CurrentCentenePolicy CPMP.157

25-hydroxyvitamin D Testing in Children and Adolescents

Defines Centene's coverage stance on 25-hydroxyvitamin D (25-OH-D) laboratory testing in pediatric populations and specifies when testing is considered not medically necessary versus when testing/screening is recommended based on clinical risk.

Policy Summary

PayerCentene

Policy25-hydroxyvitamin D Testing in Children and Adolescents

Policy CodePolicy CPMP.157

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionDo not order 25-hydroxyvitamin D testing for routine screening of healthy children; document clinical indication and risk factors when testing is requested.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not necessaryCoverage stance for routine screening

<18Age group addressed

~15%Reported deficiency prevalence

82306Referenced CPT

Coverage Criteria for 25-hydroxyvitamin D Testing (Pediatrics)

Routine screening in healthy children

Not medically necessary — routine screening

Primary rule: 25-hydroxyvitamin D testing is not medically necessary for healthy children and adolescents (age < 18), including those who are obese but otherwise healthy

Reflects Centene policy aligned with AAP and global consensus; routine universal screening is not recommended

Targeted testing in high-risk children

Clinical exceptions and guidance

When testing is appropriate: Testing is appropriate when clinical factors indicate high risk for vitamin D deficiency or when conditions associated with reduced bone mass or recurrent low-impact fractures are present

Based on AAP, Endocrine Society, and global consensus recommending targeted testing of high-risk groups

Policy Summary

PayerCentene

Policy25-hydroxyvitamin D Testing in Children and Adolescents

Policy CodePolicy CPMP.157

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionDo not order 25-hydroxyvitamin D testing for routine screening of healthy children; document clinical indication and risk factors when testing is requested.

SourceLink

On This Page

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When to consider testing with multiple risk factors: Consider measuring serum 25(OH)D in the presence of multiple clinical risk factors for vitamin D deficiency (eg, known malabsorption, chronic kidney disease, disorders affecting vitamin D metabolism, or multiple risk factors identified on clinical assessment)

Global consensus and Italian societies recommend targeted screening for patients with multiple risk factors

Therapeutic alternative: For otherwise healthy children with inadequate dietary vitamin D intake, consider empiric vitamin D supplementation rather than routine laboratory screening

Endocrine Society and AAP recommend supplementation for insufficient intake instead of universal testing

Routine universal screening for vitamin D status in asymptomatic children is excluded by this policy. Centene recommends targeted testing rather than population-wide screening: 25-hydroxyvitamin D measurement should be considered when clinical factors place a child at high risk for vitamin D deficiency or when there are conditions associated with low bone mass or recurrent low-impact fractures. This approach aligns with global expert consensus and guidance from pediatric societies that favor identification and testing of high-risk groups based on clinical indicators instead of routine screening of asymptomatic children.

25-hydroxyvitamin D testing (CPT 82306) is considered not medically necessary for routine screening of healthy children and adolescents, including those who are obese but otherwise healthy. When CPT 82306 is billed with codes for routine health examinations or obesity without other risk factors, the test may be denied per this policy; providers should reference current CPT guidance when submitting claims.

Coding

CPT codes referencedCPT

82306

Vitamin D; 25 hydroxy including fraction(s) if performed

ICD-10-CM codes referenced as not medically necessary when billed with CPTICD-10Not Covered

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
E66.9	Obesity, unspecified
Z00.00	Encounter for general adult medical examination without abnormal findings
Z00.129	Encounter for routine child health examination without abnormal findings
Z00.8	Encounter for other general examination
Z68.52	Body mass index (BMI) pediatric, 5th percentile to less than 85th percentile for age

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Provider Actions, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Prior authorization may be required for 25‑hydroxyvitamin D (25‑OH‑D) testing. Testing ordered for routine screening in otherwise healthy children (age ≥1 and <18), including those who are overweight or obese without additional clinical risk factors, is considered not medically necessary and prior authorization requests may be denied.

Affected CPT: 82306 (Vitamin D; 25‑hydroxy)
Prior auth consideration: Routine screening indications in healthy children may be denied

Note

Therapeutic Approach vs Screening

Therapeutic approach preferred over routine laboratory screening: For healthy children and adolescents who may have limited dietary vitamin D intake, professional guidance (AAP, Endocrine Society, international consensus) recommends empiric vitamin D supplementation rather than routine population screening with 25‑OH‑D laboratory testing. Routine vitamin D testing is not recommended for asymptomatic, healthy children, including those who are obese, unless specific clinical indications or risk factors are present.

Recommendation: Offer vitamin D supplementation per guideline dosing for prevention rather than universal laboratory screening
When to test: Reserve 25‑OH‑D testing for patients with clinical signs of deficiency or multiple high‑risk conditions

Documentation Required

Documentation Expectations

Documentation Expectations: When ordering 25‑OH‑D testing, providers must document the clinical indication and relevant risk factors in the medical record. Requests for testing should include supporting clinical findings (e.g., signs of rickets, recurrent low‑impact fractures, conditions associated with reduced bone mass, malabsorption, chronic kidney disease, documented malnutrition) or multiple identified risk factors as described in guidance. Absent such documentation, testing for routine screening may be denied.

Required documentation: clinical indication, relevant exam findings, comorbid conditions or multiple high‑risk factors
Operational note: Include supporting ICD‑10 code(s) that reflect the clinical indication rather than routine exam or screening codes

Denial Risk

Denial Risk for Routine Screening

Denial Risk for Routine Screening: Claims for CPT 82306 billed with routine screening or obesity-related ICD‑10 codes (for example Z00.00, Z00.129, Z00.121, Z68.52, Z68.53, E66.* series, Z00.00 encounter for general exam without abnormal findings, encounter for routine child health exam without abnormal findings) are at high risk for denial as not medically necessary when submitted for otherwise healthy children.

High‑risk code pairings: CPT 82306 + Z00.00 / Z00.121 / Z00.129
Obesity codes of concern: E66.01, E66.09, E66.1, E66.3, E66.8, E66.9
Operational guidance: Provide clinical justification and appropriate diagnosis codes that support medical necessity to reduce denial risk

Background

Measurement of 25-hydroxyvitamin D (25-OH-D) concentration is the appropriate laboratory test to assess vitamin D status. In contrast, measurement of the active metabolite 1,25-(OH)2-D has little to no predictive value for bone health and is not the preferred assay for screening or routine assessment.

Definitions

25-OH-D — Screening measurement

Term25-OH-D (25-hydroxyvitamin D)

DefinitionThe laboratory measurement used to assess vitamin D status; the appropriate screening test for vitamin D deficiency.

Clinical rolePreferred screening assay to evaluate vitamin D status in children; used to identify deficiency for targeted testing rather than routine universal screening.

Policy implicationRoutine 25-OH-D testing is not recommended for healthy children; testing should be reserved for those with clinical risk factors for deficiency.

1,25-(OH)2-D — Active form (not preferred for screening)

Term1,25-(OH)2-D

DefinitionThe active form of vitamin D; has little to no predictive value related to bone health and is not the preferred screening assay.

Clinical roleNot recommended as a screening test for vitamin D deficiency because it does not reliably reflect vitamin D stores or predict bone health outcomes.

Policy implicationUse of 1,25-(OH)2-D testing for routine assessment of vitamin D status is not appropriate; 25-OH-D is the preferred test.