CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB003

Vitamin D Testing

Coverage and lab reimbursement criteria for serum vitamin D testing (25-hydroxyvitamin D and 1,25-dihydroxyvitamin D) for Blue Cross Blue Shield - New Mexico members and participating providers.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyVitamin D Testing

Policy CodePolicy CPCPLAB003

Change TypeRevised

Effective DateJun 15, 2023

Next Review Date

Key ActionSubmit documentation supporting medical indication for vitamin D testing and use appropriate HIPAA-approved codes on claims.

SourceLink

POLICY UPDATE CHANGES

Reimbursement information revised for clarity and literature review updated.

3procedure codes listed

2vitamin D analytes discussed

~40supporting references cited

2monitoring frequency rules

Coverage Criteria for Vitamin D Testing

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25-hydroxyvitamin D (25-OH D) testing reimbursable

Conditions list: Includes disorders such as celiac disease, malabsorption, bariatric surgery, chronic liver disease, CKD stage III-V/ESRD, osteoporosis, osteomalacia, rickets, obesity, certain medications, and other listed conditions
See Note 1 for complete list

Fractionated D2/D3 testing: Testing for D2 and D3 fractions as part of total 25-hydroxyvitamin D analysis may be reimbursable when 25-OH D testing is indicated

See reimbursement point 2

Monitoring after deficiency documented: For individuals with documented vitamin D deficiency, repeat 25-hydroxyvitamin D testing is reimbursable at least 12 weeks after initiation of supplementation, limited to no more than 2 tests per year until therapeutic goal is achieved; annual testing once therapeutic range is reached12 weeks; <=2 per year; annual thereafter

See reimbursement point 3

1,25-dihydroxyvitamin D testing: Reimbursable for evaluation or treatment of conditions associated with defects in vitamin D metabolism

See Note 2 for list of qualifying conditions

Coverage for serum vitamin D testing is limited to specific clinical situations. 25-hydroxyvitamin D (25-OH D) testing may be reimbursable when the individual has an underlying disease or condition specifically associated with vitamin D deficiency or decreased bone density, or when hypervitaminosis D is suspected. Fractionated testing for D2 and D3 as part of total 25-OH D analysis may be reimbursable when 25-OH D testing is indicated. For individuals with documented vitamin D deficiency, repeat 25-OH D testing is reimbursable at least 12 weeks after initiation of supplementation, limited to no more than 2 testing instances per year until the therapeutic goal is achieved, and annual testing thereafter once therapeutic range is reached.

Covered Indications and Clinical Conditions

inv-13: Underlying diseases/conditions associated with vitamin D deficiency or decreased bone density (See Note 1 list)

See Note 1 list: Indications supporting reimbursement for serum measurement of 25-hydroxyvitamin D include: biliary cirrhosis and other biliary tract disorders; blind loop syndrome; celiac disease; coronary artery disease when considering chronic vitamin D/calcium therapy; dermatomyositis; eating disorders; prior or planned bariatric procedures (e.g., Roux-en-Y, sleeve gastrectomy, biliopancreatic diversion); disorders of calcium metabolism (hypercalcemia, hypocalcemia); hyperparathyroidism or hypoparathyroidism; individuals receiving hyperalimentation; intestinal malabsorption; liver cirrhosis; long-term use of anticonvulsants, glucocorticoids, or other medications known to lower vitamin D; malnutrition; myalgia/myositis; endocrine-related myopathy; neoplastic hematologic disorders; obesity; osteogenesis imperfecta; osteomalacia; osteopetrosis; osteoporosis; pancreatic steatorrhea; primary or miliary tuberculosis; psoriasis; regional enteritis; renal/ureteral/urinary calculus; rickets; sarcoidosis; stage III-V CKD and ESRD; systemic lupus erythematosus

Full list in Note 1

inv-14: Evaluation or treatment of defects in vitamin D metabolism for which 1,25-dihydroxyvitamin D measurement is relevant (See Note 2)

See Note 2 list: Indications supporting reimbursement for serum 1,25-dihydroxyvitamin D testing include: disorders of calcium metabolism; familial hypophosphatemia; Fanconi syndrome; hyperparathyroidism or hypoparathyroidism; individuals receiving hyperalimentation; neonatal hypocalcemia; osteogenesis imperfecta; osteomalacia; osteopetrosis; primary or miliary tuberculosis; renal/ureteral/urinary calculus; rickets; sarcoidosis; stage III-V CKD and ESRD

Full list in Note 2

Monitoring and Frequency Limits

inv-15: 25-hydroxyvitamin D — testing frequency limits

Frequency limitNo more than 2 monitoring 25-hydroxyvitamin D tests per year until therapeutic goal is achieved; annual testing thereafter

Applies toIndividuals with documented vitamin D deficiency undergoing supplementation monitoring

Effective policy datePolicy created 2023-06-15 (see policy metadata)

inv-16: 25-hydroxyvitamin D — repeat testing interval

Minimum interval for repeat testingRepeat 25-hydroxyvitamin D testing is allowed at least 12 weeks after initiation of vitamin D supplementation

Use caseIntended for monitoring response to supplementation in individuals with documented deficiency

Related restrictionSubsequent monitoring limited to no more than 2 tests per year until therapeutic goal achieved

inv-05: Monitoring frequency after supplementation

Repeat testing timingRepeat serum 25-hydroxyvitamin D at least 12 weeks after starting supplementation

Annual cap after goalOnce therapeutic range is reached, annual testing may be reimbursable

Operational limitMonitoring during supplementation should not exceed 2 testing instances per year until therapeutic goal is achieved

Provider Actions, Documentation, and Billing

Documentation Required

ORDERING REQUIREMENTS

Providers are responsible for submission of accurate documentation of services performed. Document medical necessity on the claim and retain supporting clinical records; BCBSNM may request additional documentation to substantiate medical necessity. Claims are subject to review against benefit terms, provider contract language, medical policies, clinical payment and coding policies, and code-edit logic. Use HIPAA-approved code sets and industry-standard coding guidelines (CPT®, HCPCS, ICD-10, NDC, UB, DRG, CMS NCCI) when submitting claims.

Document medical necessity on claims and retain supporting records
Submit claims using HIPAA-approved code sets and valid code combinations
BCBSNM may request additional documentation and will review claims against plan documents and policies

Billing Rule

Procedure codes subject to plan review

The following procedure codes are associated with vitamin D testing and may be subject to plan review for reimbursement. Inclusion in this list does not guarantee coverage or payment; providers should ensure claims include medical necessity documentation.

Codes: 82306 (25-hydroxyvitamin D), 82652 (1,25-dihydroxyvitamin D), 0038U (Vitamin D, LC-MS/MS)

Denial Risk

Denial risks

Routine screening of asymptomatic individuals is not reimbursable. Measurement of serum 1,25-dihydroxyvitamin D to screen for vitamin D deficiency is not reimbursable and may be denied. Providers should order 25-hydroxyvitamin D testing only when there is an underlying disease/condition associated with deficiency or suspicion of hypervitaminosis, or for documented deficiency monitoring per policy intervals.

Routine screening in asymptomatic individuals is non-reimbursable
1,25-dihydroxyvitamin D measurement for screening is non-reimbursable and may be denied

Note

Reimbursement conditions

For individuals with conditions associated with vitamin D deficiency or suspected hypervitaminosis, 25-hydroxyvitamin D testing may be reimbursable. D2/D3 fraction testing as part of total 25-hydroxyvitamin D analysis may be reimbursable. For documented deficiency, repeat 25-hydroxyvitamin D testing is allowable at least 12 weeks after starting supplementation: up to 2 tests per year until therapeutic goal achieved; thereafter annual testing may be reimbursable. For conditions with defects in vitamin D metabolism, 1,25-dihydroxyvitamin D testing may be reimbursable.

25-hydroxyvitamin D testing reimbursable when underlying disease/condition or suspected hypervitaminosis is present
D2 and D3 fraction testing reimbursable as part of total 25-hydroxyvitamin D analysis
Repeat testing allowed >=12 weeks after supplementation start; limit to 2 tests/year until goal achieved, then annual testing
1,25-dihydroxyvitamin D reimbursable for defects in vitamin D metabolism

Documentation Required

Documentation and claims submission

Providers are expected to code appropriately according to industry-standard guidelines. Claims are subject to code-edit protocols and adjudication logic; upon request, submit additional documentation to support the medical indication and the use of the billed codes.

Use appropriate CPT/HCPCS/ICD-10/NDC codes and modifiers
Answers to documentation requests may affect payment determination

Definitions of Vitamin D Analytes

inv-11: 25-hydroxyvitamin D — definition and reimbursement context

Test name25-hydroxyvitamin D (25-OH D) — serum measurement to assess vitamin D status

Reimbursement contextReimbursable when associated with underlying conditions linked to deficiency or for monitoring therapy

Fractionated testingTesting for D2 and D3 fractions as part of total 25-hydroxyvitamin D analysis may be reimbursable

inv-12: 1,25-dihydroxyvitamin D — active metabolite definition; reimbursable for specific metabolic disorders but not routine screening

Analyte1,25-dihydroxyvitamin D — the active metabolite of vitamin D used to evaluate defects in vitamin D metabolism

Reimbursable indicationsMay be reimbursable for evaluation/treatment of conditions associated with defects in vitamin D metabolism (see Note 2 list)

Not for routine screeningMeasurement of serum 1,25-dihydroxyvitamin D to screen for vitamin D deficiency is not reimbursable

Background

Clinical context: 25-hydroxyvitamin D (25-OH D) is the primary serum test used to assess vitamin D status and to monitor deficiency and response to supplementation when clinical indications are present. In contrast, 1,25-dihydroxyvitamin D is the active metabolite and is used to evaluate and manage disorders of vitamin D metabolism; its measurement is appropriate for evaluating specific metabolic or renal conditions but is not appropriate for routine deficiency screening.