(141) Lipoprotein(a) and Testing Policies: A Health Plan Claims Analysis

Background: : Lipoprotein(a) is an independent, causal risk factor for atherosclerotic cardiovascular disease (ASCVD) in 20% of individuals and identifies people at high risk of ASCVD progression. Lp(a) modifying therapies, currently in phase 3 studies, could reduce ASCVD progression and decrease a healthcare system’s CV disease burden.

Objective: : Considering the autonomy of commercial health plans and separate review committees evaluating tests and therapies, our objective is to determine if health plans have concordant Lp(a) testing policies and coverage as observed in a claims data analysis.

Methods: : An analysis of 2024 Lp(a) testing coverage policies from 25 health plans (85% of insured US population) categorized policies as covered, not covered, or silent. Claims data from 1/1/2024 to 9/30/2024 was analyzed, with a threshold for inclusion. A threshold was established so that a minimum number of claims had to be observed for each payer included in the analysis. Concordance status was assessed by comparing the ratio of a health plan’s paid and partially paid claims versus denied, unpaid or patient only paid claims compared to the policy status determined above.

Results: : Out of 25 possible policies for tests where claims data was available, 5 policies covered Lp(a) testing(20%), while 8(32%) were silent and 12(48%) did not cover Lp(a) testing. The policy coverage analysis suggests that 4.41% of Americans have an insurance policy that covers Lp(a). In contrast, analyzing the claims data at a threshold of more than 50% of a payer’s claims approved to be considered implied coverage of the test, 48.64% of Americans have an insurance policy that has implied coverage of Lp(a). Increasing that threshold to more than 65% of claims approved results in an implied coverage of 31.78%.

Conclusions: : Providers and patients are faced with many difficult decisions regarding their medical care. Ambiguity amongst policy and payment could lead to not ordering a test that could be clinically relevant and paid for by insurance. Relying on a published policy may not reflect how a claim will be processed for coverage. In fact, in one instance, it was observed that a payer whose policy stated that Lp(a) was covered, had a lower ratio of paid versus not paid claims than another payer whose policy did not cover Lp(a) testing.
As Lp(a) modifying therapies may be approved in the coming years, it’s imperative that clarity and consistency is achieved in the testing policies and the processing of claims for payment.

Sponsorship:: Roche Diagnostics