Lead Testing
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Defines medical necessity, screening, and exclusions for testing lead exposure (principally blood lead measurement) for children, pregnant/lactating women, and occupationally exposed persons; governs Aetna coverage determinations for these services.
No material clinical or coverage changes in this revision.
Coverage Criteria
inv-01: Medically necessary indications
Blood lead testing (measurement of blood lead level) is considered medically necessary when any of the following conditions apply:
Some plans may exclude work-related services; check benefit plan descriptions.
Refer to Appendix table and cited guidelines for full high-risk criteria.
Aetna considers measurement of lead in bone, hair, teeth, or urine to be experimental and investigational and therefore not covered because the effectiveness of these approaches has not been established.
Routine blood lead testing for average‑risk pregnant women without identified risk factors is not considered medically necessary; testing is indicated only for pregnant or lactating women who have any of the risk factors for lead exposure listed in the policy appendix.
Tests that measure lead in bone, hair, teeth, or urine are considered not medically necessary / experimental under this policy because their clinical effectiveness for diagnosis or management of lead exposure has not been established.
Covered Indications
inv-22: Diagnostic BLL testing for symptomatic persons, screening for high-risk children per recommended guidelines, testing pregnant/lactating women with risk factors, and occupational surveillance.
See policy for symptom examples.
Some Aetna plans may exclude preventive services; check benefit plan descriptions.
Follow ACOG/ACOG Committee Opinion guidance for pregnancy/lactation risk assessment.
OSHA mandates testing for exposed workers; recommended surveillance frequency: quarterly testing for adults with BLL 10–19 µg/dL and semiannual testing for sustained BLL <10 µg/dL; OSHA may require testing at least every 6 months for certain exposures (see Kosnett et al. recommendations).
inv-23: Screening and detection of elevated blood lead levels in children and pregnant women as referenced by cited guidelines and reviews.
Screening and detection of elevated blood lead levels in children and pregnant women are supported by the following guidelines and reviews:
Reference: AAP Committee on Environmental Health (see full citations).
Follow ACOG guidance on risk assessment and testing in pregnancy.
See USPSTF and AHRQ reviews for screening applicability and evidence.
Provides occupational surveillance frequency and removal thresholds referenced in policy.
References include CDC advisories and literature reviews supporting screening/detection practices.
Coding and References
| 83655 | Lead |
| Z33.1 | Pregnant state, incidental |
| Z34.0 - Z34.93 | Encounter for supervision of normal first pregnancy |
| D50.0 - D50.9 | Iron deficiency anemia |
| F98.3 | Pica of infancy and childhood |
| G40.001 - G40.919 | Epilepsy and recurrent seizures |
| O26.891 - O26.899 | Other specified pregnancy related conditions [lead exposure] |
| Z77.011 | Contact with and (suspected) exposure to lead |
Provider Actions and Administrative Notes
Coverage of CPT 83655 when policy criteria met
Blood lead testing (CPT 83655) is covered when the selection criteria in this policy are met; tests measuring lead in bone, hair, teeth, or urine are considered experimental/investigational and are not covered.
- Covered procedure: CPT 83655 (lead).
- Do not order bone, hair, teeth, or urine lead measurements for coverage — these are experimental/investigational per policy.
Prior authorization not specified
No prior authorization requirements are specified in this policy section.
Occupational surveillance and removal thresholds
For adults with occupational lead exposure, medical surveillance frequency: obtain quarterly blood lead measurements for BLLs between 10 and 19 µg/dL and semiannual measurements when sustained BLLs are less than 10 µg/dL; OSHA requires testing at least every 6 months for certain workplace exposures.
- Remove from exposure if single BLL >30 µg/dL or two successive BLLs ≥20 µg/dL over a 4-week interval (Kosnett et al. recommendation).
- OSHA: measure BLL at least every 6 months for employees exposed above specified airborne lead levels; increased frequency if higher BLLs per OSHA guidance.
Step therapy not required
This policy contains no step-therapy requirements.
CDC/FDA LeadCare retesting recommendation
Retesting is recommended for persons previously tested with recalled Magellan Diagnostics LeadCare analyzers: retest children younger than 6 years (72 months) who had a venous BLL <10 µg/dL analyzed using a LeadCare analyzer, and retest currently pregnant or lactating women whose prior test was analyzed with the LeadCare analyzer, per CDC/FDA guidance.
- Retest if original venous result <10 µg/dL and the test was analyzed using a recalled Magellan Diagnostics LeadCare analyzer.
- Applies to children <6 years at time of the May 17, 2017 alert and to currently pregnant or lactating women.
Consult policy history and Clinical Policy Bulletin notes
Policy history and additional Clinical Policy Bulletin resources are provided; providers should consult the Clinical Policy Bulletin Notes and Definitions links for documentation and ordering guidance.
- Last review: 08/09/2023; Effective date: 08/14/2001; Next review: 06/13/2024.
- See Clinical Policy Bulletin Notes and Definitions links for supplemental documentation guidance.
Do not order non-blood lead tests for coverage
Measurements of lead in bone, hair, teeth, or urine are considered experimental and investigational and are not covered.
Limit routine pregnancy screening without risk factors
Routine blood lead testing for average‑risk pregnant women without identifiable risk factors is not considered medically necessary under this policy.
- Perform blood lead testing in pregnant or lactating women only if they have any of the risk factors listed in the policy Appendix.
Administrative note — no explicit authorization/denial rules listed
No additional administrative authorization or explicit denial criteria are provided in these sections; providers should rely on the policy coverage criteria and consult administrative review or Clinical Policy Bulletin resources if needed.
Ordering Requirements
Perform risk assessment at first contact for pregnant/lactating women
Risk assessment for lead exposure should be performed at the first contact with pregnant or lactating women; if any single risk factor is identified, blood lead testing should be performed.
- ACOG (2012) recommends risk assessment at earliest contact and testing if any single risk factor is present.
- Examples of risk factors are listed in the Appendix and policy screening criteria.
OSHA mandates and benefit-plan check for work-related testing
OSHA mandates lead testing for employees with workplace lead exposures; providers should check the member's benefit plan for whether work-related services are excluded from coverage.
- OSHA requires testing for employees exposed to inorganic lead above specified levels (OSHA guidance cited).
- Some Aetna plans may exclude coverage of services required for work — verify benefit plan details.
Ordering authority not specified — consult full policy
The policy does not specify who may order lead testing in these excerpts; providers should consult the full policy and the Clinical Policy Bulletin Notes for ordering authority details.
Frequency Limits
Not Covered
NOT COVERED: Measurement of lead in bone, hair, teeth, or urine is excluded from coverage as these tests are considered experimental and investigational.
NOT COVERED: Within the provided reference chunks there are no additional explicit test or indication exclusions beyond those stating non‑coverage of measurements in bone, hair, teeth, or urine; providers should consult the full policy for any plan‑specific exclusions.
Definitions
Background
Background: Lead poisoning can result in neurodevelopmental deficits in children (lowered IQ, developmental delays, attention and hearing impairments) and a range of systemic effects in adults. Measurement of blood lead level (BLL) is the accepted diagnostic and monitoring biomarker; alternative matrices such as bone, hair, teeth, or urine are less reliable and are considered experimental in this policy.
References and Revision History
inv-23: Bibliographic references and guideline citations supporting screening and detection statements.
Key bibliographic references and guideline sources cited in support of the screening and detection statements include:
Consult Clinical Policy Bulletin Notes and policy history for documentation
Policy history and Clinical Policy Bulletin Notes references are provided for additional documentation guidance; providers should consult the Clinical Policy Bulletin Notes and Definitions links.
Administrative dates: Effective: 08/14/2001; Last review: 08/09/2023; Next review: 06/13/2024.
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