CurrentBlue Cross Blue Shield - MassachusettsPolicy N/A

Vitamin D testing (25-OH and 1,25-OH) — Coverage and Medical Necessity

Coverage and medical necessity criteria for measurement of 25-hydroxyvitamin D (CPT 82306) and 1,25-dihydroxyvitamin D (CPT 82652) for commercial members of the payer; describes indications, testing frequency guidance, and prior authorization rules affecting providers and facilities.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyVitamin D testing (25-OH and 1,25-OH) — Coverage and Medical Necessity

Policy CodePolicy N/A

Change TypeMinor/No material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit an appropriate listed ICD-10 diagnosis code and documentation of medical necessity when billing for 1,25-dihydroxyvitamin D (CPT 82652); precertification is required if the service is performed inpatient.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2vitamin D assays discussed

82306CPT 25-OH listed

82652CPT 1,25-OH listed

precert/PAinpatient prior auth

25-OHpreferred analyte

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Coverage and Medical Necessity Criteria

inv-01: Medically necessary indications for 25-OH Vitamin D

Measurement of 25-hydroxyvitamin D (25-OH; CPT 82306) is considered MEDICALLY NECESSARY when ANY of the following are present:

Indications for 25-OH testing: Chronic kidney disease stage III or greater; Cirrhosis; Hypocalcemia; Hypercalciuria; Hypercalcemia; Hypervitaminosis D; Malabsorption states; Parathyroid disorders; Obstructive jaundice; Osteomalacia; Osteoporosis meeting one or more of: DEXA T-score <-2.5, FRAX 10-year hip fracture risk >3% or major osteoporotic fracture risk >20%, history of fragility fractures, or FRAX >3% with T-score <-1.5; Osteosclerosis/petrosis; Rickets; Rheumatoid arthritis; Prior to initiating bisphosphonate therapy (vitamin D level and serum calcium should be determined and managed as necessary before bisphosphonate initiation); Vitamin D deficiency on replacement therapy related to a listed condition to monitor efficacy

From policy list (CPT 82306)

inv-02: Medically necessary indications for 1,25-OH Vitamin D

Measurement of 1,25-dihydroxyvitamin D (1,25-OH; CPT 82652) is considered MEDICALLY NECESSARY when ANY of the following are present:

Indications for 1,25-OH testing: Unexplained hypercalcemia (eg, suspected granulomatous disease or lymphoma); Suspected genetic childhood rickets; Unexplained hypercalciuria (eg, suspected granulomatous disease or lymphoma); Suspected tumor-induced osteomalacia; Nephrolithiasis or recurrent nephrolithiasis with hypercalciuria

From policy list (CPT 82652)

inv-03: Assay use and follow-up testing

Assay selection, combinations, and follow-up testing guidance:

Assay combination guidance: Do not routinely perform both 25-OH and 1,25-OH assays for every indication; choose the correctly preferred initial assay based on clinical context (25-hydroxyvitamin D is the preferred initial test).

Assay selection guidance

Follow-up after deficiency: Once an individual is shown to be vitamin D deficient, further 25-OH testing may be MEDICALLY NECESSARY to ensure adequate replacement until levels are within the normal range.

Repeat testing allowed until normalized

Repeat testing frequency: If 25-OH level is between 20 and 50 ng/dL and the individual is clinically stable, repeat testing is often unnecessary; if 25-OH level is <20 ng/dL or >60 ng/dL, subsequent level(s) may be MEDICALLY NECESSARY until the level is within the normal range.<20 ng/dL or >60 ng/dL

Document clinical necessity for repeats when level 20–50 ng/dL

inv-04: Routine testing not medically necessary

Testing considered NOT MEDICALLY NECESSARY:

Routine screening: Routine testing or other screening without a clinical indication is considered NOT MEDICALLY NECESSARY.

Per policy statement

inv-05: Medical necessity linkage for vitamin D testing

Tests are covered only when medical necessity criteria are met and appropriate diagnosis coding is submitted:

Coverage requirements: 1) Relevant CPT code submitted (eg, CPT 82652 for 1,25-OH); 2) One of the ICD-10 diagnosis codes listed in the policy is submitted with the claim; 3) The medical necessity criteria described in the policy are met.

Linkage of CPT, ICD-10 and medical necessity required for coverage

inv-06: Testing and treatment guidance

Additional testing and treatment considerations:

Preferred initial assay: Use 25-hydroxyvitamin D as the preferred initial assay to assess vitamin D status because it reflects total body stores.

Preferred initial assay rationale

When to order 1,25-dihydroxyvitamin D: Reserve 1,25-dihydroxyvitamin D testing for patients with suspected disorders of conversion (eg, kidney disease, liver disease, parathyroid disorders, or genetic diseases) that affect vitamin D metabolism.

Assay reserved for conversion defects

Screening versus empiric supplementation: Routine population screening of asymptomatic adults is controversial and considered unsupported by sufficient evidence (USPSTF); empiric vitamin D supplementation without testing may be reasonable for low-risk patients with likely inadequate sun exposure or intake.

Clinical rationale and Choosing Wisely guidance

Routine testing or other screening for vitamin D (25‑OH or 1,25‑OH) is considered NOT MEDICALLY NECESSARY unless the clinical indications and documentation described in this policy are present.

The ICD‑10 excerpt provided in this document lists diagnosis codes but does not include an explicit statement of coverage exclusions within that code listing.

Testing may not be used for routine or other screening; repeat measurements should be limited to situations described in the policy (for example, monitoring replacement when levels are <20 ng/dL or >60 ng/dL) and must be documented as medically necessary.

Coverage for the listed CPT codes is conditional: the policy requires that the medical necessity criteria be met and that an appropriate ICD‑10 diagnosis code from the policy be submitted for Commercial members (Managed Care HMO/POS, PPO, Indemnity, and Medicare HMO/PPO Blue).

The United States Preventive Services Task Force (USPSTF) finds current evidence insufficient to support routine population screening for vitamin D deficiency in asymptomatic adults; clinicians should consider risk factors and clinical indications before ordering testing.

The policy explicitly identifies routine testing or other screening without clinical indication as NOT MEDICALLY NECESSARY.

The limited ICD‑10 code excerpt included in the document contains diagnosis code enumeration only and does not itself state determinations of 'not medically necessary.'

The ICD listing contains a specific note that routine or screening vitamin D testing is not permitted; tests should be ordered only when clinically indicated per the policy.

Submission of CPT codes without meeting the policy's medical necessity criteria and without an appropriate ICD‑10 diagnosis code listed in the policy may result in non‑coverage.

Routine screening of asymptomatic adults without risk factors may be denied or considered low‑value per USPSTF guidance; testing without a clinical indication should be avoided and empiric supplementation considered where appropriate.

Covered Indications and Clinical Scenarios

inv-67: Conditions listed for 25-OH testing

Conditions for which 25-hydroxyvitamin D testing (CPT 82306) is listed as medically necessary include:

Conditions list (25-OH): Chronic kidney disease stage III or greater; Cirrhosis; Disorders of calcium metabolism (hypocalcemia, hypercalcemia, hypercalciuria); Malabsorption states; Parathyroid disorders; Osteoporosis with criteria (osteomalacia; DEXA T-score <-2.5; FRAX hip >3% or major fracture >20%; history of fragility fractures; FRAX>3% with T-score <-1.5); Rickets; Rheumatoid arthritis; Monitoring vitamin D replacement related to listed conditions; Initiating bisphosphonate therapy (ensure vitamin D and serum calcium determined/managed prior to initiation); Osteosclerosis/petrosis; Obstructive jaundice

From policy indications for CPT 82306

inv-68: Conditions listed for 1,25-OH testing

Conditions for which 1,25-dihydroxyvitamin D testing (CPT 82652) is listed as medically necessary include:

Conditions list (1,25-OH): Unexplained hypercalcemia (eg, suspected granulomatous disease or lymphoma); Suspected genetic childhood rickets; Unexplained hypercalciuria (eg, suspected granulomatous disease or lymphoma); Suspected tumor-induced osteomalacia; Nephrolithiasis or recurrent nephrolithiasis associated with hypercalciuria

Procedure and Diagnosis Codes

Covered CPT CodesCPTCovered

82306	Vitamin D; 25 hydroxy, includes fraction(s) if performed
82652	Vitamin D; 1,25 dihydroxy, includes fraction(s) if performed

Covered ICD-10 Diagnosis Codes (Rheumatoid and Related)ICD-10Covered

M05.029	Felty's syndrome, unspecified elbow
M05.032	Felty's syndrome, left wrist
M05.039	Felty's syndrome, unspecified wrist
M05.042	Felty's syndrome, left hand
M05.049	Felty's syndrome, unspecified hand
M05.059	Felty's syndrome, unspecified hip
M05.069	Felty's syndrome, unspecified knee
M05.079	Felty's syndrome, unspecified ankle and foot
M05.09	Felty's syndrome, multiple sites
M05.112	Rheumatoid lung disease with rheumatoid arthritis, left shoulder

1–10 of 214

1/22

Testing Frequency and Repeat Rules

25-OH Vitamin D — repeat testing guidance

When repeat testing is medically necessaryRepeat 25‑OH Vitamin D testing may be medically necessary until normalized when initial level is <20 ng/dL or >60 ng/dL.

When repeat testing is not indicatedIf 25–50 ng/dL and patient is clinically stable, repeat testing is generally not indicated unless documentation supports medical necessity.

Assay selection note25‑hydroxyvitamin D is the preferred initial assay for assessing status; further testing is used to confirm adequate replacement per limitations.

Vitamin D assay — repeat testing rules

Repeat testing allowanceVitamin D assays (25‑OH) — repeat testing allowed until level normalizes when the initial result is <20 ng/dL or >60 ng/dL.

Assay pairing guidance

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization Required / Verify for Outpatient

For services described in this policy, precertification/prior authorization IS REQUIRED for all products if the procedure is performed inpatient. For outpatient services, prior authorization requirements vary by product; Commercial PPO and Indemnity outpatient services are not required to have prior authorization per the source text — always verify member contract benefits at time of service.

Precert/PA required if procedure performed inpatient for all products
Outpatient PA: not required for Commercial PPO and Indemnity (verify member contract)
Providers must report services using current procedure, revenue, and diagnosis codes and include modifiers where applicable

Denial Risk

Testing and Denial Risk

Testing may not be used for routine or other screening. Repeat testing for 25-hydroxyvitamin D when levels are between 20–50 ng/dL is often unnecessary; if repeat testing is performed documentation must clearly indicate medical necessity. Claims for Commercial members are subject to the medical necessity criteria in this policy and may be denied if criteria are not met.

Ordering, Authorization, and Documentation Requirements

Prior Authorization

Inpatient PA required; outpatient PA varies by product

Precertification/preauthorization is required for inpatient services described in this policy; outpatient prior authorization requirements vary by product—some PPO/Indemnity outpatient settings may not require prior authorization.

Obtain inpatient precert/PA for all products.
Check product-specific outpatient PA rules (Commercial PPO/Indemnity may not require outpatient PA).

Documentation Required

Document necessity for repeat testing at 20–50 ng/dL

Documentation of medical necessity is required for repeat vitamin D testing when levels are 20–50 ng/dL; the record must clearly indicate why repeat testing is clinically necessary.

If level 20–50 ng/dL and patient clinically stable, repeat testing is often unnecessary; if performed, document why it was needed.

Services Not Covered / Exclusions

Routine screening or testing for vitamin D in the absence of a clinical indication is listed in the policy as not covered.

Vitamin D testing performed solely for routine screening is specifically identified in the document as not covered.

Claims for the CPT codes in this policy that are submitted without meeting the stated medical necessity criteria and without an appropriate listed ICD‑10 diagnosis are subject to denial and may not be covered.

Routine screening of asymptomatic adults in the absence of risk factors or clinical signs is not supported by USPSTF evidence and therefore is considered low‑value; the policy reflects this uncertainty when determining coverage.

Background and Clinical Context

25‑hydroxyvitamin D (25‑OH) testing is the preferred initial assay to assess vitamin D status because it reflects total body stores and is used both to diagnose deficiency and to monitor replacement therapy. 1,25‑dihydroxyvitamin D (1,25‑OH) is the active metabolite and is reserved for evaluation of suspected conversion disorders (for example, kidney, liver, parathyroid, or genetic diseases), unexplained hypercalcemia, hypercalciuria, tumor‑induced osteomalacia, or nephrolithiasis.

Definitions and Key Terms

25-hydroxyvitamin D — CPT 82306

CPT 82306 definitionCPT 82306: Vitamin D; 25‑hydroxy (includes fraction(s) if performed)

Preferred analyte25‑hydroxyvitamin D is the preferred serum metabolite for assessing vitamin D status because it reflects total body stores.

Common clinical useUsed to assess deficiency and to monitor replacement therapy in medically indicated situations.

1,25-dihydroxyvitamin D — CPT 82652

CPT 82652 definitionCPT 82652: Vitamin D; 1,25‑dihydroxy (includes fraction(s) if performed)

Clinical role1,25‑dihydroxyvitamin D is the active metabolite assay reserved for suspected conversion defects (e.g., kidney, liver, parathyroid, genetic diseases).

References, Endnotes, and Revision Notes

Supportive evidence citations for vitamin D testing

Supportive evidenceSystematic reviews and cohort studies linking vitamin D status with disease activity and bone outcomes in rheumatologic conditions are cited (eg, SLE, rheumatoid arthritis).

Examples of cited workCitations include systematic reviews of vitamin D and bone mineral density in SLE and studies of vitamin D supplementation effects in rheumatoid arthritis and juvenile arthritis.

Use in policy rationaleThese evidence citations underpin recommendations about when testing may be clinically useful in rheumatologic and bone‑health contexts.

Note

No prior authorization requirements specified in these excerpts

The provided excerpts do not specify any prior authorization requirements in the referenced endnote and reference sections.

This policy is based on and aligned with Local Coverage Determination (LCD) L37535 for Vitamin D Assay Testing; documentation and coverage decisions should be consistent with the LCD where applicable.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyVitamin D testing (25-OH and 1,25-OH) — Coverage and Medical Necessity

Policy CodePolicy N/A

Change TypeMinor/No material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

From policy indications for CPT 82652

inv-69: Vitamin D testing when deficiency suspected or to document replacement therapy

Guidance when deficiency is suspected or to document replacement therapy:

Repeat testing after treatment: If 25-OH level is <20 ng/dL or >60 ng/dL, subsequent testing may be MEDICALLY NECESSARY until the level is within the normal range; if level is 20–50 ng/dL and the patient is clinically stable, repeat testing is often unnecessary and requires clear documentation of medical necessity if performed.<20 ng/dL or >60 ng/dL

Repeat testing rules

inv-70: Assessment or management of vitamin D deficiency, osteomalacia/osteoporosis, or calcium metabolism disorders

Assessment or management of vitamin D deficiency, osteomalacia/osteoporosis, or calcium metabolism disorders — examples of ICD-10 diagnoses that support medical necessity for 1,25-OH testing when appropriate:

Example ICD-10 linkage for 1,25-OH: Examples include: E55.0 (Rickets, active); E55.9 (Vitamin D deficiency, unspecified); E83.50 (Unspecified disorder of calcium metabolism); E83.52 (Hypercalcemia); M83.* (adult osteomalacia codes); N20.* (kidney/ureteral calculus) — these and other listed ICD-10 codes are considered medically necessary when submitted with CPT 82652 and criteria are met.

See policy ICD-10 examples in CPT 82652 section

inv-71: Diagnosis and management of suspected vitamin D deficiency or bone health concerns

Preferred assay selection and when to order 1,25-dihydroxyvitamin D:

Preferred assay selection: 25-hydroxyvitamin D is the preferred initial assay to assess vitamin D status because it reflects total body stores.

Rationale for preferred assay

When to use 1,25-dihydroxyvitamin D: Order 1,25-dihydroxyvitamin D when conversion defects are suspected (eg, kidney disease, liver disease, parathyroid disorders, or genetic diseases) that may affect activation of vitamin D.

Reserve 1,25-OH for conversion disorders

inv-72: Supportive evidence citations

Supportive references linking vitamin D status to rheumatologic disease activity and bone turnover (selected examples):

Evidence citations: Systematic reviews and cohort studies have reported associations between vitamin D status and bone mineral density, disease activity in systemic lupus erythematosus, and clinical measures in rheumatoid arthritis; randomized trials and meta-analyses address supplementation effects on falls and fractures in older adults.

Selected references listed in policy (see References section)

Both assays (25‑OH and 1,25‑OH) need not be performed for each condition; reserve 1,25‑OH for suspected conversion disorders.

Clinical stability considerationIf level is 20–50 ng/dL and patient clinically stable, repeat testing is often unnecessary and must be justified if ordered.

82652 (1,25-dihydroxyvitamin D) — code definition and notes

CPT 82652 descriptionCPT 82652: Vitamin D; 1,25‑dihydroxy (includes fraction(s) if performed)

Intended useMeasurement of 1,25‑dihydroxyvitamin D is reserved for specific conditions affecting conversion (e.g., kidney, liver, parathyroid, genetic disorders).

Coverage linkageCPT 82652 is covered when medical necessity criteria are met and an appropriate ICD‑10 diagnosis code is submitted.

Continued abnormal findings and additional testing

Continued abnormal findingsContinued abnormal findings outside parameters outlined in the Limitations section may warrant additional testing per policy limitations.

Use of active metabolite assayReserve 1,25‑dihydroxyvitamin D testing for suspected conversion defects; 25‑OH remains preferred initial test.

Documentation importanceDocumentation should support necessity for additional testing when used beyond the specified thresholds or frequency guidance.

Do not use vitamin D testing for routine screening of asymptomatic adults (USPSTF: insufficient evidence)
If level between 20–50 ng/dL and patient clinically stable, repeat testing is often unnecessary — document medical necessity if repeated
Claims may be denied for Commercial members if medical necessity criteria are not met

Note

Local Coverage Reference (LCD L37535)

This policy references and is based on Local Coverage Determination (LCD) L37535 (Vitamin D Assay Testing). Documentation and coverage determinations should align with the referenced LCD where applicable.

Endnote: policy is based on LCD L37535
Ensure documentation aligns with the LCD when applicable

Documentation Required

Coding and Documentation Guidance

Coding and documentation guidance: Providers should report all services using the most up-to-date industry-standard CPT, HCPCS, revenue, and ICD-10 diagnosis codes, and include modifiers where applicable. When billing CPT 82652 (1,25-dihydroxyvitamin D), submit an appropriate ICD-10 diagnosis from the policy and document medical necessity.

Report services with current procedure, revenue, and diagnosis codes and modifiers where applicable
CPT 82652 requires appropriate ICD-10 diagnosis linkage listed in the policy when billed
Document medical necessity especially for repeat testing or borderline vitamin D levels

Step Therapy

Step Therapy / Reference Notes

No step therapy requirements are described in the policy excerpts or reference sections.

No step therapy or step edit rules specified in references/endnotes

Documentation Required

Submit appropriate ICD-10 diagnosis codes; applies to Commercial products

Providers must submit an appropriate ICD-10 diagnosis code listed in the policy when ordering/testing; the policy applies to Commercial product lines (Managed Care HMO/POS, PPO, Indemnity, Medicare HMO/PPO Blue).

Include one of the policy-listed ICD-10 codes with the CPT code to support coverage.

Step Therapy

Order testing when clinically indicated; consider empiric supplementation for low-risk patients

Order vitamin D testing only when clinically indicated; empiric supplementation without testing may be acceptable for low-risk patients with likely inadequate sun exposure or dietary intake, but document the clinical rationale.

Consider empiric supplementation for low-risk patients instead of testing.
Document rationale if choosing supplementation without testing.

Not initial assayNot preferred as the initial screening test because it is less reflective of total body vitamin D stores than 25‑OH.

ICD-10 diagnosis list (rheumatoid and related conditions)

Scope of listThe policy enumerates multiple ICD‑10 codes for rheumatoid and related arthropathies (eg, M05.*, M06.*, M07.*) covering site‑specific and systemic presentations.

Examples includedEntries include Felty's syndrome, rheumatoid lung disease, rheumatoid vasculitis, and rheumatoid arthritis with/without rheumatoid factor across many sites.

Use with testingAn appropriate ICD‑10 diagnosis from the listed codes must accompany CPT submissions to support medical necessity for vitamin D testing.

Enteropathic Arthropathies

DefinitionEnteropathic arthropathies: arthritic conditions associated with inflammatory bowel disease, documented with multiple site‑specific ICD‑10 subcodes (M07.*).

Site specificityPolicy lists site‑specific codes for shoulders, elbows, wrists, hands, hips, knees, ankles/feet, vertebrae, and multiple‑site entries.

Relevance to testingThese diagnoses are among the ICD‑10 codes that may justify medically necessary vitamin D testing when accompanying CPT codes.

Juvenile Rheumatoid Arthritis

DefinitionJuvenile rheumatoid arthritis: pediatric forms of arthritis represented by multiple ICD‑10 site‑ and subtype‑specific codes (M08.*).

ExamplesIncluded codes cover systemic onset, pauciarticular, polyarthritis, and other juvenile subtypes with site‑specific designations.

Testing contextJuvenile arthritis codes are listed among diagnoses that may support medically necessary vitamin D testing in affected patients.

Age-related Osteoporosis with Current Pathological Fracture

DefinitionAge‑related osteoporosis with current pathological fracture: ICD‑10 codes (M80.*) that specify fracture site and encounter type (initial, subsequent with routine healing, delayed healing, nonunion, malunion, sequela).

Clinical detailPolicy lists multiple M80.* subcodes for different anatomical sites (shoulder, humerus, forearm, hand, femur, lower leg, ankle/foot, vertebrae, pelvis) and encounter types.

RelevanceThese diagnoses are included among codes that may justify medically necessary 25‑OH Vitamin D testing in osteoporosis/fragility contexts.

Vitamin D (calciferol)

Basic definitionVitamin D (calciferol) is a fat‑soluble vitamin involved in calcium homeostasis and bone metabolism, with additional effects on vascular and inflammatory pathways.

Physiologic rolesRoles include regulation of calcium absorption, bone health, modulation of inflammation, and effects on other systems (eg, renin‑angiotensin, coagulation).

Clinical implicationsDeficiency is commonly due to inadequate intake and sun exposure; kidney or liver disease can impair conversion to active metabolites.

25-hydroxyvitamin D — preferred serum metabolite

Preferred metabolite25‑hydroxyvitamin D is the serum metabolite preferred for assessing vitamin D status because it reflects total body stores.

Reason for preference25‑OH has a longer half‑life and better represents body stores compared with the short‑lived active metabolite 1,25‑OH.

Clinical useUsed as the initial assay to assess deficiency and to monitor replacement therapy in indicated patients.

25-hydroxyvitamin D — rationale for preference

Rationale25‑hydroxyvitamin D reflects total body stores and is therefore preferred to assess vitamin D status over the active 1,25‑dihydroxy form.

Assay implicationsBecause 1,25‑OH may be normal or elevated in deficiency states, 25‑OH gives a more reliable assessment of deficiency.

Policy recommendationPolicy recommends using 25‑OH as the preferred initial assay; reserve 1,25‑OH for suspected conversion disorders.

1,25-dihydroxyvitamin D — active metabolite

Active metabolite role1,25‑dihydroxyvitamin D is the active metabolite and its assay is reserved for evaluation when conversion defects (eg, kidney, liver, parathyroid, genetic disorders) are suspected.

Not for routine status assessment1,25‑OH is not recommended for routine assessment of vitamin D status because it does not reflect total body stores.

Clinical triggersIndications include unexplained hypercalcemia, suspected genetic rickets, unexplained hypercalciuria, tumor‑induced osteomalacia, nephrolithiasis.

References — Vitamin D and rheumatic diseases

Bibliographic scopeReferences include systematic reviews, randomized trials, and cohort studies addressing vitamin D status and associations with rheumatic disease activity and bone health.

Selected topicsCited studies examine vitamin D status in SLE, rheumatoid arthritis, juvenile rheumatoid arthritis, and effects of supplementation on disease markers and bone turnover.

Policy basisThese references support the policy rationale and the listed clinical indications for testing in rheumatologic and bone‑health conditions.