CurrentAmbetter NevadaPolicy CP.MP.157

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

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

1CPT 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.

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

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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.

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

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.

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.

E66.01	Morbid (severe) obesity due to excess calories
E66.09	Other obesity due to excess calories
E66.1	Drug-induced obesity
E66.3	Overweight
E66.8	Other obesity
E66.81	Obesity class
E66.811	Obesity, class 1
E66.812	Obesity, class 2
E66.813	Obesity, class 3
E66.89	Other obesity not elsewhere classified

OpenPayer

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

Coverage criteria for 25-hydroxyvitamin D testing

Coding guidance and affected codes

Provider actions, billing and documentation

Background and clinical context

Definitions