Natriuretic peptide, describes a test that measures Natriuretic peptide levels and is often recognized as “BNP” or B-Natriuretic peptide.
Indications and Limitations of Coverage
Code 83880 may be reasonable once a month for an individual patient. There must be supportive medical record documentation to demonstrate the medical necessity of more frequent testing.
Reasons for Noncoverage
Routine assays of BNP to assess the effectiveness of CHF therapy, for the titration of heart failure therapy, or for the prognostic uses remain investigational. More data is needed before the clinical utility of BNP in these situations is proved. A provider can bill the member for the denied service.
Services exceeding the frequency guidelines and any diagnosis other than those listed under the "Diagnosis Codes" section will be denied as not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.
The patient's medical record must document the medical necessity of services performed for each date of service submitted on a claim, and documentation must be available upon request.
Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
Use of these codes does not guarantee reimbursement. The patient’s medical record must document that the coverage criteria in this policy have been met.
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.
Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.
Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.