Does Medicare Cover a C-Reactive Protein Test? 

When your body is injured or exposed to harmful substances (bacteria, viruses or toxic chemicals), your immune system sends inflammatory cells to heal the damage or attack the invaders.

Acute inflammation is your body’s immediate response to damage, which allows the healing process to begin without delay. You may experience pain, swelling or tenderness. With chronic inflammation, your body can trigger the immune system when you don’t have an injury or illness. Conditions associated with chronic inflammation include asthma, rheumatoid arthritis, acute pancreatitis and myocardial infarction.

Your liver produces a protein known as C-reactive in response to inflammation. An excess level of C-reactive protein in your blood is a biomarker of inflammation in your body.

C-reactive protein (CRP) testing

Your doctor can check your CRP levels with a simple blood test. CRP test results do not reveal the specific source of the inflammation. However, a high-sensitivity CRP test (hs-CRP test) has the capacity to detect smaller CRP increases than the standard CRP test. This information helps your doctor determine your risk of coronary heart disease. If you have already had a heart attack, high amounts of CRP in your blood indicate an increased risk of having another. 

The Mayo Clinic suggests that the hs-CRP test is most beneficial for people with an intermediate risk of a heart attack, defined as someone with a 10% to 20% chance of suffering from a heart attack within the next 10 years. 

Medicare coverage for C-reactive protein test

According to the Centers for Medicare & Medicaid Services (CMS), CRP testing qualifies for Medicare coverage if it is reasonable and necessary, performed to detect and evaluate inflammatory conditions, tissue injury or infection. Your doctor should not order CRP testing as a screening or monitoring tool.

The Medicare Coverage Database defines what constitutes reasonable and necessary for coverage of the hs-CRP test. Medicare may cover the hs-CRP test if the doctor orders it to obtain significant incremental data that helps to establish the best lipid-lowering drug therapy for patients with an intermediate risk of coronary artery disease (CAD). Patients must be metabolically stable with no obvious inflammatory or infectious ailments.

Medically necessary laboratory testing is a Medicare Part B benefit. Covered tests include bloodwork, urinalysis and some tissue specimen testing. Medicare usually provides 100% coverage for approved lab tests.

Reducing chronic inflammation

Health professionals recommend specific lifestyle behaviors that may prevent or reduce chronic inflammation, including healthy weight maintenance, smoking cessation, stress management and daily exercise. If you have Original Medicare Part B or Medicare Advantage, review the benefits for preventive services. You may be eligible for benefits promoting behaviors to improve your overall health.