CurrentHumanaPolicy LAB2023049

Laboratory - Parathyroid Hormone, Phosphorus, Calcium and Magnesium Testing

Humana Medicare Advantage payment policy describing reimbursement and non-reimbursement rules for PTH, phosphorus, calcium and magnesium laboratory testing for Medicare Advantage members.

Policy Summary

PayerHumana

PolicyLaboratory - Parathyroid Hormone, Phosphorus, Calcium and Magnesium Testing

Policy CodePolicy LAB2023049

Change TypeRoutine review — no material changes

Effective Date

Next Review Date03/2026

Key ActionOrder serum intact PTH (CPT 83970) only for listed clinical indications and follow the frequency limits tied to diagnosis and CKD stage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5procedure codes listed

12 moPTH freq (stage 3 CKD)

3 moPTH freq (stage 4/5 CKD)

4Tests not reimbursable

Coverage Criteria for Testing

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Reimbursable indications for PTH (83970)

As needed for individuals who have
- Signs of hypoparathyroidism
  - Abnormal magnesium
  - Elevated serum phosphorus
  - Hypercalciuria
  - Hypocalcemia
  - Low calcitriol
- Abnormal calcium
- Familial medullary thyroid carcinoma
- Multiple endocrine neoplasia type 2A
- Osteoporosis or low bone mass
- Undergone parathyroidectomy
Diagnosis-based frequency rules
- Diagnosed hyperparathyroidism without parathyroidectomy — one test per year1/year
- Stage 3 chronic kidney disease (CKD) — one test every 12 months1/12 months
- Stage 4 or stage 5 CKD — one test every 3 months1/3 months
- Individuals <18 years with pseudohypoparathyroidism type 1A or 1B, pseudopseudohypoparathyroidism, progressive osseous heteroplasia or acrodysostosis — one test every 3 months1/3 months

This policy addresses reimbursement for laboratory testing of parathyroid hormone, calcium, phosphorus and magnesium for Humana Medicare Advantage members. Specifically, serum, blood or fecal magnesium (CPT 83735), serum ionized calcium (CPT 82330), urine calcium (CPT 82340), and urine phosphorus/phosphate (CPT 84105) are identified in the policy as tests that are not reimbursable when the member’s primary diagnosis is a general encounter without abnormal findings. Coverage for parathyroid hormone testing (CPT 83970) and other indicated uses are addressed separately with specific clinical indications and frequency limits.

Indications Where Testing Is Covered

PTH testing indications with frequencies

PTH testing is covered for the clinical indications listed below; where noted, follow the specified testing frequency.

Indications for PTH testing

Signs suggestive of hypoparathyroidism (abnormal magnesium, elevated serum phosphorus, hypercalciuria, hypocalcemia, low calcitriol)
Abnormal serum calcium
Familial medullary thyroid carcinoma
Multiple endocrine neoplasia type 2A (MEN2A)
Osteoporosis or low bone mass
Post-parathyroidectomy monitoring
Hyperparathyroidism: Diagnosed hyperparathyroidism in individuals who have not undergone parathyroidectomy — one test per year1/year
Chronic kidney disease: Stage 3 CKD — one test every 12 months; Stage 4 or 5 CKD — one test every 3 monthsstage 3: 1/12 months; stage 4-5: 1/3 months
Pseudohypoparathyroidism and related pediatric/adult disorders: Individuals <18 years with pseudohypoparathyroidism type 1A or 1B, pseudopseudohypoparathyroidism, progressive osseous heteroplasia or acrodysostosis — one test every 3 months; individuals >=18 years with these diagnoses — one test per year<18: 1/3 months; >=18: 1/year

Clinical guideline–referenced conditions where testing may be relevant

Guidelines and clinical references cited in the policy support use of PTH and related biochemical testing in the following conditions; inclusion here provides context for when testing may be appropriate.

Guideline-referenced clinical contexts

Primary hyperparathyroidism — see American Association of Endocrine Surgeons guideline (Wilhelm et al., 2016) cited in policy
Chronic kidney disease — guideline context for mineral and bone disorder management (Wright et al., 2019) cited in policy
Recurrent or suspected nephrolithiasis (kidney stones) — guideline context referenced in policy literature list
Suspected hypoparathyroidism or disorders of calcium/phosphate homeostasis — endocrine society/Endotext references cited (Shaker & Deftos; Ross et al.)

Testing Frequency Limits and Intervals

PTH (83970) — hyperparathyroidism without parathyroidectomy; adults with pseudohypoparathyroidism-related disorders

Test and CPTSerum intact parathyroid hormone (PTH) — CPT 83970

IndicationDiagnosed hyperparathyroidism without parathyroidectomy

Allowed frequencyOne test per year

NotesReimbursable when any listed reimbursable indication is present per policy

PTH (83970) — stage 3 CKD

Test and CPTSerum intact parathyroid hormone (PTH) — CPT 83970

IndicationStage 3 chronic kidney disease (CKD)

Allowed frequencyOne test every 12 months

NotesReimbursable when stage 3 CKD is the documented indication per policy

PTH (83970) — stage 4 or 5 CKD; pediatric pseudohypoparathyroidism-related disorders

Test and CPTSerum intact parathyroid hormone (PTH) — CPT 83970

IndicationsStage 4 or stage 5 CKD; individuals younger than 18 years with pseudohypoparathyroidism types 1A/1B, pseudopseudohypoparathyroidism, progressive osseous heteroplasia, or acrodysostosis

Allowed frequencyOne test every 3 months

NotesFrequency applies to both CKD stage 4/5 and specified pediatric pseudohypoparathyroidism-related disorders per policy

Additional frequency notes

General frequency rulePTH testing frequency is diagnosis-specific; see per-diagnosis limits (annual, 12-month, or every 3 months)

Age-specific frequencyIndividuals <18 years with specified pseudohypoparathyroidism-related disorders: every 3 months; individuals ≥18 years with those diagnoses: one test per year

ScopeFrequencies apply when a reimbursable indication from policy is documented

Relevant Procedure Codes

Applicable CPT codes listedCPT

82330	Calcium; ionized.
82340	Calcium; urine quantitative, timed specimen.
83735	Magnesium.
83970	Parathormone (parathyroid hormone).
84105	Phosphorus inorganic (phosphate); urine

PTH (83970) - Covered with criteriaCPTCovered

83970

Parathormone (parathyroid hormone).

Other tests (listed for reference)CPT

83735	Magnesium.
82330	Calcium; ionized.
82340	Calcium; urine quantitative, timed specimen.
84105	Phosphorus inorganic (phosphate); urine

Not reimbursable for general encounter without abnormal findingsCPTNot Covered

83735	Serum, blood or fecal magnesium testing — listed as not reimbursable in specified circumstances.
82330	Serum ionized calcium — listed as not reimbursable in specified circumstances.
82340	Urine calcium testing — listed as not reimbursable in specified circumstances.
84105	Urine phosphorus or phosphate testing — listed as not reimbursable in specified circumstances.

What Providers and Billers Must Do

Documentation Required

General documentation context

As a Medicare Advantage plan, claims remain subject to medical necessity, reasonableness, and any applicable referral or authorization requirements. Providers should ensure that testing is supported by clinical indications and that claims reflect applicable plan rules.

Applies to Medicare Advantage products

Billing Rule

PTH (CPT 83970) reimbursement conditions and frequency

Serum intact parathyroid hormone testing (CPT 83970) is reimbursable only for the listed clinical indications and at the specified frequencies (e.g., annual for hyperparathyroidism without parathyroidectomy; every 12 months for stage 3 CKD; every 3 months for stage 4–5 CKD). Follow the frequency limits when ordering and billing to avoid denials.

Affected code: CPT 83970
Frequency examples: one test/year for hyperparathyroidism without parathyroidectomy; one test/12 months for stage 3 CKD; one test/3 months for stage 4–5 CKD

Denial Risk

Denial risk for non-specific primary diagnosis

Claims for the listed tests (eg, serum magnesium CPT 83735; serum ionized calcium CPT 82330; urine calcium CPT 82340; urine phosphorus CPT 84105) are not reimbursable when the primary diagnosis is a general encounter code without abnormal findings. Submitting a non‑specific primary diagnosis places the claim at risk of denial.

Non‑reimbursable when primary diagnosis = general encounter without abnormal findings
Affected codes: CPT 83735, 82330, 82340, 84105

Note

Prior Authorization

The source policy does not state any explicit prior authorization requirements for these laboratory tests. Verify member plan documents and local requirements for any additional preauthorization rules.

Step Therapy

Step therapy

No step therapy requirements are described in the policy for these tests. Order tests based on clinical indications and applicable coverage criteria.

Documentation Required

Documentation requirements

The policy does not list additional, explicit documentation requirements beyond the general expectation of medical necessity and reasonableness. Maintain clinical records that support the medical indication and frequency of testing in case of medical review.

Note

No explicit denial triggers are present

The policy does not enumerate specific denial triggers beyond the items noted above (eg, non‑specific primary diagnosis or testing outside stated frequencies/indications). Treat this as informational — follow coding, frequency, and medical‑necessity guidance to minimize risk of denial.

Note

Provider action

Provider note: confirm member coverage, referral, or authorization rules applicable to the specific Medicare Advantage plan before submitting claims; retain clinical documentation supporting test necessity and frequency.

Ordering and Provider Restrictions

Documentation Required

Ordering requirements — claims subject to medical necessity and plan rules

Reiterate that Humana Medicare Advantage claims remain subject to medical necessity, reasonableness, and applicable referral or authorization requirements — ensure orders and billing reflect those requirements.

Note

Ordering provider restrictions — none stated in provided text

The policy does not state any explicit restrictions on which ordering provider may request these tests in the provided chunks; confirm any plan- or contract-specific ordering-provider limits separately if needed.

Not Covered Tests and Situations

Explicitly not covered: serum, blood or fecal magnesium (CPT 83735), serum ionized calcium (CPT 82330), urine calcium (CPT 82340), and urine phosphorus/phosphate (CPT 84105) when billed with a primary diagnosis representing a general encounter without abnormal findings. Claims for these tests in that diagnostic context are not reimbursable.

No additional tests or scenarios are listed as not covered beyond those specified above.

Background and Clinical Context

Background: Measurement of parathyroid hormone (PTH), calcium, phosphorus and magnesium supports diagnosis and management of disorders of mineral metabolism and the parathyroid axis. These tests are used in the evaluation of suspected or confirmed hypoparathyroidism (for example when there is hypocalcemia, elevated serum phosphorus, low calcitriol, hypercalciuria or abnormal magnesium), hyperparathyroidism (including monitoring and pre-/post-parathyroidectomy care), chronic kidney disease–related mineral and bone disorder (with testing frequency stratified by CKD stage), and other endocrine or metabolic bone conditions. Policy guidance distinguishes appropriate clinical indications and frequency limits for PTH testing (CPT 83970) from scenarios where certain calcium, phosphorus or magnesium assays are not reimbursable, such as when the primary diagnosis is a general encounter without abnormal findings.

Definitions and Test Labels

Definition — PTH (CPT 83970)

TermPTH (CPT 83970)

DefinitionSerum intact parathyroid hormone testing (parathormone, parathyroid hormone)

Coding noteListed procedure code in policy: 83970 — Parathormone (parathyroid hormone)

Parathyroid hormone (PTH) — key term

TermParathyroid hormone (PTH)

Short definitionHormone measured to evaluate calcium, phosphorus and magnesium homeostasis and related disorders

ContextPTH measurement informs diagnosis and management of hypoparathyroidism, hyperparathyroidism, CKD-related mineral bone disorder and related conditions

Policy Summary

PayerHumana

PolicyLaboratory - Parathyroid Hormone, Phosphorus, Calcium and Magnesium Testing

Policy CodePolicy LAB2023049

Change TypeRoutine review — no material changes

Effective Date

Next Review Date03/2026

Key ActionOrder serum intact PTH (CPT 83970) only for listed clinical indications and follow the frequency limits tied to diagnosis and CKD stage.

SourceLink

On This Page

OpenPayer

Laboratory - Parathyroid Hormone, Phosphorus, Calcium and Magnesium Testing

Coverage Criteria for Testing

Indications Where Testing Is Covered

Testing Frequency Limits and Intervals

Relevant Procedure Codes

What Providers and Billers Must Do

Ordering and Provider Restrictions

Not Covered Tests and Situations

Background and Clinical Context

Definitions and Test Labels

Policy Revision History