ModifiedHealthfirstPolicy PO-RE-001v6

Vitamin D Testing

Coverage policy for serum vitamin D (25-hydroxyvitamin D and 1,25-dihydroxyvitamin D) testing, including D2/D3 fraction testing, indications, limitations, and related laboratory considerations for Healthfirst members.

Policy Summary

PayerHealthfirst

PolicyVitamin D Testing

Policy CodePolicy PO-RE-001v6

Change TypeCoverage consolidation and frequency limit update

Effective DateMay 1, 2026

Next Review Date

Key ActionOrder 25-hydroxyvitamin D testing only for listed clinical indications and no more than once every six months for covered situations; document supporting clinical indication.

SourceLink

POLICY UPDATE CHANGES

Combined prior coverage categories CC1 and CC3 into a single criterion permitting 25-hydroxyvitamin D testing no more than once every six months for specified clinical situations.

Added 'chemotherapy' to Note 1 as a medication known to lower vitamin D levels.

3Medicare tests/year

1/6moMax frequency (covered)

<20 ng/mLDeficiency threshold

2Primary CPT-coded analytes

Coverage Criteria for Vitamin D Testing

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inv-01: Covered Indications — Covered when the following criteria are met

Covered when the following criteria are met

Primary coverage for 25-hydroxyvitamin D: Testing for 25-hydroxyvitamin D serum meets coverage for individuals with an underlying disease or condition specifically associated with vitamin D deficiency or decreased bone density (see enumerated indications in Note 1).

Medicare population allowed three tests per year.

D2/D3 fraction testing: Testing for D2 and D3 fractions as part of total 25-hydroxyvitamin D analysis meets coverage criteria.

1,25-dihydroxyvitamin D testing indications: Serum 1,25-dihydroxyvitamin D testing meets coverage when evaluating or treating conditions associated with defects in vitamin D metabolism (see Note 2).

Not for routine screening of deficiency.

inv-03: When testing is appropriate (general synthesis of guideline statements) — Covered when ONE of the following guideline‑supported indications is present

Covered when ONE of the following guideline-supported indications is present:

Indications: 1) Patients with bone disease or osteoporosis where vitamin D status affects management (e.g., AACE/ACE, ROS). 2) Patients at risk for deficiency due to malabsorption or pre/post bariatric surgery (AACE/Obesity Society/ASMBS; RYGB, sleeve gastrectomy, BPD/DS). 3) Patients with symptomatic deficiency (e.g., hypocalcemia, osteomalacia) or where correction is needed prior to specific therapy. 4) Children/adolescents with low bone mineral density or recurrent low‑impact fractures (AAP).

Guideline consensus generally advises against routine population screening; testing during pregnancy is not routinely recommended except in individual circumstances.

inv-04: Retesting/follow-up criteria — Covered when retesting meets guideline timing or specific clinical scenarios

Covered when retesting meets guideline timing or specific clinical scenarios:

Retest: 1) Retest no earlier than 3 months after initiation or dose change of vitamin D replacement. 2) Annual or end-of-winter assessment may be appropriate in older individuals or when risk factors have changed. 3) Repeat testing reserved for symptomatic deficiency, malabsorption, those on antiresorptive therapy with low baseline 25(OH)D, or where poor adherence is suspected.3 months

Do not retest within 3 months; preferably wait 3–6 months per guidance.

inv-05: Consolidated Coverage Criterion — Covered when the consolidated criterion is met

Covered when the consolidated criterion is met:

Consolidated CC: For individuals with an underlying disease or condition specifically associated with vitamin D deficiency or decreased bone density, for individuals suspected of hypervitaminosis of vitamin D, or for individuals with vitamin D deficiency, 25-hydroxyvitamin D serum testing meets coverage criteria when performed no more than once every six months.once per 6 months

See Note 1 for enumerated conditions and medications (chemotherapy added to Note 1).

Routine screening of asymptomatic individuals for vitamin D deficiency and the use of 1,25-dihydroxyvitamin D as a screening test are excluded from coverage. The policy explicitly states that measurement of serum 1,25-dihydroxyvitamin D to screen for vitamin D deficiency DOES NOT MEET COVERAGE CRITERIA, and that routine screening for vitamin D deficiency with serum testing in asymptomatic individuals and/or during general encounters DOES NOT MEET COVERAGE CRITERIA.

Multiple professional bodies and guideline panels advise against routine population screening of asymptomatic adults for vitamin D deficiency. The Endocrine Society (2024) recommends against routine 25(OH)D testing across adult age groups and during pregnancy; the USPSTF concluded the evidence is insufficient to assess benefits and harms of screening asymptomatic adults (I statement); and the American Academy of Pediatrics similarly finds insufficient evidence to support universal screening in otherwise healthy children and adolescents.

The policy distinguishes the roles of vitamin D analytes and specifies that measurement of serum 1,25-dihydroxyvitamin D is not appropriate for routine screening of vitamin D deficiency. While 1,25-dihydroxyvitamin D testing meets coverage criteria for evaluation of disorders of vitamin D metabolism, it is explicitly excluded when used solely to screen for deficiency; 25-hydroxyvitamin D (CPT 82306) is the preferred test for routine assessment of vitamin D status.

Testing asymptomatic, otherwise healthy individuals for screening purposes is not supported by guideline evidence and therefore is not recommended. Guideline panels (Endocrine Society, USPSTF, AAP) advise against routine screening in the general adult population and in most asymptomatic pediatric and pregnant populations; the policy follows this guidance and does not cover routine, population‑based vitamin D screening absent specific risk factors or clinical indications.

Previously separate coverage criteria were operationally consolidated to standardize frequency limits and simplify application. The policy combined earlier CC entries into a single consolidated criterion that permits 25-hydroxyvitamin D testing for covered indications no more than once every six months; Note 1 was also updated to add 'chemotherapy' as a medication associated with lower vitamin D levels.

Included Clinical Indications

inv-39: Conditions associated with vitamin D deficiency or decreased bone density (examples listed in Note 1) and disorders of vitamin D metabolism (Note 2).

Conditions associated with vitamin D deficiency or decreased bone density (examples listed in Note 1) and disorders of vitamin D metabolism (Note 2).

Examples (Note 1): Examples include biliary cirrhosis and other biliary tract disorders; blind loop syndrome; celiac disease; coronary artery disease in selected individuals; dermatomyositis; eating disorders; bariatric procedures (Roux-en-Y, sleeve gastrectomy, biliopancreatic diversion ± duodenal switch); disorders of calcium metabolism; hyperparathyroidism/hypoparathyroidism; individuals receiving hyperalimentation; inflammatory bowel disease; intestinal malabsorption; liver cirrhosis; long-term use of anticonvulsants, glucocorticoids, chemotherapy and other medications known to lower vitamin D levels; malnutrition; myositis/myopathy; neoplastic hematologic disorders; osteogenesis imperfecta; osteomalacia; osteopetrosis; osteoporosis; pancreatic steatorrhea; tuberculosis; psoriasis; regional enteritis; renal/urinary calculus; rickets; sarcoidosis; stage III-V CKD and ESRD; systemic lupus erythematosus.

This list is illustrative; see Note 1 for full enumerated indications.

Disorders (Note 2): Indications for 1,25-dihydroxyvitamin D testing include disorders of calcium metabolism; familial hypophosphatemia; Fanconi syndrome; hyperparathyroidism/hypoparathyroidism; individuals receiving hyperalimentation; neonatal hypocalcemia; osteogenesis imperfecta; osteomalacia; osteopetrosis; rickets; sarcoidosis; stage III-V CKD and ESRD; renal/urinary calculus.

1,25-dihydroxyvitamin D testing is for evaluating defects in vitamin D metabolism per Note 2.

inv-40: Evaluation and management of bone disease/osteoporosis, symptomatic vitamin D deficiency, malabsorption, pre/post bariatric surgery monitoring, and patients on antiresorptive therapy where vitamin D status affects treatment.

Evaluation and management indications supported by specialty guidance:

Bone disease/osteoporosis: Measure serum 25-hydroxyvitamin D in patients at risk for vitamin D insufficiency, particularly those with osteoporosis; maintain 25(OH)D ≥30 ng/mL in patients with osteoporosis per AACE/ACE guidance.≥30 ng/mL

AACE/ACE recommends maintaining ≥30 ng/mL for osteoporosis; ACOG references ≥20 ng/mL to avoid bone problems.

Malabsorption and bariatric surgery: Baseline and postoperative evaluation for vitamin D deficiency is recommended for patients undergoing Roux-en-Y gastric bypass, sleeve gastrectomy, or biliopancreatic diversion (with or without duodenal switch); monitor and manage deficiency in malabsorption syndromes.

Guidelines from AACE/Obesity Society/ASMBS and bariatric literature support testing in these populations.

Symptomatic deficiency and therapy preparation:

inv-41: Individuals with conditions associated with vitamin D deficiency or decreased bone density; suspected hypervitaminosis; individuals with vitamin D deficiency — coverage permits testing with a maximum frequency of once every six months; Note 1 includes chemotherapy.

Individuals with conditions associated with vitamin D deficiency or decreased bone density; suspected hypervitaminosis; individuals with vitamin D deficiency — coverage permits testing with a maximum frequency of once every six months.

Frequency limitation: 25-hydroxyvitamin D testing is covered for the indicated individuals when performed no more than once every six months.once per 6 months

Revision history added chemotherapy to Note 1 as a medication associated with lower vitamin D levels.

Medicare exception note: Medicare population allowance: three (3) Vitamin D tests per year (per Medicare guidance).3 per year

Providers should consider both payer-specific limits and the universal once-per-six-months operational rule when applicable.

Excluded Indications and Uses

inv-02: Not Covered — 1 top-level node

Not Covered — coverage does not meet medical necessity for the following:

Not covered uses: Measurement of serum 1,25-dihydroxyvitamin D to screen for vitamin D deficiency; routine screening for vitamin D deficiency with serum testing in asymptomatic individuals and/or during general encounters.

Routine population screening and use of 1,25-dihydroxyvitamin D for screening are excluded from coverage.

Routine screening of asymptomatic individuals and use of 1,25-dihydroxyvitamin D to screen for deficiency are designated as not covered. Specifically, the policy states that measurement of serum 1,25-dihydroxyvitamin D to screen for vitamin D deficiency does not meet coverage criteria, and it aligns with guideline positions that routine population screening (including routine screening during pregnancy) is not recommended without supporting clinical indications.

Routine population screening of asymptomatic individuals is not covered. The Endocrine Society (2024) explicitly suggests against routine 25(OH)D testing across adult age groups and during pregnancy, and the USPSTF (2021) found insufficient evidence to support screening asymptomatic adults; consistent with these positions, routine testing during pregnancy or in otherwise healthy adults without risk factors is considered not covered absent clinical indication.

This excerpt does not enumerate every specific test or scenario that may be excluded. Operational changes consolidated prior criteria and instituted a universal once‑per‑six‑months frequency limit for covered indications; for the complete list of explicit exclusions and prior not‑covered conditions, refer to the full policy text and revision history.

Testing Frequency and Retesting Intervals

Denial Risk

Early retesting risk

Retesting earlier than guideline-recommended intervals is discouraged and may result in claim denial. Providers should not routinely repeat testing within 3 months of initiation or dose change and should follow the policy operational limit of one test every six months unless prior authorization is obtained for an exception.

Early retesting (<3 months) discouraged — may trigger denial
Operational limit (1 per 6 months) will be enforced unless exception authorized

Documentation Required

Provider-action / Billing and Documentation requirements

Provider actions — Coding, Authorization, Documentation, and Billing Rules
Providers must follow national coding standards when submitting claims. Use the appropriate CPT code(s) (e.g., 82306 for serum 25‑OH‑vitamin D) and include modifiers only when supported by national guidance. Prior authorization may be required for exceptions to the frequency limits — check payer-specific prior authorization requirements before ordering repeat testing outside the stated intervals. Routine screening of asymptomatic individuals is not covered; empiric treatment without testing is an accepted practice for certain at-risk asymptomatic individuals and may be preferable to routine testing. Failure to follow correct coding, billing, or prior authorization procedures may result in claim denial or recoupment. Maintain and provide supporting documentation on request, including clinical indication, symptoms or conditions prompting testing, dates of treatment initiation or dose changes, and laboratory results from prior tests (including the laboratory name when available). Claims must adhere to national coding standards and include documentation supporting medical necessity for tests performed outside standard intervals.

Coding: Use national CPT codes (e.g., 82306) and follow national coding guidance.
Prior authorization: Obtain prior authorization for exceptions to frequency limits when required by payer.
Testing frequency authorization: Tests beyond 1 per 6 months require justification and prior authorization.
Routine screening exclusion: Routine screening of asymptomatic individuals is not covered.
Empiric treatment over testing: For some at-risk asymptomatic patients, treat empirically without testing per guidance.
Early retesting risk: Retesting earlier than 3 months (and operationally, earlier than 6 months) may be denied.
Failure to follow proper coding/billing: Incorrect coding, missing prior auth, or inadequate documentation can lead to denial.
Recommended supporting documentation: Clinical indication, symptoms/conditions, dates of supplementation or dose changes, prior lab results (same laboratory if available), and any prior authorization approvals.
Claims must follow national coding standards: Submit correct CPT/HCPCS codes and modifiers consistent with national guidance.

Applicable Codes and Definitions

Applicable Codes (section header present)mixed

No codes listed

Covered CPT Codes - 25(OH)DCPTCovered

82306

Vitamin D; 25 hydroxy, includes fraction(s), if performed.

Covered CPT Codes - 1,25(OH)2DCPTCovered

82652

Vitamin D; 1, 25 dihydroxy, includes fraction(s), if performed.

Proprietary/Other CPTCPT

0038U

Vitamin D, 25 hydroxy D2 and D3, by LC-MS/MS, serum microsample, quantitative Proprietary test: Sensieva™ Droplet 25OH Vitamin D2/D3 Microvolume LC/MS Assay.

Procedure coding notemixed

Procedure codes appearing in Reimbursement Policy documents

Included only as a general reference; may not be all-inclusive

inv-17: Vitamin D deficiency threshold — commonly used threshold <20 ng/mL

Common deficiency thresholdSerum 25OHD < 20 ng/mL is typically used to define vitamin D deficiency.

Insufficiency range notedSome organizations consider 25OHD < 30 ng/mL as insufficient (noted distinction in guidance).

Clinical significanceLevels <20 ng/mL are considered suboptimal for skeletal health and associated with rickets/osteomalacia.[chunk 7]

inv-18: Vitamin D toxicity threshold — >200 ng/mL (>500 nmol/L)

Toxicity threshold> 200 ng/mL (equivalent to >500 nmol/L) is cited as the level at which vitamin D toxicity occurs.

Clinical consequencesToxicity may cause hypercalciuria, hypercalcemia, renal stones, and renal calcification with potential renal failure.

RarityVitamin D toxicity is described as very rare and occurs only at very high 25OHD concentrations.[chunk 9]

inv-19: Treatment/target level for osteoporosis — >= 30 ng/mL per AACE/ACE; ACOG references >=20 ng/mL

AACE/ACE osteoporosis targetMaintain serum 25(OH)D ≥ 30 ng/mL in patients with osteoporosis (preferable range 30–50 ng/mL).

ACOG referenceACOG notes most guidelines agree a serum level of at least 20 ng/mL is needed to avoid bone problems; ACOG recommends checking and supplementing if <30 ng/mL in certain scenarios.

Supplement dosing noteAACE/ACE suggests daily vitamin D3 (1,000–2,000 IU) typically required to maintain optimal levels; higher doses may be needed for obesity or malabsorption.

Provider Responsibilities and Documentation

Billing Rule

Use specified CPT codes and expect authorization rules

Use the listed procedure codes when ordering or billing: CPT 82306 for 25‑hydroxyvitamin D, CPT 82652 for 1,25‑dihydroxyvitamin D, and CPT 0038U for the proprietary Sensieva™ 25OH D2/D3 LC‑MS/MS microsample assay; these codes may be subject to usual payer authorization and billing rules.

CPT 82306 — Vitamin D; 25 hydroxy (includes fractions).
CPT 82652 — Vitamin D; 1,25 dihydroxy (includes fractions).
CPT 0038U — Sensieva™ Droplet 25OH Vitamin D2/D3 Microvolume LC/MS Assay (proprietary).

Prior Authorization

Limit testing to once every 6 months for covered indications

Coverage was revised to permit 25‑hydroxyvitamin D testing for covered indications no more than once every six months; confirm testing frequency when submitting claims to meet this limit.

Consolidated coverage criterion: 25‑hydroxyvitamin D testing meets coverage when performed no more than one test every six months for specified indications.
Ensure claim dates reflect the once-per-six-months frequency for covered indications.

Step Therapy

Empiric supplementation may be appropriate instead of testing

Some guideline bodies recommend empiric vitamin D supplementation for asymptomatic high‑risk individuals without prior measurement; consider treating without testing where guidance supports it.

Asymptomatic high‑risk individuals may be treated empirically without measurement per Manchester University NHS recommendations.
Repeat testing is reserved for symptomatic deficiency, malabsorption, or other specific scenarios.

Documentation Required

Document supporting clinical indication (refer to Note 1)

Document the underlying disease or condition that justifies vitamin D testing by referencing the enumerated indications (e.g., malabsorption, CKD stage III–V/ESRD, liver cirrhosis, bariatric surgery, osteoporosis, rickets, sarcoidosis, chemotherapy, etc.).

Support clinical indication using items listed in Note 1 (e.g., malabsorption, bariatric procedures, stage III–V CKD, osteoporosis, chemotherapy).
Include the specific condition in the medical record when ordering/testing.

Documentation Required

Include baseline biochemical indicators and prior 25‑OH‑D results

When relevant, include baseline biochemical data and prior vitamin D results with the test request or chart documentation — examples include serum calcium, phosphorus, alkaline phosphatase, parathyroid hormone (PTH), and previous 25‑OH‑vitamin D within the past 6 months.

Document serum calcium and phosphorus levels and alkaline phosphatase when indicated.
Include PTH values if abnormal and prior 25‑OH‑vitamin D results (preferably within 6 months) when available.

Denial Risk

Do not order routine screening in asymptomatic individuals

Routine screening of asymptomatic individuals (including use of 1,25‑dihydroxyvitamin D for screening) does not meet coverage criteria and should not be ordered for general population screening.

Measurement of serum 1,25‑dihydroxyvitamin D to screen for deficiency is specifically excluded.
Routine screening in asymptomatic individuals or during general encounters is not covered.

Billing Rule

Ensure claims follow coding, modifier, and state billing rules

Follow national coding standards (CPT/HCPCS/ICD‑10), appropriate modifier usage, and applicable state-specific billing rules when submitting claims; ensure documentation supports medical necessity per the policy and evidence of coverage.

Adhere to NCCI, NCD/LCD, and CMS/CPT guidance referenced by the payer.
Include documentation that demonstrates medical necessity for the test per policy criteria.

Denial Risk

Noncompliance with coding/billing may lead to denial/recoupment

Failure to comply with payer coding, billing, or documentation standards may result in claim denial or recoupment; ensure proper code selection and supporting documentation to reduce audit risk.

Noncompliance with coding and billing policies can lead to denial and/or recoupment.
Use industry standards referenced in the policy (CMS, AMA CPT, state rules) when filing claims.

Note

Order only when clinician managing listed conditions justifies testing

Order vitamin D testing only for patients with an appropriate clinical indication from the enumerated list or when managed by clinicians responsible for the listed conditions (primary care or relevant specialists).

Manchester University NHS and other guidance note clinicians managing bone disease, malabsorption, or post‑bariatric patients should determine need for testing.
Ensure the ordering clinician documents the relevant condition that justifies the test.

Billing Rule

Ordering and claims must follow payer coding and documentation standards

Ordering and claims submission must conform to Healthfirst's coding, billing, and documentation standards; the excerpt does not impose specific restrictions on which provider types may order tests but requires adherence to payer standards.

No specific ordering provider restrictions are specified in this excerpt.
Ensure claims and orders conform to payer coding and documentation requirements.

Definitions and Assay Notes

inv-34: 25-hydroxyvitamin D (25OHD) — predominant/stable circulating form; half-life ~15 days.

Definition25-hydroxyvitamin D (25OHD, calcidiol) is the predominant and most stable circulating form of vitamin D used to assess status.

Half-lifeCirculating half-life approximately 15 days.

Preferred testMeasurement of serum 25OHD (CPT 82306) is the generally accepted preferred test to evaluate vitamin D status despite assay standardization issues.

inv-35: 1,25-dihydroxyvitamin D — metabolically active form with short half-life; measured for specific disorders.

Definition1,25-dihydroxyvitamin D (calcitriol) is the metabolically active form of vitamin D with a much shorter circulating half-life.

Half-lifeCirculating half-life approximately 15 hours.

Indications for measurementMeasured primarily for specific disorders of vitamin D metabolism; not appropriate for routine screening of deficiency.

inv-36: 25‑hydroxyvitamin D — Serum 25‑OH‑vitamin D measurement (CPT 82306) — primary test to assess vitamin D status.

Test identity and codeSerum 25‑hydroxyvitamin D measurement — CPT 82306 (Vitamin D; 25 hydroxy, includes fraction(s), if performed).

RolePrimary laboratory test to assess vitamin D status and preferred for routine evaluation of deficiency or monitoring replacement.

D2/D3 fractionsD2 and D3 fraction testing may be performed as part of total 25OHD analysis and meets coverage when indicated.

inv-37: 1,25‑dihydroxyvitamin D — Active form measurement (CPT 82652) — not recommended for routine assessment.

Test identity and code1,25‑dihydroxyvitamin D measurement — CPT 82652 (Vitamin D; 1,25 dihydroxy).

Routine useNot recommended for routine assessment of vitamin D status; meets coverage only for evaluating/treating disorders of vitamin D metabolism (Note 2).

Screening exclusionMeasurement of serum 1,25-dihydroxyvitamin D to screen for vitamin D deficiency does not meet coverage criteria.

inv-38: Assay standardization and certification — CDC VDSCP referenced for assay performance/standardization.

CDC VDSCP referencePolicy references the CDC Vitamin D Standardization-Certification Program (VDSCP) for assay certification and performance criteria.

Performance criteriaVDSCP performance expectations cited include total CV ≤10% and mean bias within -5% to +5% for certified assays.

Laboratory guidanceUse certified assays or documented standardized LDTs (HPLC/LC‑MS/MS) meeting VDSCP criteria when reporting 25‑hydroxyvitamin D results.

OpenPayer

Vitamin D Testing

Coverage Criteria for Vitamin D Testing

Included Clinical Indications

Excluded Indications and Uses

Testing Frequency and Retesting Intervals

Applicable Codes and Definitions

Provider Responsibilities and Documentation

How to Order and What to Document

Definitions and Assay Notes

Background and Rationale

Policy Revision History