Neighborhood Health Plan RI vitamin D Coverage

Coverage Criteria

Medically Necessary Indications

Measurement of 25-hydroxy vitamin D (CPT 82306) and 1,25-dihydroxy vitamin D (CPT 82652) is considered medically necessary when ANY of the following conditions are present:

Supported indications for CPT 82306 (25-hydroxy): Chronic kidney disease stage III or greater; Cirrhosis; Hypocalcemia; Hypercalcemia; Hypercalciuria; Hypervitaminosis D; Parathyroid disorders; Malabsorption states; Obstructive jaundice; Osteomalacia; Osteoporosis meeting any of: T-score on DEXA <= -2.5; history of fragility fractures; FRAX >3% 10-year hip fracture risk or >20% 10-year major osteoporotic fracture risk; FRAX >3% (any fracture) with T-score <= -1.5; initiating bisphosphonate therapy (vitamin D level and serum calcium should be determined and managed before initiation); Osteosclerosis/petrosis; Rickets; Rheumatoid arthritis; Vitamin D deficiency on replacement therapy related to a listed condition (to monitor efficacy).

From reimbursement requirements for 82306.

Supported indications for CPT 82652 (1,25-dihydroxy): Unexplained hypercalcemia (suspected granulomatous disease or lymphoma); Unexplained hypercalciuria (suspected granulomatous disease or lymphoma); Suspected genetic childhood rickets; Suspected tumor-induced osteomalacia; Nephrolithiasis or hypercalciuria.

From reimbursement requirements for 82652.

Diagnosis-code required coverage criteria

Covered when the claim includes an acceptable diagnosis code pairing for the CPT code billed

82306 coverage condition: Claim for CPT 82306 must include one of the acceptable diagnosis code pairings listed in the coding grids (see document sections containing acceptable diagnosis codes for 82306).

Exact pairings are enumerated across the coding grid (see chunks containing mappings for 82306).

82652 coverage condition: Claim for CPT 82652 must include one of the acceptable diagnosis codes listed in the coding grid for 82652.

Mappings for 82652 are provided in the coding grid (see chunk 27).

Neighborhood covers vitamin D blood testing only when the test claim is submitted with an acceptable diagnosis code pairing from the coding grids provided for the billed CPT code. Measurement of 25-hydroxy vitamin D (CPT 82306) and 1,25-dihydroxy vitamin D (CPT 82652) will be considered medically necessary and eligible for coverage only if one of the diagnosis codes mapped to the applicable CPT in the policy’s coding grids is reported on the claim.

Claims for vitamin D testing submitted without an acceptable diagnosis code pairing as enumerated in the coding grids may be denied or excluded from coverage. Providers must therefore ensure the submitted diagnosis code(s) match the mappings shown for the billed CPT (see the coding grids for 82306 and 82652).

If a claim for vitamin D testing does not include one of the policy’s listed acceptable diagnosis pairings for the billed CPT code, the service is not supported by this policy and is at risk for non-coverage or denial. For CPT 82306, acceptable diagnosis code pairings are enumerated across the policy’s coding grid (chunks containing the mappings); for CPT 82652, acceptable diagnosis codes are listed in the mapping for that CPT.

Providers should confirm the diagnosis code(s) on the claim correspond exactly to the allowed mappings in the policy. Neighborhood may request medical records to substantiate medical necessity, and absence of documentation or an acceptable diagnosis code pairing may result in claim denial.

Vitamin D (1,25 dihydroxy) testing - Diagnosis codes

Acceptable diagnosis codes for CPT 82652 are listed in the coding grid and must be used on claim submissions billed with CPT 82652.

82652 diagnosis mapping: Use one of the acceptable diagnosis codes mapped for 82652 as listed in the coding grid (see chunk 27).

Chunk 27 contains the enumerated acceptable diagnosis code mappings for 82652.

Coding

Covered CPT CodesCPTCovered

82306

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

Covered CPT Codes (1,25-dihydroxy)CPTCovered

82652

Vitamin D; 1,25 dihydroxy (active)

Acceptable Diagnosis Codes for 82306ICD-10

multiple ICD-10-CM codes

Extensive grid of acceptable diagnosis codes for CPT 82306 as listed in the document (see chunks 9-19 for full mappings)

Acceptable Diagnosis Codes for 82306 (continued)mixed

82306

Listed acceptable diagnosis code pairings for CPT 82306 (see chunks 18-26 for mappings)

Acceptable Diagnosis Codes for 82652mixed

82652

Vitamin D; 1,25 dihydroxy, includes fraction(s), if performed — acceptable diagnosis code mappings listed in chunk 27

Provider Actions and Billing Requirements

Prior Authorization

Verify authorization

Providers must verify member eligibility, coverage and any required prior authorization before rendering services. Verification should include plan-specific prior authorization rules found on Neighborhood's Prior Authorization Reference page and any Clinical Medical Policies that apply.

Verify eligibility, coverage and authorization prior to service delivery — contact Provider Services at 1-800-963-1001 for questions.
Refer to Neighborhood's plan-specific Prior Authorization Reference page and Clinical Medical Policies for authorization rules.

Billing Rule

Required diagnosis coding on claims

Claims must include the appropriate diagnosis code(s) that support medical necessity and match the policy's required pairings for the billed CPT code. Failure to submit an acceptable diagnosis-code pairing may result in claim denial or request for medical records.

Definitions

inv-20: Vitamin D testing — Measurement of 25-hydroxy vitamin D (CPT 82306) and 1,25-dihydroxy vitamin D (CPT 82652) definitions and purpose.

Test names (CPT)82306 = Vitamin D; 25 hydroxy, includes fraction(s), if performed; 82652 = Vitamin D; 1,25 dihydroxy (active)

PurposeLaboratory measurement of 25-hydroxy and 1,25-dihydroxy vitamin D to assess vitamin D status and identify abnormalities related to bone disorders, nutritional problems, organ damage, or other medical conditions.

When medically necessaryMeasurement of 25-hydroxy vitamin D (CPT 82306) and 1,25-dihydroxy vitamin D (CPT 82652) is considered medically necessary when the member meets the clinical indications listed in the policy's coverage criteria (see coverage criteria for specific indications).

inv-21: 82652 definition — 82652 = Vitamin D; 1,25 dihydroxy, includes fraction(s), if performed.

Code definition82652 = Vitamin D; 1,25 dihydroxy, includes fraction(s), if performed.

Background

Vitamin D blood testing measures circulating forms of vitamin D used to assess a member’s vitamin D status and guide clinical management. The policy addresses two laboratory tests: measurement of 25-hydroxy vitamin D (CPT 82306), commonly used to evaluate vitamin D deficiency or monitor replacement therapy, and measurement of 1,25-dihydroxy vitamin D (CPT 82652), used in select clinical scenarios such as unexplained hypercalcemia or suspected genetic rickets.

Abnormal vitamin D levels can indicate bone metabolism disorders (for example, osteomalacia, rickets, osteoporosis in specific circumstances), conditions affecting absorption or metabolism (malabsorption, chronic liver disease, chronic kidney disease), or disorders associated with calcium homeostasis (hypercalcemia, hypercalciuria, parathyroid disorders). Testing informs diagnosis, monitoring of replacement therapy, and treatment decisions when ordered for medically necessary indications listed in this policy.

Ordering Requirements

Step Therapy

Verify eligibility, coverage and authorization before ordering

Providers must verify member eligibility, coverage and any applicable authorization criteria before ordering vitamin D testing; the policy does not specify required ordering provider types in these chunks.

Frequency Limits

inv-24: FREQUENCY LIMITS — (inventory placeholder; no chunk indices provided).

Frequency limitsNo specific frequency limits are defined in this policy document.

Monitoring guidanceFollow clinical indications and treating provider judgment for timing and repeat testing; policy requires acceptable diagnosis coding for coverage.

DocumentationMedical record must support medical necessity for repeat tests; Neighborhood may request records to substantiate frequency and indication.

Not Covered

Testing that is not billed with an acceptable diagnosis code from the coding grids provided in this policy is not supported and may be denied. Claims for CPT 82306 must include one of the acceptable diagnosis code pairings listed in the 82306 coding mappings; claims for CPT 82652 must include an acceptable diagnosis code from the 82652 mappings.

To avoid claim denials, providers must submit the specific diagnosis codes shown in the policy’s coding grids on the claim and ensure medical record documentation supports the medical necessity of the test.

Revision History

2025-01-01policy_effectiveLatest

Policy became effective for the INTEGRITY line of business.

2024-06-01policy_effective

Policy effective date for Medicaid and Commercial lines of business.

OpenPayer

Vitamin D blood testing (25-hydroxy and 1,25-dihydroxy) — Coverage Criteria