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    v1.0.28
    OpenPayerPolicy UpdatesPediatrics/NeonatologyAmbetter Nevada 25‑OH‑D Testing Coverage | OpenPay…
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    CurrentAmbetter NevadaPolicy CP.MP.157

    Clinical Policy: 25-hydroxyvitamin D Testing in Children and Adolescents

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    Defines medical necessity and coding guidance for 25-hydroxyvitamin D (25-OH-D) testing in children and adolescents (age ≥1 to ≤18) for Ambetter Nevada / Centene-affiliated health plans.

    Policy Summary
    PayerAmbetter Nevada
    Policy25-hydroxyvitamin D Testing in Children and Adolescents
    Policy CodePolicy CP.MP.157
    Change TypeNo material changes
    Effective Date
    Next Review Date
    Key ActionDo not perform routine 25-hydroxyvitamin D testing for healthy children age ≥1 to ≤18; target testing to high-risk groups and consider supplementation instead.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    ≥1–≤18age range
    ~15%deficiency prevalence
    1

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    CPT codes not covered
    multipleICD-10 codes listed

    Coverage criteria for 25-hydroxyvitamin D testing

    Routine screening — Not medically necessary

    Not medically necessary for routine screening in healthy children.

    Primary policy statement: 25-hydroxyvitamin D testing in healthy children (age ≥1 to ≤18), including obese but otherwise healthy children, is not medically necessary because these tests have not been demonstrated to have a clear clinical benefit.

    Applies to routine/asymptomatic screening; does not apply to targeted testing of high-risk children or those with signs of reduced bone mass or recurrent low-impact fractures (see exclusions).

    Screening for vitamin D deficiency is recommended for children and adolescents with conditions associated with reduced bone mass and/or recurrent low-impact fractures. Clinical guidelines cited in the policy (including the American Academy of Pediatrics and specialty society statements) advise targeted measurement of serum 25-hydroxyvitamin D in these high-risk clinical scenarios rather than routine population screening.

    This policy specifies that 25-hydroxyvitamin D testing is not medically necessary for routine screening of otherwise healthy children and adolescents aged ≥1 to ≤18 years, including those who are overweight or obese but have no other clinical concerns. Claims for CPT 82306 in these asymptomatic, healthy pediatric encounters may be denied when submitted with the listed routine pediatric encounter or obesity diagnosis codes.

    Coding guidance and affected codes

    CPT codes not medically necessary (when billed with corresponding ICD-10 codes in Table 2)CPTNot Covered
    82306Vitamin D; 25 hydroxy, includes fraction(s), if performed
    ICD-10-CM diagnosis codes (listed as not medically necessary when billed with CPT 82306)ICD-10Not Covered
    E66.01Morbid (severe) obesity due to excess calories
    E66.09Other obesity due to excess calories
    E66.1Drug-induced obesity
    E66.3Overweight
    E66.8Other obesity
    E66.81Obesity class
    E66.811Obesity, class 1
    E66.812Obesity, class 2
    E66.813Obesity, class 3
    E66.89Other obesity not elsewhere classified
    1–10 of 17
    1/2

    Provider actions, billing and documentation

    Denial Risk

    Denial risk for routine testing in healthy children

    CPT 82306 (25-hydroxyvitamin D) is listed in the policy as not medically necessary when billed with the ICD-10-CM diagnosis codes shown in Table 2. Claims for this test submitted for otherwise healthy children (age ≥1 to ≤18) using those diagnosis codes are at risk of denial.

    • Affected CPT: 82306 — Vitamin D; 25 hydroxy, includes fraction(s), if performed
    • Affected ICD-10-CM examples: Z00.129, Z00.8, Z68.52, Z68.53, Z68.54, Z00.00
    Documentation Required

    Claim documentation guidance

    When submitting claims for 25-hydroxyvitamin D testing, providers should document the specific clinical indication that meets medical necessity (refer to the CPT–ICD pairs listed in the policy). Include clinical findings, relevant history, and any risk factors or conditions associated with reduced bone mass or recurrent low-impact fractures. Claims lacking documentation of an appropriate clinical indication may be denied.

    Background and clinical context

    Measurement of serum 25-hydroxyvitamin D (25-OH-D) concentration is the appropriate test for assessing vitamin D status; by contrast, assays of the active metabolite (1,25-dihydroxyvitamin D [1,25-OH2-D]) have little predictive value for bone-health screening and are not recommended for routine deficiency screening. There is variability and some disagreement about assay types and threshold cutoffs to define deficiency, and major pediatric and endocrine organizations recommend focusing testing on high-risk groups and using supplementation strategies for prevention in healthy children.

    Definitions

    25-OH-D (25-hydroxyvitamin D) — screening test
    Test used for screening25-hydroxyvitamin D (25-OH-D) concentration is the appropriate screening test for vitamin D deficiency.
    PurposeDetects circulating storage form of vitamin D to assess deficiency risk.
    Assay considerationsThere is lack of agreement concerning the best type of assay to measure 25-OH-D; standardization efforts exist (Vitamin D Standardization Program).
    Prevalence contextApproximately 15% of children have vitamin D levels <20 ng/mL, with higher risk in Black, Hispanic, and overweight/obese youth.
    1,25-OH2-D (1,25-dihydroxyvitamin D) — active metabolite
    Analyte description1,25-dihydroxyvitamin D (1,25-OH2-D) is the active vitamin D metabolite.
    Policy Summary
    PayerAmbetter Nevada
    Policy25-hydroxyvitamin D Testing in Children and Adolescents
    Policy CodePolicy CP.MP.157
    Change TypeNo material changes
    Effective Date
    Next Review Date
    Key ActionDo not perform routine 25-hydroxyvitamin D testing for healthy children age ≥1 to ≤18; target testing to high-risk groups and consider supplementation instead.
    SourceLink
    On This Page
    Coverage criteria for 25-hydroxyvitamin D testingCoding guidance and affected codesProvider actions, billing and documentationBackground and clinical contextDefinitions
    • Reference the CPT and ICD-10-CM pairs in Table 1 and Table 2 when filing claims
    • Document: clinical signs/symptoms, pertinent history, risk factors, and any diagnostic findings supporting testing
    Billing Rule

    Non-testing management preference

    Professional societies recommend against routine 25(OH)D testing in healthy children and adolescents. For healthy children who are not ingesting sufficient vitamin D from diet, clinicians should recommend and document vitamin D supplementation rather than routine laboratory screening.

    • Recommend vitamin D supplementation for healthy children not consuming adequate dietary vitamin D
    • Reserve serum 25(OH)D testing for children with multiple risk factors or conditions linked to low bone mass or recurrent fractures
    Documentation Required

    Claim preparation and coding reminders

    Providers are advised to check current professional coding guidance before claim submission. When testing is performed for a medically appropriate indication, ensure the claim pairs the CPT code with the supporting ICD-10-CM diagnosis and includes the clinical documentation in the medical record in case of audit.

    • Verify up-to-date CPT/ICD coding before submission
    • Include clinical justification in the record and on the claim where applicable
    • Examples: do not bill CPT 82306 with routine screening encounter codes (e.g., Z00.129) for healthy children without documented risk factors
    Screening valueHas little to no predictive value related to bone health and is not appropriate for routine screening for vitamin D deficiency.
    Clinical roleTypically reserved for evaluation of specific metabolic or renal disorders rather than population screening.
    Testing guidanceUse 25-OH-D rather than 1,25-OH2-D to assess vitamin D status for screening purposes.