Medical Mutual - Ohio Vitamin D Coverage Update

Coverage Criteria for Vitamin D Testing

Covered indications

Covered when the specified conditions below are met

25-hydroxyvitamin D (25OHD) coverage: 25-hydroxyvitamin D serum testing meets coverage criteria for individuals with an underlying disease/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.testing limited to no more than one test every six months

Refer to Note 1 for list of qualifying conditions (see Note 1, letters A–FF).

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

Included as part of total 25(OH)D analysis.

1,25-dihydroxyvitamin D coverage: Serum 1,25-dihydroxyvitamin D testing meets coverage criteria for the evaluation or treatment of conditions associated with defects in vitamin D metabolism.

Refer to Note 2 for qualifying indications (disorders of calcium metabolism, renal disease, granulomatous disorders, etc.).

Indications for targeted testing / when covered

Covered when testing is ordered for patients with risk factors or clinical conditions associated with potential vitamin D deficiency, as supported by specialty guidance.

Primary covered indications: Patients with osteoporosis or low bone mineral density; patients with conditions causing malabsorption (e.g., celiac disease, inflammatory bowel disease, pancreatic insufficiency); patients undergoing bariatric surgery (preoperative and postoperative assessments); symptomatic vitamin D deficiency (for example, hypocalcemia or bone disease); patients with recurrent low‑impact fractures or other bone disease where vitamin D status will change management.

References: AACE/ACE, ROS, AAP, and bariatric surgery society guidance.

Not routinely covered / screening discouraged

Testing is generally not supported for routine screening in asymptomatic general population groups.

Populations for whom routine screening is discouraged: Asymptomatic adults (including across adult age groups and during pregnancy), healthy children without conditions associated with reduced bone mass, individuals without risk factors, and population‑based screening (including adults with obesity or dark complexion) — routine 25(OH)D screening is not recommended.

Guideline sources (Endocrine Society, USPSTF, AAP, Manchester University NHS Trust) advise against population screening or find evidence insufficient.

Retesting and monitoring criteria

Retesting is appropriate only when clinically indicated and not earlier than recommended intervals.

Retesting rules: Do not retest within 3 months of initiating vitamin D replacement or after a large loading dose; many guidelines recommend retesting no earlier than 3 months and preferably not within 6 months after initial testing or treatment. Avoid routine annual testing when levels are normal and risk factors are unchanged.>= 3 months (preferably >= 6 months)

RACGP and Manchester University NHS Trust guidance: retest no earlier than 3 months and preferably not within 6 months; retesting within 4 weeks after a large loading dose may give misleading results.

Combined CC (previously CC1 and CC3)

Covered when ALL of the following are met

Universal six-month testing frequency: 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 (no more than one test every six months) MEETS COVERAGE CRITERIA.once per 6 months

See Note 1 and Note 2 for qualifying conditions; Note 1 letter N now explicitly includes chemotherapy as a medication known to lower vitamin D; Note DD and Note 2 N updated to 'Chronic Kidney Disease and End Stage Renal Disease'.

Measurement of serum vitamin D is guided by clinical indications. Serum 25-hydroxyvitamin D (25OHD) testing is the recommended analyte for assessing vitamin D status and is covered when ordered for individuals with conditions specifically associated with vitamin D deficiency or decreased bone density, for suspected hypervitaminosis D, or for known vitamin D deficiency. The policy explicitly states that measurement of serum 1,25-dihydroxyvitamin D to screen for deficiency and routine screening of asymptomatic individuals do not meet coverage criteria.

Routine population screening of asymptomatic individuals is discouraged. Multiple guideline sources cited in the policy — including the Endocrine Society and the American Academy of Pediatrics — recommend against routine 25(OH)D testing in the general adult population, during pregnancy, and in otherwise healthy children without risk factors. Testing should be targeted to patients with clinical indications or risk factors described in the policy notes rather than performed as population screening.

The policy includes frequency limitations that operationally exclude repeat testing more often than every six months for covered indications. Retesting intervals are intended to allow sufficient time for serum concentrations to change after intervention; therefore, repeat 25‑hydroxyvitamin D testing performed more frequently than once every six months would not meet the revised coverage criterion except where otherwise noted in the qualifying conditions.

The policy delineates the appropriate role of 1,25-dihydroxyvitamin D testing: it is covered for evaluation or management of conditions associated with defects in vitamin D metabolism but is not appropriate for routine screening to assess vitamin D status. For routine assessment of vitamin D status, 25-hydroxyvitamin D is the recommended and more stable analyte.

Repeat testing guidance emphasizes clinical timing: do not retest within 3 months of initiating vitamin D replacement (including after a large loading dose), because early retesting may not reflect the true response to supplementation and can give misleading results. Many guidelines advise waiting up to six months before reassessment when monitoring therapy.

Requests for 25-hydroxyvitamin D testing that occur more frequently than the policy limit of one test every six months for the covered indications are outside the updated coverage criteria and may be considered not medically necessary or subject to utilization review.

Covered Indications and Qualifying Conditions

inv-39: Individuals with diseases/conditions specifically associated with vitamin D deficiency or decreased bone density; suspected hypervitaminosis D; individuals with vitamin D deficiency; evaluation/treatment of defects in vitamin D metabolism.

Underlying diseases/conditions list (refer to Note 1): Individuals with diseases/conditions specifically associated with vitamin D deficiency or decreased bone density (Note 1 includes: biliary cirrhosis; blind loop syndrome; celiac disease; coronary artery disease when considering chronic vitamin D therapy; dermatomyositis; eating disorders; bariatric surgery patients; disorders of calcium metabolism; hyperparathyroidism/hypoparathyroidism; hyperalimentation; inflammatory bowel disease; intestinal malabsorption; liver cirrhosis; long term use of anticonvulsants, glucocorticoids, chemotherapy and other medications known to lower vitamin D; malnutrition; myositis/myopathy; neoplastic hematologic disorders; osteogenesis imperfecta; osteomalacia; osteopetrosis; osteoporosis; pancreatic steatorrhea; tuberculosis; psoriasis; regional enteritis; renal/urinary calculus; rickets; sarcoidosis; Chronic Kidney Disease and End Stage Renal Disease; systemic lupus erythematosus; granulomatous disorders.

See full Note 1 in policy for alphabetical list (A–FF).

Conditions for 1,25-dihydroxyvitamin D testing (refer to Note 2): Individuals evaluated for conditions associated with defects in vitamin D metabolism (Note 2 includes: disorders of calcium metabolism; familial hypophosphatemia; Fanconi syndrome; hyperparathyroidism/hypoparathyroidism; hyperalimentation; neonatal hypocalcemia; osteogenesis imperfecta; osteomalacia; osteopetrosis; tuberculosis; renal/urinary calculus; rickets; sarcoidosis; Chronic Kidney Disease and End Stage Renal Disease; granulomatous disorders).

Testing Frequency Limits

inv-42: 25-hydroxyvitamin D — No more than one test

Frequency limitNo more than one test

Applicable test25-hydroxyvitamin D (25OHD) serum testing

ContextApplies to individuals with an underlying disease/condition associated with vitamin D deficiency, suspected hypervitaminosis D, or documented vitamin D deficiency

inv-43: 25‑hydroxyvitamin D (25(OH)D) — No repeat testing within 3 months of starting vitamin D replacement; preferably not within 6 months in many cases; avoid routine annual testing in some settings

Minimum retest interval after starting replacementDo not retest within 3 months of beginning vitamin D replacement; many guidelines prefer not to retest within 6 months

Routine annual testingAvoid routine annual testing when levels are normal and risk factors unchanged

Procedure Codes and Thresholds

Covered CPT Codes (25‑hydroxyvitamin D)CPT

82306

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

Covered CPT Codes (1,25‑dihydroxyvitamin D)CPT

82652

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

Proprietary / HCPCS‑like codemixed

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

Covered CPT/HCPCS CodesCPTCovered

82306	Vitamin D; 25 hydroxy, includes fraction(s), if performed
82652	Vitamin D; 1, 25 dihydroxy, includes fraction(s), if performed
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

inv-16: Vitamin D deficiency threshold — < 20 ng/mL

Deficiency thresholdSerum 25OHD < 20 ng/mL

IOM recommended rangeMaintain serum 25OHD between 20 and 40 ng/mL (50–100 nmol/L)

Alternative expert targetSome experts favor 30–50 ng/mL as optimal for certain patients

inv-17: Recommended serum targets or thresholds — ROS/AACE thresholds and guidance

ROS thresholds (nmol/L)<25 nmol/L = deficient; 25–50 nmol/L = possibly inadequate; >50 nmol/L = sufficient

AACE threshold for osteoporosis patients

Provider Actions, Documentation, and Billing Guidance

Billing Rule

Procedure codes and review

Procedure codes for vitamin D testing are listed below. Use these codes on claims and expect standard coding review for medical necessity and frequency limits.

82306 — Vitamin D; 25 hydroxy, includes fraction(s), if performed
82652 — Vitamin D; 1,25 dihydroxy, includes fraction(s), if performed
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)

Denial Risk

Required coverage determination for vitamin D assay codes

Testing for 25-hydroxyvitamin D (and D2/D3 fractions) is covered only when the policy's clinical coverage criteria are met. The policy incorporates a universal frequency limit: no more than one 25-hydroxyvitamin D test every six months for covered indications.

Ordering Requirements

Note

Order tests based on policy clinical indications

Order vitamin D tests only when the clinical indications listed in the policy are present (underlying diseases, disorders of vitamin D metabolism, medications affecting vitamin D).

See Note 1 and Note 2 for full lists of qualifying conditions and medications.

Note

Order tests for listed clinical conditions (osteoporosis, malabsorption, bariatric patients, symptomatic deficiency)

Place orders for testing when clinically indicated by the conditions listed (for example, osteoporosis/low BMD, malabsorption, pre/post bariatric surgery, or symptomatic deficiency).

ROS and AACE guidance cited for osteoporosis‑related testing recommendations.

Billing Rule

Use referenced codes and document indication; follow frequency limits

When ordering, use the referenced CPT/HCPCS codes and document the clinical indication consistent with the policy; adhere to the stated frequency limits to avoid denial.

Services Not Covered

The policy does not support routine population screening for vitamin D deficiency in asymptomatic individuals; it also specifies that measurement of serum 1,25-dihydroxyvitamin D for general screening purposes does not meet coverage criteria. Orders for vitamin D testing should be limited to the clinical indications and qualifying conditions listed in the policy notes.

Routine screening of asymptomatic groups — including the general adult population, healthy children without risk factors, and routine pregnancy screening — is not routinely supported and therefore not covered. Guideline statements cited in the policy (e.g., Endocrine Society, USPSTF, AAP) advise against population‑based screening and recommend targeted measurement only for individuals with relevant clinical indications.

Repeat 25-hydroxyvitamin D testing more frequently than once every six months for covered indications is not supported by the revised coverage criteria. The policy combines prior criteria to enforce a universal six‑month frequency limit for 25‑OH vitamin D testing in the specified patient groups.

Definitions and Test Names

inv-33: 25(OH)D / 25OHD — 25-Hydroxyvitamin D, the predominant and most stable circulating form used to assess vitamin D status.

Definition25-Hydroxyvitamin D (25OHD) — the predominant and most stable circulating form used to assess vitamin D status

SynonymsAlso referred to as 25(OH)D or calcidiol

Clinical rolePreferred laboratory analyte for evaluating vitamin D status due to longer half-life (~15 days)

inv-34: 1,25-dihydroxyvitamin D — The metabolically active form of vitamin D (calcitriol) with a short circulating half-life, used for evaluation of defects in vitamin D metabolism.

Definition1,25-dihydroxyvitamin D (calcitriol) — the metabolically active form of vitamin D with a short circulating half-life (~15 hours)

Clinical use

Background and Rationale

For clinical context, 25-hydroxyvitamin D (25OHD) is the predominant and most stable circulating form used to assess vitamin D status and is therefore the primary analyte for testing. By contrast, 1,25-dihydroxyvitamin D is the active metabolite with a much shorter circulating half-life and is reserved for evaluation of specific metabolic defects rather than routine status screening.