CurrentAetnaPolicy 0553

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.

Policy Summary

PayerAetna

PolicyLead Testing

Policy CodePolicy 0553

Change TypeNo material changes

Effective Date08/14/2001

Last ReviewAug 9, 2023

Next Review Date06/13/2024

Key ActionOrder blood lead testing (CPT 83655) only when selection criteria in this policy are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

blood leadprincipal medically necessary test

bone/hair/teeth/urine

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CurrentAetnaPolicy 0553

Lead Testing

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Policy Summary

PayerAetna

PolicyLead Testing

Policy CodePolicy 0553

Change TypeNo material changes

Effective Date08/14/2001

Last ReviewAug 9, 2023

Next Review Date06/13/2024

Key ActionOrder blood lead testing (CPT 83655) only when selection criteria in this policy are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

blood leadprincipal medically necessary test

bone/hair/teeth/urine

5 µg/dLCDC reference level

08/09/2023last review

08/14/2001effective date

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:

Medically necessary indications for BLL testing: 1) Diagnosis in persons with signs and symptoms of lead poisoning (e.g., lowered IQ scores, decreased attention span, impaired hearing, speech and other developmental delays, abdominal pain, headaches, vomiting, constipation);

Medically necessary indications for BLL testing: 2) Pregnant or lactating women who have any of the risk factors for lead exposure listed in the Appendix table. Routine blood lead testing for average-risk pregnant women without risk factors is not considered medically necessary.

Medically necessary indications for BLL testing: 3) Persons with occupational lead exposures (OSHA mandates testing for individuals with workplace lead exposures).

Some plans may exclude work-related services; check benefit plan descriptions.

Medically necessary indications for BLL testing: 4) Preventive screening for children per CDC/USPSTF/AAP/AAN guidelines when in high-risk groups (children who are developmentally delayed; exposed to contaminated dust or soil; victims of abuse or neglect; have abnormal oral behaviors such as pica; have close contact with a person who has or had an elevated lead level; emigrated from countries where lead poisoning is prevalent; have iron deficiency; have unexplained illness such as abdominal pain, lethargy, seizures, or severe anemia; live in communities with high or undefined prevalence of elevated lead levels; live in or frequently visit homes or child care facilities built before 1950 or before 1978 and recently renovated; live near lead industry or heavy traffic; live with someone whose job or hobby involves lead exposures; take traditional ethnic remedies that contain lead; or use lead-based pottery).

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.

Covered indications: Diagnostic BLL testing for symptomatic persons (signs/symptoms of lead poisoning).

See policy for symptom examples.

Covered indications: Screening for high-risk children as recommended by CDC, USPSTF, AAP, and AAN (see policy Appendix for specified high-risk groups).

Some Aetna plans may exclude preventive services; check benefit plan descriptions.

Covered indications: Testing of pregnant or lactating women who have any identified risk factors for lead exposure (risk assessment at first contact). Routine testing of average-risk pregnant women without risk factors is not considered medically necessary.

Follow ACOG/ACOG Committee Opinion guidance for pregnancy/lactation risk assessment.

Coding and References

Covered CPT Codes (if selection criteria met)CPTCovered

83655

Lead

ICD-10 codes not covered for indications listed in the CPB (not all-inclusive)ICD-10Not Covered

Z33.1	Pregnant state, incidental
Z34.0 - Z34.93	Encounter for supervision of normal first pregnancy

ICD-10 codes covered if selection criteria are met (not all-inclusive)ICD-10

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

Elevated blood lead level reference — CDC reference level

CDC reference level (2019)5 µg/dL (CDC reference level for elevated BLL per 2019 USPSTF update)

Historic CDC definition of lead poisoning10 µg/dL (CDC historically defined lead poisoning as 10 µg/dL)

Interpretation noteUSPSTF and CDC use the 5 µg/dL reference level to define elevated BLL in recent guidance; clinical significance increases with higher sustained levels.

Occupational removal and surveillance thresholds

Removal threshold (single result)Single BLL > 30 µg/dL — consider removal from occupational exposure

Removal threshold (serial results)

Provider Actions and Administrative Notes

Billing Rule

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

Prior authorization not specified

No prior authorization requirements are specified in this policy section.

Ordering Requirements

Documentation Required

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.

Billing Rule

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.

Frequency Limits

blood lead level — Quarterly testing

TestBlood lead level (BLL)

FrequencyQuarterly testing for adults with BLL 10–19 µg/dL

ContextRecommended medical surveillance for lead-exposed workers per Kosnett et al. (2007)

blood lead level — Semiannual testing

TestBlood lead level (BLL)

FrequencySemiannual (every 6 months) testing for adults with sustained BLL < 10 µg/dL

ContextRecommended medical surveillance for lead-exposed workers per Kosnett et al. (2007)

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

BLL — Blood lead level (definition and notes)

DefinitionBlood lead level (BLL) — measurement of lead concentration in whole blood; the clinical monitoring test for diagnosing lead toxicity.

Clinical useBLL reflects recent exposure (previous few weeks) and is the gold standard for diagnosis and monitoring in children and adults.

Testing limitationsBone and dentine lead measurements reflect total body burden but are not routinely recommended by CDC; tests measuring lead in urine, hair, or other media are less reliable.

Non-blood lead testing — Policy on bone, hair, teeth, urine testing

Policy stanceMeasurement of lead in bone, hair, teeth, or urine is considered experimental and investigational and is not covered.

RationaleEffectiveness and reliability of non-blood lead tests are not established; BLL remains the recommended diagnostic/monitoring test.

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:

Selected references: American Academy of Pediatrics Committee on Environmental Health. Screening for elevated blood lead levels. Pediatrics. 1998;101(6):1072-1078; and Lead exposure in children: Prevention, detection, and management. Pediatrics. 2005;116(4):1036-1046.

Selected references: ACOG, Committee on Obstetric Practice. Lead screening during pregnancy and lactation. Committee Opinion No. 533. August 2012 (reaffirmed 2018).

Selected references: U.S. Preventive Services Task Force. Screening for elevated blood lead levels in children and pregnant women. Pediatrics. 2006;118(6):2514-2518; and USPSTF recommendation statement JAMA. 2019;321(15):1502-1509.

Policy Summary

PayerAetna

PolicyLead Testing

Policy CodePolicy 0553

Change TypeNo material changes

Effective Date08/14/2001

Last ReviewAug 9, 2023

Next Review Date06/13/2024

Key ActionOrder blood lead testing (CPT 83655) only when selection criteria in this policy are met.

SourceLink

On This Page

Covered indications: Occupational surveillance for persons with workplace lead exposures.

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:

Guideline and evidence sources: American Academy of Pediatrics: screening for elevated blood lead levels and lead exposure prevention (Pediatrics 1998; 2005).

Reference: AAP Committee on Environmental Health (see full citations).

Guideline and evidence sources: ACOG Committee Opinion on lead screening during pregnancy and lactation (Committee Opinion No. 533, 2012; reaffirmed 2018).

Follow ACOG guidance on risk assessment and testing in pregnancy.

Guideline and evidence sources: USPSTF recommendation statement and evidence synthesis on screening for elevated blood lead levels in children and pregnant women (AHRQ 2006; USPSTF 2019 update).

See USPSTF and AHRQ reviews for screening applicability and evidence.

Guideline and evidence sources: Kosnett et al. (2007) recommendations for medical management of adult lead exposure including surveillance and removal thresholds.

Provides occupational surveillance frequency and removal thresholds referenced in policy.

Guideline and evidence sources: Additional systematic reviews and studies addressing lead exposure and health outcomes (see cited references list for details).

References include CDC advisories and literature reviews supporting screening/detection practices.

Two successive BLLs ≥ 20 µg/dL measured over a 4-week interval — consider removal

Surveillance frequency — intermediate BLLsQuarterly blood lead measurements for individuals with BLL 10–19 µg/dL

Surveillance frequency — lower BLLsSemiannual blood lead measurements when sustained BLL < 10 µg/dL

OSHA workplace testing frequencyOSHA: determine BLL at least every 6 months for employees exposed above action levels; increased frequency for higher exposures; monthly testing after removal until returned to work

Step Therapy

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

Step therapy not required

This policy contains no step-therapy requirements.

Documentation Required

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.

Documentation Required

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.

Denial Risk

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.

Denial Risk

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.

Note

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.

Note

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.

blood lead level — At least every 6 months

TestBlood lead level (BLL)

FrequencyAt least every 6 months — OSHA-required frequency for employees with workplace lead exposures (per OSHA 1995 guidance)

ContextOSHA mandates BLL determination at least every 6 months for employees exposed above specified airborne lead levels; frequency may increase with higher exposures.

Not specified in these chunks (frequency details may be in full policy)

Policy detailFrequency details beyond those cited (e.g., pediatric screening intervals, repeat testing intervals) are not specified in these chunks and should be obtained from the full policy or referenced guidance documents.

References availableSee listed references (AAP, USPSTF, Kosnett et al., ACOG, CDC) for supplemental frequency guidance for children and pregnant women.

ActionConsult full Clinical Policy Bulletin Notes and referenced guidelines for complete frequency specifications.

Clinical guidanceBone/dentine testing methods (e.g., K X-ray fluorescence) are not routinely available and are not recommended by CDC; urine and hair testing are less accurate.

Selected references:

Kosnett MJ, Wedeen RP, Rothenberg SJ, et al. Recommendations for medical management of adult lead exposure. Environ Health Perspect. 2007;115(3):463-471.

Selected references: CDC advisory on potential falsely low results from LeadCare analyzers and CDC recommendation to retest persons tested with recalled Magellan Diagnostics LeadCare analyzers (CDC Health Advisory, May 17, 2017).

Documentation Required

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.