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Medical Policy: 02.04.04
Original Effective Date: September 2002
Reviewed: September 2011
Revised: September 2008
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:
A high serum cholesterol level is recognized as a major risk factor for coronary artery disease (CAD), also known as coronary heart disease (CHD). Serum cholesterol is transported in low-density lipoprotein (LDL) particles, and these are considered the most atherogenic component of serum cholesterol. The statin drugs (i.e., HMG CoA reductase inhibitors) mainly lower levels of LDL and clinical trials have shown that the use of these drugs has resulted in a significant reduction in new coronary events.
However, LDL particles are not uniform in size or density, and two subclass patterns, (A and B) have been described. The subclass pattern B is frequently associated with a more atherogenic lipoprotein profile (ALP). LDL subclass pattern B consists of higher levels of triglyceride, apoprotein B (which indicates the number of LDL particles rather than their content), intermediate density lipoprotein (IDL), very low-density lipoprotein (VLDL) and a lower level of high-density lipoprotein (HDL). An increased prevalence of small dense LDL particles has been noted in patients with CAD.
Therefore, measurement of LDL particle density or diameter has been proposed as a technique for further risk stratification in patients with elevated LDL levels, or for patients with normal LDL levels who have other high risk factors for CAD, or to predict response to a particular therapy.
LDL particle diameter can be measured using nuclear magnetic resonance or ultracentrifugation while particle density can be measured by gradient gel electrophoresis (GGE). GGE is the most commonly used lab technique.
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Prior Approval:
Not applicable
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Policy:
Measurement of small-diameter lipoprotein particles or number of lipoprotein particles (i.e., particle concentration) is considered investigational as a technique of assessing cardiac risk or response to therapy.
Numerous non-traditional lipid measurements have been proposed for use in improving risk prediction for cardiovascular disease. In general, while there is evidence that several markers provide some incremental accuracy in risk prediction, it has not been established that the incremental accuracy provides clinically important information beyond that of traditional lipid measures. Furthermore, no study has provided high-quality evidence that measurement of lipid markers leads to changes in management that improve health outcomes.
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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 diagnostic codes.
- 83700 Lipoprotein, blood; electrophoretic separation and quantitation
- 83701 Lipoprotein, blood; high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed (eg, electrophoresis, ultracentrifugation)
- 83704 Lipoprotein, blood; quantitation of lipoprotein particle numbers and lipoprotein particle subclasses (eg, by nuclear magnetic resonance spectroscopy)
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Selected References:
- St-Pierre, A.C., Ruel, I.L., Cantin, B., et al. Comparison of various Electrophoretic Characteristics of LDL Particles and Their Relationship to the Risk of Ischemic Heart Disease. Circulation 2001; 104:2295-2299.
- Lamarche, B., St-Pierre, A.C., Ruel, I.L., Cantin, B., Dagenais, G.R., Despres, J.P. A prospective, population-based study of low density lipoprotein particle size as a risk factor of ischemic heart disease in men. The Canadian Journal of Cardiology 2001;17(8):859-865.
- Superko, H.R. Small, dense, low-density lipoprotein and atherosclerosis. Current Atherosclerosis Report 2000; 2:226-231.
- Festa, A. Small, Dense Low Density Lipoprotein (LDL) and the Insulin Resistance Syndrome (IRS). Clinical Laboratory 2001; 47:111-118.
- Williams, PT, et al. Smallest LDL Particles Are Most Strongly Related to Coronary Disease Progression in Men. Arteriodcler Thromb Vasc Biol. February 2003;(23) 314-321.
- Mackey RH, Kuller LH, et al. Hormone therapy, lipoprotein subclasses, and coronary calcification: the Healthy Women Study. Arch Intern Med. 2005 Mar 14;165(5):510-5.
- St-Pierre AC, Cantin B, et al. Low-density lipoprotein subfractions and the long-term risk of ischemic heart disease in men: 13-year follow-up data from the Quebec Cardiovascular Study. Arterioscler Thromb Vasc Bio. 2005 Mar;25(3)553-9.
- National Cholesterol Education Program. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel. Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Final Report. National Heart, Lung, Blood Institute. National Institutes of Health. NIH Publication No. 02-5215. September 2002.
- Brunzell JD, Davidson M, et al. Lipoprotein Management in Patients With Cardiometabolic Risk. Diabetes Care, volume 31, number 4, April 2008
- Greenland P, Alpert JS, Beller GA et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll cardiol 2010; 56(25):e50-103.
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Policy History:
Date Reason Action
September 2011 Annual review Policy renewed
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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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