CAR039 Comprehensive Lipid Profile Testing in the Evaluation of ...

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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. For Medicare and Medicaid Determinations Related to States Outside of Nevada: Please review Local Coverage Determinations that apply to other states outside of Nevada. http://www.cms.hhs.gov/mcd/search Important Note: Please also review local carrier Web sites in addition to the Medicare Coverage database on the Centers for Medicare and Medicaid Services’ Website BACKGROUND Cardiovascular disease (defined as coronary artery disease (CAD), cerebrovascular disease (CVD), and peripheral vascular disease (PVD)) is a major cause of morbidity and mortality in the Western world. It Comprehensive Lipid Profile Testing in the Evaluation of Cardiovascular Disease Page 4 of 14
is well known that CAD alone is the largest killer of American men and women, amounting to more than 500,000 deaths per year. The highest incidence of new CAD events is in persons >65 years of age and 85% of all deaths attributable to CAD occur in this population. Unfortunately, up to 1/3 of initial presentation of CAD is sudden death. This statistic underscores the importance of appropriate cholesterol testing and management, since cholesterol blood level predicts CAD risk. The National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP III) guidelines, released in 2001, focus on multiple risk factors and use the Framingham risk calculation to identify certain patients for more intense treatment. The ATP III guidelines are endorsed by the American College of Cardiology (ACC) and American Heart Association (AHA). By strict ATP III definition, risk factors include: 1. Family history (primary male relative with CAD before age 55, female relative before age 65), 2. Hypertension (blood pressure >140/90), 3. Low HDL (45). In general, low cardiac risk is described as no risk or one risk factor. Moderate cardiac risk is defined as two risk factors and a 10-year Framingham risk of less than 10%. Moderate high risk is defined as two or more risk factors and a 10-year Framingham risk of 10%-20%. High risk individuals have existing CAD (previous history of MI, stable or unstable angina, or revascularization with coronary artery bypass grafting or percutaneous coronary angioplasty), or a CAD risk equivalent (e.g., diabetes mellitus, abdominal aortic aneurysm, PVD, significant coronary artery disease, a 10-year Framingham risk that exceeds 20%). In July 2004, the NCEP updated some elements of the ATP III guidelines based on review of 5 additional clinical trials. In this update, very high risk patients (recent heart attack, or those who have cardiovascular disease combined with diabetes, continued smoking, PVD, or metabolic syndrome) had an optional goal LDL less than 70 mg/dL. The National Heart Lung and Blood Institute (NHLBI) anticipates the release of ATP IV in the Spring of 2012. CLINICAL EVIDENCE I. BASIC LIPOPROTEIN PROFILE A basic lipoprotein profile typically includes total cholesterol, HDL, triglycerides, and calculated LDL. In some clinical situations (e.g. presence of chylomicrons, elevated triglycerides >400 mg/dl), indirect LDL calculation may not be considered accurate (i.e. underestimated) and direct LDL calculations may be considered more appropriate. A. LDL. The ATP III guidelines identify elevated LDL cholesterol as the primary target of therapy and establish goals for LDL cholesterol that depend on a patient’s risk status. The ATP III guidelines do not define the total cholesterol: HDL ratio as a specified target of therapy; LDL remains the primary lipid lowering target. The data on LDL predicting CVD in randomized controlled trials (RCT) is Comprehensive Lipid Profile Testing in the Evaluation of Cardiovascular Disease Page 5 of 14
Page 1 and 2: COMPREHENSIVE LIPID PROFILE TESTING
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CAR039 Comprehensive Lipid Profile Testing in the Evaluation of ...

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