ICD-10 E78.1 is officially defined as "Pure hyperglyceridemia." code E78.1 is referenced in 9 tracked payer policy changes from Independence Blue Cross and Aetna. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code E78.1 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Independence Blue Cross Medicare Advantage expanded coverage for inclisiran (Leqvio®) effective 2026-10-12. New covered indications include primary hypercholesterolemia in adults 18+, heterozygous familial hypercholesterolemia (HeFH) in adults 18+ and pediatric patients 12-<18 years, and homozygous familial hypercholesterolemia (HoFH) in pediatric patients 12-<18 years. ICD-10 code E78.010 (HoFH) was added to the policy.
Independence Blue Cross expanded coverage for inclisiran (Leqvio®) effective 2026-10-12 to include three new indications: primary hypercholesterolemia in adults 18+, heterozygous familial hypercholesterolemia (HeFH) in adults 18+ and pediatric patients 12-17, and homozygous familial hypercholesterolemia (HoFH) in pediatric patients 12-17. The policy adds ICD-10 code E78.010 (HoFH) and establishes specific LDL-C thresholds and statin therapy requirements for each indication.
Independence Blue Cross reissued policy 08.01.91a for Inclisiran (Leqvio®) with one diagnostic code change: replaced E78.01 (Familial hypercholesterolemia) with E78.011 (Heterozygous familial hypercholesterolemia [HeFH]) effective 10/01/2025. Medical necessity criteria and coverage remain unchanged. Billing teams must update coding systems to reflect the new ICD-10 code for claims.
Aetna's Clinical Policy Bulletin 0525 addresses screening for lipid disorders, and Aetna considers directly measured LDL-C medically necessary in persons with triglyceride levels greater than 250 mg/dL and in persons with type 2 diabetes. Serum triglycerides, and total cholesterol, HDL-C and non-HDL-C, are considered medically necessary for screening and diagnosis of lipid abnormalities, while cholesterol screening of asymptomatic persons is not covered for members whose plans do not provide coverage for preventive services. Breath isoprene measurement, cholesterol skin testing for predicting coronary heart disease risk, directly measured LDL-C in persons without type 2 diabetes or hypertriglyceridemia, and direct VLDL cholesterol measurement are considered experimental, investigational, or unproven.
Aetna's Clinical Policy Bulletin 0381 treats apolipoprotein B, one-time lipoprotein(a) and high-sensitivity CRP as medically necessary only when the stated criteria are met, and lists many other cardiovascular risk tests as experimental, investigational or unproven. Apolipoprotein B is medically necessary for adults aged 19 and older on stable lipid-lowering therapy who have met an LDL-C or non-HDL-C goal and have established ASCVD, cardiovascular-kidney-metabolic syndrome, type 2 diabetes, or elevated triglycerides, while repeated or serial apo B measurements without a documented change in therapy or clinical status are not covered. A single lipoprotein(a) test is medically necessary for all adults aged 19 and older and repeat Lp(a) testing is considered not medically necessary, and hsCRP is covered for adults aged 30 to 79 with no known ASCVD, a borderline 10-year PREVENT-ASCVD risk estimate of 3% to less than 5%, no current statin therapy, and uncertain LDL-lowering decisions after standard risk assessment and shared decision making.
Aetna requires precertification for metreleptin (Myalept) for all participating providers and members in applicable plan designs. Aetna considers metreleptin medically necessary for congenital or acquired generalized lipodystrophy when the initial approval criteria are met, and considers it experimental, investigational, or unproven for partial lipodystrophy, HIV-related lipodystrophy, generalized obesity not associated with generalized lipodystrophy, and liver disease including metabolic dysfunction associated steatohepatitis (MASH). Continuation of therapy is medically necessary when the member has improved from baseline in metabolic control and continues dietary modifications along with regular exercise.
Aetna considers directly measured LDL-C medically necessary in persons with triglyceride levels greater than 250 mg/dL and in persons with type 2 diabetes. Aetna considers serum triglyceride measurement, and total cholesterol, HDL-C and non-HDL-C measurement, medically necessary for screening and diagnosis of lipid abnormalities. Breath isoprene measurements, cholesterol skin testing, directly measured LDL-C in persons without type 2 diabetes or hypertriglyceridemia, and direct VLDL cholesterol measurement are considered experimental, investigational, or unproven. Cholesterol screening of asymptomatic persons is not covered for members whose plans do not provide coverage for preventive services, while diagnostic cholesterol testing is covered when medically necessary regardless of preventive coverage.
Aetna's Clinical Policy Bulletin 0989 covers Evkeeza (evinacumab-dgnb) for homozygous familial hypercholesterolemia (HoFH) in members 1 year of age or older when the listed criteria are met, and precertification is required for all Aetna participating providers and members in applicable plan designs. For commercial plans, the Site of Care Utilization Management Policy for Specialty Drug Infusions also applies. The recommended dose is 15 mg/kg by intravenous infusion over 60 minutes once every 4 weeks, and the policy considers evinacumab experimental, investigational, or unproven for chylomicronemia, hypertriglyceridemia, and lipodystrophies.
Independence Blue Cross reissued Policy 08.01.91a with no substantive coverage changes to Inclisiran (Leqvio). The policy replaced ICD-10 diagnosis code E78.01 (Familial hypercholesterolemia) with E78.011 (Heterozygous familial hypercholesterolemia [HeFH]) effective 10/01/2025. Medical necessity criteria, billing codes, and coverage determinations remain unchanged.
Watch E78.1
Get one email when a payer policy names E78.1, a payer adds or drops it from a prior auth list, or Medicare changes its NCCI pairs, unit limit, payment or coverage articles.
Get alerts for changes like this
Save a search and get email alerts when a new policy change matches your filters: daily or weekly, your choice, on every plan.