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DESCRIPTIONLipoproteins are a class of heterogeneous particles of varying sizes and densities containing lipid and protein. These lipoproteins include cholesterol esters and free cholesterol, triglycerides, phospholipids and A, C, and E apoproteins. Total cholesterol comprises all the cholesterol found in various lipoproteins.
Factors that affect blood cholesterol levels include age, sex, body weight, diet, alcohol and tobacco use, exercise, genetic factors, family history, medications, menopausal status, the use of hormone replacement therapy, and chronic disorders such as hypothyroidism, obstructive liver disease, pancreatic disease (including diabetes), and kidney disease.
In many individuals, an elevated blood cholesterol level constitutes an increased risk of developing coronary artery disease. Blood levels of total cholesterol and various fractions of cholesterol, especially low density lipoprotein cholesterol (LDL -C) and high density lipoprotein cholesterol (HDL-C) are useful in assessing and monitoring treatment for that risk in patients with cardiovascular and related diseases.
The serum LDL concentration may be calculated using the Friedenwald formula (LDL=total cholesterol-HDL-triglcerides/5). This formula is valid only for triglyceride levels less than 400mg/dL. The LDL should be measured directly when the triglyceride level exceeds this value. This calculation may not accurately calculate the LDL in alcoholic patients. These patients may also require direct measurement of the serum LDL.
Blood levels of the above cholesterol components including triglyceride have been separated into desirable, borderline and high-risk categories by the National Heart, Lung, and Blood Institute in their report in 1993. These categories form a useful basis for evaluation and treatment of patients with hyperlipidemia. Therapy to reduce these risk parameters includes diet, exercise and medication, and fat weight loss, which is particularly powerful when combined with diet and exercise.
Related medical policies are –
POLICYScreening Lipid Testing
A lipid panel (CPT code 80061) is covered once per calendar year as part of the Healthy You! wellness benefit. Refer to Healthy You! Wellness Procedures medical policy for specific coverage guidelines per age group.
Diagnostic Lipid Testing
A lipid panel or any component of the panel may be considered medically necessary for evaluating atherosclerotic cardiovascular disease for patients meeting any of the following criteria:
A diagnostic lipid panel or any component of the panel may be considered medically necessary up to three (3) times per calendar year for monitoring dietary or pharmacologic therapy.
If no dietary or pharmacological therapy is advised, monitoring is considered not medically necessary.
POLICY GUIDELINESTo monitor the progress of patients on anti-lipid dietary management and pharmacologic therapy for the treatment of elevated blood lipid disorders, total cholesterol, HDL cholesterol and LDL cholesterol may be used. Triglycerides may be obtained if this lipid fraction is also elevated or if the patient is put on drugs (for example, thiazide diuretics, beta-blockers, estrogens, glucocorticoids, and tamoxifen) which may raise the triglyceride level.
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY05/01/2013: New policy added. Approved by Medical Policy Advisory Committee.
03/17/2014: Added ICD-9 Diagnosis code 706.1 to the Code Reference section. Policy statement unchanged.
05/15/2014: Added ICD-9 codes 070.0-070.9, 570, 571.40-571.49, 571.5, 572.0-572.8, 573.0, 573.3, 573.4, 646.70-646.73, and 751.62 to the Code Reference section.
09/02/2014: Added ICD-9 Diagnosis code 583.9 to the Code Reference section.
05/06/2015: Added ICD-9 diagnosis codes 256.4 and 277.7 to the Code Reference section.
SOURCE(S)Medicare National Coverage Determination 190.23 – Lipids Testing
Novitas LCD L32559 - Lipid Profile/Cholesterol Testing
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.