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Medical Policy: 02.04.22
Original Effective Date: December 2009
Reviewed: August 2011
Revised: July 2010
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Homocysteine is an amino acid found normally in the body. Several vitamins, including B6, B12, and folic acid aid in the metabolism of homocysteine. Evidence suggests that elevated levels of homocysteine provoke an inflammatory response in the arteries and increase the potential for thrombosis contributing to the development of atherosclerosis.
Plasma levels of homocysteine have been researched as a risk factor for cardiovascular disease, initially based on the observation that patients with hereditary homocystinuria, an inborn error of metabolism associated with high plasma levels of homocysteine, had a markedly increased risk of cardiovascular disease. Interest in homocysteine, as a potentially modifiable risk factor, has been stimulated by the epidemiologic finding that levels of homocysteine are inversely correlated with levels of folate. This has raised the possibility that treatment with folic acid might lower homocysteine levels and, in turn, reduce the risk of coronary artery disease (CAD). While there is significant evidence for a relationship between plasma homocysteine and cardiovascular disease, studies have not shown a clinical benefit to lowering plasma levels. Despite the evidence suggesting an increased intake of folic acid will reduce homocysteine levels; it has not been proven that reduction in homocysteine by vitamin therapy and/or dietary modification will reduce cardiovascular disease risk. Additionally, no studies have demonstrated an effect of homocysteine-lowering therapy on mortality or major cardiovascular events in patients with known coronary artery disease.
Recently, the Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine (SEARCH) trial revealed that, despite lowering blood homocysteine levels for up to 7 years, supplementation with folic acid and vitamin B12, had no beneficial effects on major vascular events such as stroke and coronary events. While there is a known association between increased homocysteine levels and increased risk of heart disease, the most recent evidence indicates the association is not causal.
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Prior Approval:
Not applicable
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Policy:
Measurement of plasma homocysteine is considered not medically necessary in the screening, diagnosis, and management of cardiovascular disease
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
- 83090 Homocysteine
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Selected References:
- Eikelboom JW, Lonn E, Genest J Jr et al. Homocyst(e)ine and cardiovascular disease: a critical review of the epidemiologic evidence. Ann Intern Med. 1999 Sep 7; 131(5):363-75.
- Lonn E, Yusuf S, Arnold MJ et al. Homocysteine lowering with folic acid and B vitamins in vascular disease. N Engl J Med. 2006 Apr 13; 354(15):1567-77.
- Jamison RL, Hartigan P, Kaufman JS et al. Effect of homocysteine lowering on mortality and vascular disease in advanced chronic kidney disease and end-stage renal disease: a randomized controlled trial. JAMA. 2008 Sep 12; 298(10):1163-70.
- Ebbing M, Bleie O, Ueland PM et al. Mortality and cardiovascular events in patients treated with homocysteine-lowering B vitamins after coronary angiography: a randomized controlled trial. JAMA. 2008 Aug 20; 300(7): 795-804.
- Song Y, Cook NR, Albert CM et al. Effects of homocysteine-lowering treatment with folic acid and B vitamins on risk of type-2 diabetes mellitus in women: a randomized controlled trial. Diabetes. 2009 Jun 2. [Epub ahead of print]
- Wald DS, Law M, Morris JK. Homocysteine and cardiovascular disease: evidence on causality from a meta-analysis. BMJ. 2002 Nov 23; 325(7374):1202.
- Grundy SM, Cleeman JI, Merz CN et al. Implications of recent trials for the National Cholesterol Education program Adult Treatment Panel III guidelines. Circulation. 2004 Jul 13; 110(2):227-39.
- Moat SJ. Plasma total homocysteine: instigator or indicator of cardiovascular disease? Ann Clin Biochem. 2008 Jul; 45(Pt 4):345-8.
- Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine (SEARCH) Collaborative Group, Armitage JM, Bowman L, Clarke RJ et al. Effects of homocysteine-lowering with folic acid plus vitamin B12 vs placebo on mortality and major morbidity in myocardial infarction survivors: a randomized trial. JAMA. 2010;303(24):2486-94.
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Policy History:
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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