399 Type 2 Diabetes Mellitus With Moderate Nonproliferative Diabetic Retinopathy Without Macular Edema, Unspecified Eye E11.341 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema E11.3411 Type 2 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy With Macular Edema, Right Eye E11.3412 Type 2 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy With Macular Edema, Left Eye E11.3413 Type 2 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy With Macular Edema, Bilateral E11.3419 Type 2 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy With Macular Edema, Unspecified Eye E11.349 Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema E11.3491 Type 2 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy Without Macular Edema, Right Eye E11.3492 Type 2 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy Without Macular Edema, Left Eye E11.3493 Type 2 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy Without Macular Edema, Bilateral E11.3499 Type 2 Diabetes Mellitus With Severe Nonproliferative Diabetic Retinopathy Without Macular Edema, Unspecified Eye E11.351 Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema E11.3511 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Macular Edema, Right Eye E11.3512 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Macular Edema, Left Eye E11.3513 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Macular Edema, Bilateral E11.3519 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Macular Edema, Unspecified Eye E11.3521 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Involving The Macula, Right Eye E11.3522 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Involving The Macula, Left Eye E11.3523 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Involving The Macula, Bilateral E11.3529 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Involving The Macula, Unspecified Eye E11.3531 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Not Involving The Macula, Right Eye

7 E11.3532 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Not Involving The Macula, Left Eye E11.3533 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Not Involving The Macula, Bilateral E11.3539 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Traction Retinal Detachment Not Involving The Macula, Unspecified Eye E11.3541 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Combined Traction Retinal Detachment And Rhegmatogenous Retinal Detachment, Right Eye E11.3542 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Combined Traction Retinal Detachment And Rhegmatogenous Retinal Detachment, Left Eye E11.3543 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Combined Traction Retinal Detachment And Rhegmatogenous Retinal Detachment, Bilateral E11.3549 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Combined Traction Retinal Detachment And Rhegmatogenous Retinal Detachment, Unspecified Eye E11.3551 Type 2 Diabetes Mellitus With Stable Proliferative Diabetic Retinopathy, Right Eye E11.3552 Type 2 Diabetes Mellitus With Stable Proliferative Diabetic Retinopathy, Left Eye E11.3553 Type 2 Diabetes Mellitus With Stable Proliferative Diabetic Retinopathy, Bilateral E11.3559 Type 2 Diabetes Mellitus With Stable Proliferative Diabetic Retinopathy, Unspecified Eye E11.359 Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema E11.3591 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy Without Macular Edema, Right Eye E11.3592 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy Without Macular Edema, Left Eye E11.3593 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy Without Macular Edema, Bilateral E11.3599 Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy Without Macular Edema, Unspecified Eye E11.36 Type 2 diabetes mellitus with diabetic cataract E11.37X1 Type 2 Diabetes Mellitus With Diabetic Macular Edema, Resolved Following Treatment, Right Eye E11.37X2 Type 2 Diabetes Mellitus With Diabetic Macular Edema, Resolved Following Treatment, Left Eye E11.37X3 Type 2 Diabetes Mellitus With Diabetic Macular Edema, Resolved Following Treatment, Bilateral E11.37X9 Type 2 Diabetes Mellitus With Diabetic Macular Edema, Resolved Following Treatment, Unspecified Eye E11.39 Type 2 diabetes mellitus with other diabetic ophthalmic complication E11.40 Type 2 diabetes mellitus with diabetic neuropathy, unspecified E11.41 Type 2 diabetes mellitus with diabetic mononeuropathy E11.42 Type 2 diabetes mellitus with diabetic polyneuropathy E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy E11.44 Type 2 diabetes mellitus with diabetic amyotrophy E11.49 Type 2 diabetes mellitus with other diabetic neurological complication E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene E11.52 Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene E11.59 Type 2 diabetes mellitus with other circulatory complications E11.610 Type 2 diabetes mellitus with diabetic neuropathic arthropathy E11.618 Type 2 diabetes mellitus with other diabetic arthropathy E11.620 Type 2 diabetes mellitus with diabetic dermatitis E11.621 Type 2 diabetes mellitus with foot ulcer

8 E11.622 Type 2 diabetes mellitus with other skin ulcer E11.628 Type 2 diabetes mellitus with other skin complications E11.630 Type 2 diabetes mellitus with periodontal disease E11.638 Type 2 diabetes mellitus with other oral complications E11.641 Type 2 diabetes mellitus with hypoglycemia with coma E11.649 Type 2 diabetes mellitus with hypoglycemia without coma E11.65 Type 2 diabetes mellitus with hyperglycemia E11.69 Type 2 diabetes mellitus with other specified complication E11.8 Type 2 diabetes mellitus with unspecified complications E11.9 Type 2 diabetes mellitus without complications E11.A Type 2 diabetes mellitus without complications in remission E78.0 Pure hypercholesterolemia E78.00 Pure hypercholesterolemia, unspecified E78.010 Homozygous familial hypercholesterolemia [HoFH] E78.011 Heterozygous familial hypercholesterolemia [HeFH] E78.019 Familial hypercholesterolemia, unspecified E78.1 Pure hyperglyceridemia E78.2 Mixed hyperlipidemia E78.5 Hyperlipidemia, unspecified F17.210 Nicotine dependence, cigarettes, uncomplicated F17.218 Nicotine dependence, cigarettes, with other nicotine-induced disorders F17.219 Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders I10 Essential (primary) hypertension I16.0 Hypertensive urgency I16.1 Hypertensive emergency I16.9 Hypertensive crisis, unspecified R03.0 Elevated blood-pressure reading, without diagnosis of hypertension

Description C-reactive protein (CRP) is an acute phase reactant produced by the liver that has long been used to monitor inflammatory processes, such as infection and autoimmune diseases. Recent studies have suggested that low-level chronic inflammation may play a role in atherogenesis, and thus measurement of CRP has been investigated in various settings of cardiovascular disease, i.e., in patients with known cardiovascular disease, in patients with risk factors for cardiovascular disease, and as a general risk assessment tool for cardiovascular disease. To be used as a risk assessment tool, a greater precision at lower levels of CRP is needed such that the range of values collected in epidemiologic studies can be subdivided into quartiles and quintiles; in this way, the data from large epidemiologic studies can be applied to individual patients. Such technologies are collectively known as high sensitivity C-reactive protein (hsCRP).

An example of high-sensitivity C-reactive protein testing for assessment of coronary artery disease risk includes the ELISA test. All measurements of high-sensitivity C-reactive protein for assessment of coronary artery disease risk are considered investigational regardless of the commercial name, the manufacturer or FDA approval status except as noted in the policy statement.

Summary The existing observational evidence establishes that CRP is an independent predictor of cardiovascular disease across a wide spectrum of patient populations. The evidence also suggests that using CRP as a component of a risk assessment tool will result in a more accurate cardiac risk prediction. While there is no scientific literature that directly tests the hypothesis that measurement of C-reactive protein to assess CHD risk results in improved patient outcomes, following discussion with local practitioners and a review of the existing literature, BCBSMA has determined that measurement of high sensitivity C-reactive protein

9 (hsCRP) for assessment of coronary artery disease risk in the patients described in the policy statement is medically necessary.

Policy History Date Action 10/2025 Clarified coding information.
4/2025 Clarified Coding.
11/2024 Annual policy review. References reviewed. Policy statements unchanged. 11/2024.
1/2023 Medicare information removed. See MP #132 Medicare Advantage Management for local coverage determination and national coverage determination reference.
11/2022 Annual policy review. Policy updated with literature review through October 2022. References added. Policy statements unchanged. 4/2022 Annual policy review. Policy updated with literature review through April 2022.
References added. Policy statements unchanged. 5/2020 Annual policy review. Policy updated with literature review through April 2020. References added. Policy statements unchanged. 2/2016 Clarified coding language. 8/2015 Added coding language. 11/2011- 4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates.
No changes to policy statements.
4/2011 Reviewed - Medical Policy Group – Cardiology and Pulmonology. No changes to policy statements. 4/2010
Reviewed - Medical Policy Group – Cardiology. No changes to policy statements. 4/2009 Reviewed - Medical Policy Group – Cardiology. No changes to policy statements. 4/2008 Reviewed - Medical Policy Group – Cardiology. No changes to policy statements. 4/2007 Reviewed - Medical Policy Group – Cardiology. No changes to policy statements. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References

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    Endnotes

    1 Based on local expert opinion