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National Coverage Determination (NCD)

Lipid Testing

190.23

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Tracking Information

Publication Number
100-3
Manual Section Number
190.23
Manual Section Title
Lipid Testing
Version Number
2
Effective Date of this Version
01/01/2005
Ending Effective Date of this Version
Implementation Date
03/11/2005
Implementation QR Modifier Date

Description Information

Benefit Category
Diagnostic Laboratory Tests


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

Lipoproteins 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. 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.
Indications and Limitations of Coverage

Indications

The medical community recognizes lipid testing as appropriate for evaluating atherosclerotic cardiovascular disease. Conditions in which lipid testing may be indicated include:

  • Assessment of patients with atherosclerotic cardiovascular disease.
  • Evaluation of primary dyslipidemia.
  • Any form of atherosclerotic disease, or any disease leading to the formation of atherosclerotic disease.
  • Diagnostic evaluation of diseases associated with altered lipid metabolism, such as: nephrotic syndrome, pancreatitis, hepatic disease, and hypo and hyperthyroidism.
  • Secondary dyslipidemia, including diabetes mellitus, disorders of gastrointestinal absorption, chronic renal failure.
  • Signs or symptoms of dyslipidemias, such as skin lesions.
  • As follow-up to the initial screen for coronary heart disease (total cholesterol + HDL cholesterol) when total cholesterol is determined to be high (>240 mg/dL), or borderline-high (200-240 mg/dL) plus two or more coronary heart disease risk factors, or an HDL cholesterol, <35 mg/dl.

To 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.

When monitoring long term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it may be reasonable to perform the lipid panel annually. A lipid panel at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia.

Any one component of the panel or a measured LDL may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.

Electrophoretic or other quantitation of lipoproteins may be indicated if the patient has a primary disorder of lipoid metabolism.

Effective January 1, 2005, the Medicare law expanded coverage to cardiovascular screening services. Several of the procedures included in this NCD may be covered for screening purposes subject to specified frequencies. See 42 CFR 410.17 and section 100, chapter 18, of the Claims Processing Manual Opens in a new window, for a full description of this benefit.

Limitations

Lipid panel and hepatic panel testing may be used for patients with severe psoriasis which has not responded to conventional therapy and for which the retinoid etretinate has been prescribed and who have developed hyperlipidemia or hepatic toxicity. Specific examples include erythrodermia and generalized pustular type and psoriasis associated with arthritis.

Routine screening and prophylactic testing for lipid disorder are not covered by Medicare. While lipid screening may be medically appropriate, Medicare by statute does not pay for it. Lipid testing in asymptomatic individuals is considered to be screening regardless of the presence of other risk factors such as family history, tobacco use, etc.

Once a diagnosis is established, one or several specific tests are usually adequate for monitoring the course of the disease. Less specific diagnoses (for example, other chest pain) alone do not support medical necessity of these tests.

When monitoring long term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it is reasonable to perform the lipid panel annually. A lipid panel at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia.

Any one component of the panel or a measured LDL may be medically necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.

If no dietary or pharmacological therapy is advised, monitoring is not necessary.

When evaluating non-specific chronic abnormalities of the liver (for example, elevations of transaminase, alkaline phosphatase, abnormal imaging studies, etc.), a lipid panel would generally not be indicated more than twice per year.

Note: Scroll down for links to the quarterly Covered Code Lists (including narrative).
Cross Reference

Medicare Claims Processing Manual Opens in a new window, Chapter 120, Clinical Laboratory Services Based on Negotiated Rulemaking.
Claims Processing Instructions

Transmittal Information

Transmittal Number
28
Coverage Transmittal Link
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/r28ncd.pdf Opens in a new window
Revision History

02/2005 - Added reference to screening benefits. Effective date 1/01/05. Implementation date 3/11/05. (TN 28 Opens in a new window) (CR 3690)

07/2004 - Published NCD in NCD Manual without change to narrative contained in PM AB-02-110. Coding guidance published in Medicare Lab NCD Manual. Effective and Implementation dates NA. (TN 17 Opens in a new window) (CR 2130)

07/2002 - Implemented NCD. Effective date 11/25/02. Implementation date 1/01/03. (TN AB-02-110 Opens in a new window) (CR 2130)
Other

Covered Code Lists (including narrative)

January 2025 (PDF) (ICD-10 Opens in a new window)
October 2024 (PDF) (ICD-10 Opens in a new window)
July 2024 (PDF) (ICD-10 Opens in a new window)
April 2024 (PDF) (ICD-10 Opens in a new window)
January 2024 (PDF) (ICD-10 Opens in a new window)
October 2023 (PDF) (ICD-10 Opens in a new window)
July 2023 (PDF) (ICD-10 Opens in a new window)
April 2023 (PDF) (ICD-10 Opens in a new window)
January 2023 (PDF) (ICD-10 Opens in a new window)
October 2022 (PDF) (ICD-10 Opens in a new window)
July 2022 (PDF) (ICD-10 Opens in a new window)
April 2022 (PDF) (ICD-10 Opens in a new window)
January 2022 (PDF) (ICD-10 Opens in a new window)
October 2021 (PDF) (ICD-10 Opens in a new window)
July 2021 (PDF) (ICD-10 Opens in a new window)
April 2021 (PDF) (ICD-10 Opens in a new window)
January 2021 (PDF) (ICD-10 Opens in a new window)
October 2020 (PDF) (ICD-10 Opens in a new window)
July 2020 (PDF) (ICD-10 Opens in a new window)
April 2020 (PDF) (ICD-10 Opens in a new window)
January 2020 (PDF) (ICD-10 Opens in a new window)
October 2019 (PDF) (ICD-10 Opens in a new window)
July 2019 (PDF) (ICD-10 Opens in a new window)
April 2019 (PDF) (ICD-10 Opens in a new window)
January 2019 (PDF) (ICD-10 Opens in a new window)
October 2018 (PDF) (ICD-10 Opens in a new window)
July 2018 (PDF) (ICD-10 Opens in a new window)
April 2018 (PDF) (ICD-10 Opens in a new window)
January 2018 (ICD-10 Opens in a new window)
October 2017 (ICD-10 Opens in a new window)
July 2017 (ICD-10 Opens in a new window)
April 2017 (ICD-10 Opens in a new window)
January 2017 (ICD-10 Opens in a new window)
October 2016 (ICD-10 Opens in a new window)
January 2016 (ICD-10 Opens in a new window)
October 2015 (ICD-10 Opens in a new window, ICD-9 Opens in a new window)
October 2014 (ICD-10 Opens in a new window, ICD-9 Opens in a new window)

Changes to Lab NCD Edit Software

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January 2016 Opens in a new window
October 2014 Opens in a new window

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between View the document version
Lipid Testing 2 01/01/2005 - N/A You are here
Lipid Testing 1 11/25/2002 - 01/01/2005 View
CPT Copyright Statement
CPT only copyright 2002-2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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