Management of risk factors for cardiovascular disease (CVD) may be considered primary prevention for those who have not previously experienced an atherosclerotic vascular event, and there are several diagnostic tests designed to help assess non-traditional risk factors for cardiovascular disease.

Clinical Guideline Coverage Criteria

The Plan considers cardiovascular risk testing as reasonable and medically necessary when used to predict the risk of recurrent events in those with coronary artery disease (CAD) so that applicable interventions can be introduced and improved.

Limitations

The Plan does not cover the following as they are non-covered or investigational due to insufficient evidence of efficacy:

1. Advanced and novel lipoprotein analysis (subfractions, apolipoproteins,) for evaluation of cardiovascular risk.
2. Multi-protein diagnostic biomarker, such as 3 proteins (high sensitivity [hs] troponin, adiponectin, and kidney injury molecule-1 [KIM-1]) or 4 proteins (NT-proBNP, osteopontin, tissue inhibitor of metalloproteinase-1 [TIMP-1], and KIM-1) with algorithm and reported as a risk score.
3. Cardiovascular disease risk panels, consisting of multiple individual biomarkers intended to assess cardiac risk to include:
• Long-chain omega-3 fatty acids for cardiovascular risk testing.
• LDL subclass (e.g., Boston Heart Cholesterol Balance® Test).
• Lipoprotein (e.g., direct measurement, intermediate density lipoproteins (IDL) remnant lipoproteins).
• Lipoprotein- associated phospholipase (LP-PLA2).
4. Arterial compliance testing using waveform analysis to determine cardiovascular risk.
5. Carotid intima-media thickness (CIMT) measurement.
6. Endothelial function assessment tools (e.g., peripheral arterial tonometry, brachial artery pressure ultrasound).

Please refer to the Noncovered and Investigational Services MNG: Harvard Pilgrim Health Care and Tufts Health Plan.