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CurrentFidelis CarePolicy FC.CG.PP.10

Nutrition and Metabolism Non-Genetic Testing

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Defines coverage and reimbursement rules for non-genetic nutrition and metabolism laboratory tests (e.g., vitamin D, vitamin B12/folate, iron studies, homocysteine) for Fidelis Care Medicaid and Health Insurance Marketplace products and the conditions under which those tests are covered.

Policy Summary

PayerFidelis Care

PolicyNutrition and Metabolism Non-Genetic Testing

Policy CodePolicy FC.CG.PP.10

Change TypeNo material changes noted

Effective Date

Next Review Date

Key ActionObtain and document medical necessity (clinical indication and monitoring frequency) before submitting claims for listed nutrition and metabolism tests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3max annual 25-hydroxyvitamin D tests covered

2max annual 1,25-dihydroxyvitamin D tests covered

3max annual vitamin B12/folate tests covered

4max annual serum iron tests covered

Medicaid & MarketplaceProducts governed

02/2026revision noted

Coverage Criteria for Nutrition & Metabolism Tests

Serum 25-hydroxyvitamin D (25(OH)D) Tests

Covered when ALL of the following are met:

Overall

Indication: Member is being monitored during treatment for vitamin D deficiency or insufficiency (serum 25(OH)D < 30 ng/mL) OR being monitored during treatment for hypervitaminosis D OR has ≥1 risk factor for vitamin D deficiency OR has ≥1 sign or symptom of vitamin D deficiency/excess

Serum 1,25-dihydroxyvitamin D (1,25(OH)2D) Tests

Covered when ALL of the following are met:

Overall

Indication: Chronic kidney disease OR hypercalcemia OR hereditary phosphate-losing disorders OR oncogenic osteomalacia OR vitamin D-resistant/pseudovitamin D-deficiency rickets OR granuloma-forming disorder

Policy Summary

PayerFidelis Care

PolicyNutrition and Metabolism Non-Genetic Testing

Policy CodePolicy FC.CG.PP.10

Change TypeNo material changes noted

Effective Date

Next Review Date

Key ActionObtain and document medical necessity (clinical indication and monitoring frequency) before submitting claims for listed nutrition and metabolism tests.

SourceLink

On This Page

Serum/Plasma Homocysteine Tests

Covered when ALL of the following are met:

Indication: Member is being monitored during treatment for homocystinuria OR member meets BOTH: (1) has ≥1 listed clinical feature (high myopia, ectopia lentis, thromboembolism, skeletal abnormalities including Marfanoid features, intellectual disability/developmental delay, extrapyramidal signs, psychiatric disorder, seizures, or a biological sibling with homocystinuria) AND (2) it has been at least one year since the member's last test

General coverage application

Policy governs payment for listed non-genetic nutrition and metabolism laboratory tests when billed under applicable plan terms and clinical guidelines

Coverage application: Tests listed in the policy (CPT codes enumerated) are subject to payment determinations based on the member's coverage documents, plan-level administrative policies, and applicable state and federal requirements; providers must apply professional judgment and follow relevant clinical guidelines cited in references.

Claims and coverage determinations are subject to terms, conditions, exclusions and limitations of coverage documents; state Medicaid provisions take precedence where applicable.

The use of serum 25-hydroxyvitamin D (25(OH)D) tests for indications other than those explicitly listed in this policy is not covered. Providers should order 25(OH)D testing only when the member meets one of the policy-specified indications and adheres to the stated frequency limits.

Serum 1,25-dihydroxyvitamin D (1,25(OH)2D) testing is not covered for indications beyond those specified in this policy. In particular, 1,25(OH)2D testing is not covered for evaluation of vitamin D status and should only be performed when the member meets one or more of the listed clinical conditions and the frequency limit.

Vitamin B12 and/or folate laboratory tests are not covered for indications other than those enumerated in this policy. Orders for these tests must correspond to the covered indications and comply with the policy's frequency limitations to be considered for payment.

The use of iron binding capacity testing performed simultaneously with transferrin testing is not covered. Additionally, serum iron/ferritin/iron-binding related tests are not covered for indications outside those listed in the policy.

Serum/plasma homocysteine testing is not covered for indications other than those specified. This includes use of homocysteine testing for confirmation of borderline vitamin B12 or folate deficiency, which is explicitly not covered.

Where state Medicaid coverage provisions conflict with this payment policy, the state Medicaid provisions take precedence. Coverage and payment decisions are governed by the member's coverage documents and applicable state and federal requirements.

Serum 25(OH)D testing for indications not listed in this policy is considered not covered (not medically necessary). Providers must document that testing aligns with the policy's enumerated indications and frequency limits to support payment.

Payment determinations are guided by this payment policy but remain subject to the terms, conditions, exclusions and limitations of the member's coverage documents. Services inconsistent with those documents may be denied in accordance with plan-level and legal requirements.

Applicable Codes and Coding Guidance

Referenced CPT Codes (non-exhaustive list)CPT

82009	Ketone body(s); qualitative
82010	Ketone body(s); quantitative
82306	Vitamin D; 25 hydroxy, includes fraction(s), if performed
82652	Vitamin D; 1, 25 dihydroxy, includes fraction(s), if performed
82746	Folic acid; serum
82747	Folic acid; RBC
82728	Ferritin
82930	Gastric acid analysis, includes pH if performed
82947	Glucose; quantitative, blood (except reagent strip)
82948	Glucose; blood, reagent strip

1–10 of 11

1/2

No codes listed

Listed chemistry and specialized assaysCPT

82652	Vitamin D; 1, 25 dihydroxy, includes fraction(s), if performed.
82657	Enzyme activity in blood cells, cultured cells, or tissue, not elsewhere specified; nonradioactive substrate, each specimen.
82658	Enzyme activity in blood cells, cultured cells, or tissue, not elsewhere specified; radioactive substrate, each specimen.
82664	Electrophoretic technique, not elsewhere specified.
82725	Fatty acids, nonesterified.
82726	Very long chain fatty acids.
82728	Ferritin.
82746	Folic acid; serum.
82747	Folic acid; RBC

No codes listed

Additional chemistry, immunology, coagulation and related testsCPT

82930	Gastric acid analysis, includes pH if performed, each specimen.
82947	Glucose; quantitative, blood (except reagent strip).
82962	Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use.
83003	Growth hormone, human (HGH) (somatotropin).
83020	Hemoglobin fractionation and quantitation; electrophoresis (eg, A2, S, C, and/or F).
83090	Homocysteine.
83540	Iron.
84460	Transferase; alanine amino (ALT) (SGPT).
84999	Unlisted chemistry procedure.
86003	Allergen specific IgE; quantitative or semiquantitative, crude allergen extract, each.

1–10 of 11

1/2

No codes listed

inv-18: 25-hydroxyvitamin D deficiency threshold

25-hydroxyvitamin D deficiency thresholdSerum 25(OH)D < 30 ng/mL

Frequency limitMaximum 3 tests per year for 25(OH)D when covered

Documentation triggerTesting supported when monitoring treatment for deficiency/insufficiency or when listed risk factors/signs present

inv-19: Glucose tolerance test (GTT) specimen count

GTT specimen count (primary)Code 82951 = Glucose tolerance test (GTT), 3 specimens (includes glucose)

Additional specimensCode 82952 = GTT, each additional specimen beyond 3 (report in addition to primary procedure)

Coding noteReport 82952 only when more than 3 specimens are collected in the same tolerance test event

Provider Responsibilities, Documentation & Utilization Controls

Prior Authorization

Obtain medical necessity documentation before submitting claims

Specific tests listed in this policy are covered only when the member meets the clinical criteria and frequency limits described for each test; obtain and retain medical necessity documentation prior to claim submission.

Examples of listed tests include CPT codes such as 82306 (25‑hydroxyvitamin D), 82652 (1,25‑dihydroxyvitamin D), 82746/82747 (folate), 82728 (ferritin), 83090 (homocysteine), and others enumerated in the policy.
Frequency limits and indication-specific criteria (e.g., 25(OH)D max 3/year, 1,25(OH)2D max 2/year) must be met.

Prior Authorization

Check plan-level prior authorization and NCD/LCD requirements

This payment policy is a guide; prior authorization requirements are determined by the health plan and may apply — review plan-level administrative rules and any applicable NCDs/LCDs before ordering or billing these tests.

State Medicaid provisions take precedence where they conflict with this policy.
Consult CMS NCDs/LCDs as appropriate for Medicare members.

Step Therapy

Adhere to stated frequency limits (utilization controls)

Frequency limits in the policy are utilization controls; repeated testing must meet the monitoring indications and the maximum annual counts (e.g., 25(OH)D: up to 3/year).

25(OH)D tests: covered a maximum of three times per year when criteria met.
1,25(OH)2D tests: covered a maximum of two times per year when criteria met.
Vitamin B12/folate tests: covered a maximum of three times per year when criteria met.
Serum iron studies: covered a maximum of four times per year when criteria met.

Note

Provider action (reserved)

Reserved for additional provider action instructions.

Documentation Required

Document clinical rationale for 25(OH)D testing

Document indications that support 25(OH)D testing such as monitoring during treatment for vitamin D deficiency (serum 25(OH)D < 30 ng/mL), monitoring during treatment for hypervitaminosis D, listed risk factors, or listed signs/symptoms.

Record serum 25(OH)D level < 30 ng/mL when monitoring treatment for deficiency.
Document specific risk factors (e.g., chronic kidney disease, malabsorption, granuloma‑forming disorders) or signs/symptoms (e.g., abnormal calcium, low phosphate, elevated PTH, low BMD, non‑traumatic fracture, bone pain, muscle weakness).

Documentation Required

Document clinical rationale for vitamin B12/folate testing

Document clinical evidence that supports vitamin B12 and/or folate testing — either monitoring during treatment for deficiency, one or more listed risk factors, or one or more listed signs/symptoms of deficiency.

Risk factors to document include undernutrition, malabsorption, excessive alcohol use, nitrous oxide use, age ≥75, low‑B12 diet, relevant medications, or genetic disorders.
Signs/symptoms to document include abnormal blood counts, neurological abnormalities, dementia‑like symptoms, glossitis, or optic nerve dysfunction.

Documentation Required

Document clinical rationale for iron studies

Document clinical signs/symptoms, risk factors, or age‑based screening eligibility to support serum iron studies (ferritin, iron, iron binding capacity, transferrin saturation).

Clinical signs/symptoms include abnormal blood counts, acute/chronic blood loss, integumentary changes, fatigue/weakness, pica, restless legs, exertional dyspnea, or tachycardia.
Risk factors include hereditary hemochromatosis, chronic kidney or liver disease, porphyria hemin therapy, reduced iron absorption, chronic RBC transfusions, or suspected excess iron exposure.
For children 0–3 years, document specific pediatric risk factors to qualify for testing.

Documentation Required

Document clinical rationale and timing for homocysteine testing

Document the diagnosis or monitoring indication for homocysteine testing: either monitoring during treatment for homocystinuria, or the combination of at least one listed clinical feature plus an interval of at least one year since the previous test.

Clinical features include high myopia, ectopia lentis, thromboembolism, skeletal abnormalities (e.g., marfanoid features), intellectual disability/developmental delay, extrapyramidal signs, psychiatric disorder, seizures, or a biological sibling with homocystinuria.
Ensure ≥1 year has elapsed since the member's last homocysteine test when using the listed combination criterion.

Documentation Required

Ensure claims and documentation meet contractual and plan requirements

Follow plan‑level administrative policies and procedures and ensure claims align with the member's coverage documents; state Medicaid rules override this policy where they conflict.

Verify evidence of coverage, certificate of coverage, policy or contract terms prior to billing.
Comply with any applicable state or federal requirements governing coverage determinations.

Denial Risk

Denied if 25(OH)D is ordered for unlisted indications

Ordering 25(OH)D tests for indications other than the specific criteria listed in the policy risks claim denial as not covered.

25(OH)D is covered only for the listed monitoring indications, risk factors, or signs/symptoms; other uses are not covered.

Denial Risk

Denied if 1,25(OH)2D used for unlisted indications (including routine vitamin D status)

Ordering 1,25(OH)2D tests for routine evaluation of vitamin D status or for indications not listed in the policy risks denial — 1,25(OH)2D is covered only for the specific conditions enumerated.

Policy explicitly states 1,25(OH)2D is not covered for evaluation of vitamin D status or other unlisted indications.

Denial Risk

Denied if vitamin B12/folate tests ordered for unlisted indications

Vitamin B12 and/or folate testing ordered for indications outside those listed in the policy may be denied as not covered.

Coverage is limited to monitoring during deficiency treatment, listed risk factors, or listed signs/symptoms.

Denial Risk

Denied if serum iron tests or simultaneous iron binding + transferrin are used for unlisted indications

Serum iron testing (including ferritin, iron, iron binding capacity, transferrin saturation) ordered for indications not described in the policy may be denied; use of iron binding capacity testing performed simultaneously with transferrin testing is not covered.

Policy permits serum iron studies only for listed signs/symptoms, risk factors, pediatric screening criteria, or universal screening condition described.
Do not bill iron binding capacity when it is performed simultaneously with transferrin testing — that combination is excluded.

Denial Risk

Denied if homocysteine tests ordered for unlisted indications (including borderline B12/folate confirmation)

Homocysteine testing ordered for indications other than monitoring homocystinuria or the specified clinical feature + interval combination (including to confirm borderline B12/folate) is not covered and may be denied.

Policy explicitly excludes homocysteine testing for confirmation of borderline vitamin B12 or folate deficiency.

Denial Risk

Coverage decisions are subject to contract terms and legal requirements

Coverage and payment are subject to the member's coverage documents and applicable state and federal requirements; discrepancies between this policy and those documents may affect payment.

For Medicaid members, state Medicaid coverage provisions take precedence where they conflict with this policy.
Providers should verify contract terms before ordering and billing tests.

Background and Scope

This policy defines coverage criteria for commonly ordered nutrition and metabolism laboratory tests, including vitamin D metabolites (25(OH)D and 1,25(OH)2D), vitamin B12 and folate, iron studies (ferritin, iron, iron binding capacity, transferrin saturation), and homocysteine. For each test category the policy specifies covered clinical indications, required documentation, and maximum testing frequency per year to determine medical necessity and payment.

Definitions and Term Clarifications

inv-36: High myopia

DefinitionNear-sightedness of -6.00 diopters or greater or an axial length greater than 26.5 mm

SourceDefined by the American Association for Pediatric Ophthalmology & Strabismus as cited in policy

Use in criteriaApplied as a listed clinical feature for homocysteine testing indications

inv-37: Marfanoid features

DefinitionPhysical features associated with Marfan Syndrome (e.g., disproportionately tall, slender build; abnormally long/slender fingers and toes; protruding or caving sternum; scoliosis)

SynonymMarfanoid habitus

ContextListed in policy as a clinical feature relevant to homocysteine testing/diagnosis

inv-39: 82652 — Vitamin D; 1,25-dihydroxy (code reference)

CPT code82652 — Vitamin D; 1,25-dihydroxy (includes fraction(s), if performed)

CategoryListed under chemistry and specialized assays in policy coding section

Clinical note1,25(OH)2D testing has specific covered indications and is not for routine vitamin D status evaluation

inv-38: Undernutrition

DefinitionWHO-defined malnutrition types: wasting (low weight-for-height), stunting (low height-for-age), underweight (low weight-for-age), and micronutrient-related malnutrition (deficiencies or excesses)

ScopeIncludes both micronutrient deficiencies and micronutrient excess (e.g., obesity) per WHO framing

RelevanceListed as a risk factor for vitamin B12/folate deficiency in policy criteria

inv-40: 84999 — Unlisted chemistry procedure (code reference)

CPT code84999 — Unlisted chemistry procedure

Usage guidanceUse when no listed CPT code accurately describes the chemistry procedure performed

Coding locationIncluded in the policy's additional chemistry and related tests list

Policy Development & Revision History

02/2026policy_revisionLatest

Policy revision recorded (listed in brief statistics as 'Revision history: 02/2026'); updates to coverage criteria and frequency limits confirmed in the current policy document.

publication_note

Payment policy is effective as of the date determined by Fidelis Care; posting date may differ from effective date.