New Medical Policy: General Inflammation Testing

8/28/18

Inflammatory response can occur due to tissue injury and/or various disorders to include arthritis, lupus, and infection. Acute phase reactants such as serum C-reactive protein (CRP) and the erythrocyte sedimentation rate (ESR) can be used to measure inflammation.

Effective Nov. 1, 2018, BlueCross® BlueShield® of South Carolina and BlueChoice HealthPlan will implement a new medical policy addressing inflammation testing. The policy, CAM 205 – General Inflammation Testing, has been published on the Medical Policies pages of the BlueCross and BlueChoice® websites.

A portion of the policy reads:

  1. Measurement of ESR for patients with Hodgkin Lymphoma is considered medically necessary.
  2. Measurement of either CRP or ESR in the diagnosis, assessment and monitoring of inflammatory disorders, and/or undiagnosed conditions, and/or to detect acute phase inflammation is considered medically necessary.
  3. Measurement of both CRP and ESR, at the same visit, in the diagnosis, assessment and monitoring of inflammatory disorders, and/or undiagnosed conditions, and/or to detect acute phase inflammation is considered NOT medically necessary.
  4. Measurement of either CRP and/or ESR during general exam without abnormal findings is considered NOT medically necessary.

For complete information about CAM 205, visit our Medical Policies page. Please remember medical necessity is not a guarantee of payment. Payment is subject to the member’s plan coverage, to include prior authorization requirements and benefits, at the time the service is performed. You may contact Provider Education by using the Provider Education Contact Form or by calling 803-264-4730 with additional questions.

BlueCross BlueShield of South Carolina is an independent licensee of the Blue Cross Blue Shield Association.