Biomarker Testing in Risk Assessment and Management of Cardiovascular Disease

This policy covers biomarker testing and use of validated cardiovascular risk‑prediction models—including standard lipid measurements (total cholesterol, LDL‑C, HDL‑C, triglycerides), risk scores (e.g., Framingham), select genetic/pharmacogenetic markers, and assessment for metabolic syndrome—to estimate future coronary artery disease risk and guide preventive and therapeutic decisions (for example, statin initiation) in patients being evaluated for CVD risk (including considerations of age, race, diabetes/metabolic syndrome, smoking, hypertension and other clinical risk factors). Major limitations/requirements: nontraditional lipid and non‑lipid biomarkers and multi‑marker CVD risk panels (eg, apolipoproteins, LDL/HDL subclass, Lp[a], Lp‑PLA2 and many emerging markers) are considered experimental/unproven and not covered; coverage is subject to the member’s benefit plan, requires CLIA high‑complexity laboratory testing where applicable, and must demonstrate clinical validity and utility to change management.