Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Premature atherosclerotic cardiovascular disease (ASCVD)

Treatment: Current procedural terminology (CPT) code 83695, lipoprotein (Lp) A and CPT code 83704, lipoprotein, blood; quantitation of lipoprotein particle numbers, includes lipoprotein particle subclasses when performed to assess for cardiac risk factors
The insurer denied coverage for (CPT) code 83695, lipoprotein A and CPT code 83704, lipoprotein, blood; quantitation of lipoprotein particle numbers, includes lipoprotein particle subclasses when performed to assess for cardiac risk factors
The denial is upheld

This patient has a history of coronary artery disease (CAD), including a myocardial infarction (MI). He reported no history of hyperlipidemia, no obesity, and no active smoking, although he did have a family history of heart disease. His Cardiologist tested his blood and found high levels of lipoprotein(a). He was started on Repatha, which lowered his lipoprotein(a). 

The only clinical documentation submitted for review is a note by the patient's physician. In that note, a prior history of elevated lipids is noted, as well as a "very strong family history of early onset coronary disease." He was doing well at that visit. Repatha had previously been started after an "extremely elevated lipoprotein a of 582." At the time Repatha was started, LDL (low density lipoprotein) was 87, and "Lipid values are adequate but need further improvement." The patient was also taking atorvastatin (Lipitor) 80 milligrams daily and  Vascepa 2 grams twice daily; his physician considered adding Niacin. A treatment goal for that visit was to reduce lipoprotein A by 10 to 30 percent (%). 

Note that for the purposes of this review, the terms apolipoprotein(a), lipoprotein (a) and apo(a) are essentially synonymous in this context. As a statement of background knowledge, the association between apo(a) and CAD is well-established in the literature and has been for many years.

The current scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome by the measurement of apo(a) in a patient who has an existing indication to initiate anti-hyperlipidemia therapy beyond a statin. In this case, the patient likely has familial hyperlipidemia, based on his family history(8). While the elevated apo(a) level adds additional support to this diagnosis, it does not change current treatment methods nor treatment goals, and therefore is not related to an improvement in a health outcome for him. In a patient with known CAD, particularly after MI, Repatha is already indicated without the need for apo(a) testing. In other words, Repatha is an appropriate medication based purely on the patient's history of MI and failure to achieve a low-density lipoprotein (LDL) of 70 or lower with high-intensity statin therapy, and/or for familial hyperlipidemia;(10) the testing of apo(a) does not change nor augment that recommendation. Therefore, based upon current treatment guidelines, testing for apo(a) will not meaningfully change treatment recommendations nor expected outcomes at this stage in his treatment.

The patient is not a good candidate for the test above. His risk of CAD is well established (in fact, it is definitively 100%, given his history of MI), so risk-stratification is no longer a reasonable justification as it otherwise might be. Additionally, he already has an established indication for additional antihyperlipidemic therapy as he has not achieved a satisfactory LDL level on a high-intensity statin, and he has familial hyperlipidemia. 

This laboratory study is not the best treatment for the patient at this time. 

The carrier's denial of current procedural terminology (CPT) code 83695, lipoprotein A and CPT code 83704, lipoprotein, blood; quantitation of lipoprotein particle numbers, includes lipoprotein particle subclasses when performed, should be upheld.