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Clinical Policy Bulletin:
Rheumatic Diseases: Selected Tests
Number: 0866


Policy

Aetna considers measurement of anti-cyclic citrullinated peptide (anti-CCP) antibodies medically necessary for diagnosis of rheumatoid arthritis. Aetna considers measurement of anti-CCP antibodies experimental and investigational for all other indications.

Aetna considers measurement of anti-mutated citrullinated vimentin (MCV) antibodies (e.g., the Avise MCV test) experimental and investigational in diagnosing rheumatoid arthritis and for all other indications because there is insufficient clinical evidence to support the use of this test in the diagnosis of rheumatoid arthritis.

Aetna considers the myositis antibody panel medically necessary for diagnosing persons with inflammatory myopathy. Aetna considers the myositis antibody panel experimental and investigational for all other indications.

 

 



Background

Rheumatoid arthritis (RA) is a chronic syndrome characterized by nonspecific, usually symmetric inflammation of the peripheral joints, potentially resulting in progressive destruction of articular and periarticular structures, with or without generalized manifestations

Avise MCV measures antibodies to mutated citrullinated vimentin (MCV), a protein found in the inflamed synovium of patients with RA. Elevated levels of anti-MCV indicate an increased likelihood of having rheumatoid arthritis, and also identify those who may develop more severe forms of RA.

The Avise MCV test is a proprietary personalized medicine test of Cypress Biosciences. No information on the Avise MCV test was found on the U.S. Food and Drug Administration website.

In patients with undiagnosed early inflammatory arthritis or established RA, the diagnostic and prognostic value of adding anti-MCV antibody testing to anti-CCP and rheumatoid factor (RF) testing, or substituting anti-MCV for other tests, remains uncertain. Further study is required to more clearly define its role in routine clinical practice.

The idiopathic inflammatory myopathies are a group of systemic rheumatological diseases of unknown etiology, characterized by a chronic inflammatory myositis resulting in muscular weakness with or without organ system dysfunction. The three disorders that comprise this group of muscle disorders are polymyositis, dermatomyositis, and a more recently defined disorder called inclusion body myositis.

The Myositis Antibody Panel Plus is a test for autoantibodies commonly present in the sera of patients with idiopathic inflammatory myopathies, a type of autoimmune disorder. The autoantibodies measured in the test include Jo-1, PL-7, PL-12, EJ, OJ, SRP, KU and Mi2.  The detection of specific autoantibodies can differentiate polymyositis and dermatomyositis from other autoimmune disorders.

Use of the Myositis Antibody Panel Plus aids in the detection of specific autoantibodes that differentiate the idiopathic inflammatory myopathies; therefore, it is a recommended test for the diagnosing of an idiopathic inflammatory myopathy.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered for indications listed in the CPB:
83516
86200
CPT codes not covered for indications listed in the CPB:
83520
ICD-9 codes covered if selection criteria are met:
359.79 Other inflammatory and immune myopathies, NEC
714.0 - 714.9 Rheumatoid arthritis and other inflammatory polyarthropathies


The above policy is based on the following references:
  1. Amato AA; Barohn RJ. Idiopathic inflammatory myopathies. Neurologic Clinics, 15(3) August 1997.
  2. Goldman: Cecil Textbook of Medicine. Twenty-First Edition. 2000.
  3. Habif: Clinical Dermatology. Fourth Edition. 2004.
  4. Mastaglia FL; Phillips BA. Idiopathic inflammatory myopathies: epidemiology, classification, and diagnostic criteria. Rheumatic Diseases of North America, 28(4) November 2002.
  5. Ruddy: Kelly’s Textbook of Rheumatology. Sixth Edition. 2001.
  6. Targoff IN. Laboratory testing in the diagnosis and management of idiopathic inflammatory myopathies. Rheum Dis Clin North Am, Vol 28 Num 4 November 2002.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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