CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

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

Policy governs medical necessity and reimbursement for laboratory measurement of 25-hydroxy vitamin D (CPT 82306) and 1,25-dihydroxy vitamin D (CPT 82652) for Neighborhood Health Plan of Rhode Island members across Commercial, Medicaid (excluding EFP), and INTEGRITY lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

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

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionVerify medical necessity and provider should confirm eligibility, coverage, and any plan-specific prior authorization requirements prior to rendering services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2CPT tests addressed

Commercial, Medicaid, INTEGRITYApplicable lines of business

Medical necessity requiredPrerequisite for reimbursement

multipleListed diagnosis codes

Medical Necessity and Coverage Rules

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Medical necessity criteria for 25-hydroxy vitamin D (82306)

Measurement of 25 hydroxy vitamin D (CPT 82306) is considered medically necessary when ANY of the following conditions are present:

Indications for 82306: Chronic kidney disease stage III or greater; Cirrhosis; Hypocalcemia; Hypercalcemia; Hypercalciuria; Hypervitaminosis D; Parathyroid disorders; Malabsorption states; Obstructive jaundice; Osteomalacia; Osteoporosis if: T-score on DEXA scan <-2.5 OR history of fragility fractures OR FRAX 10-year probability: hip >=3% OR major osteoporotic fracture >=20% OR FRAX>3% (any fracture) with T-score <-1.5 OR initiating bisphosphonate therapy (Vitamin D level and serum calcium should be determined and managed as necessary before bisphosphonate is initiated.); Osteosclerosis/petrosis; Rickets; Rheumatoid arthritis; Vitamin D deficiency on replacement therapy related to a listed condition (to monitor treatment efficacy).see node text

Includes requirement to determine/manage vitamin D level and serum calcium before initiating bisphosphonates.

Medical necessity criteria for 1,25-dihydroxy vitamin D (82652)

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

Indications for 82652: 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.

Coverage contingent on acceptable diagnosis codes

Coverage is contingent on billing with one of the acceptable diagnosis codes listed

Billing requirement: Procedure (CPT 82306 or 82652) is covered when submitted with one of the acceptable diagnosis codes listed in the policy extract.

Exact ICD-10 mappings are enumerated across chunks 18-27

This policy is informational and does not guarantee reimbursement. Payments are subject to plan benefit coverage, member eligibility, claims payment edit rules, coding and documentation guidelines, authorization policies, provider contract agreements, and state/federal regulations. Neighborhood may update this policy at any time and reserves the right to audit billed services.

Claims for CPT 82306 or 82652 must be submitted with one of the acceptable diagnosis codes listed in the policy. Any claim submitted without an acceptable diagnosis code may be excluded or denied.

Within the provided extract there are no explicit statements labeling services as 'not medically necessary'. Coverage determinations are based on the medical necessity criteria and diagnosis code mappings enumerated elsewhere in the policy.

CPT and Diagnosis Code Guidance

Covered CPT CodesCPTCovered

82306

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

Covered CPT CodesCPTCovered

82652

Vitamin D; 1,25 dihydroxy

Acceptable Diagnosis Codes for 82306ICD-10

multiple ICD-10 entries

Long grid of acceptable diagnosis codes for CPT 82306 (detailed list in document)

Covered when billed with acceptable diagnosis codesmixedCovered

82306

Acceptable diagnosis codes list (extensive list of ICD-10 codes shown across chunks 18-26)

Covered when billed with acceptable diagnosis codesCPTCovered

82652

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

FRAX 10-year probability

FRAX thresholdsHip fracture 10-year probability >= 3% OR major osteoporotic fracture 10-year probability >= 20%; alternatively, FRAX >3% (any fracture) when T-score <-1.5

Context for useApplies as part of medical necessity criteria for CPT 82306 (25‑hydroxy vitamin D) when assessing osteoporosis/fragility fracture risk

Related requirementWhen initiating bisphosphonate therapy, vitamin D level and serum calcium should be determined and managed as necessary before initiation

None specified

SpecificationNone specified in the policy extract

NotesNo additional threshold or numeric criteria provided in the document for this entry

ActionRefer to policy medical necessity lists or clinical guidelines as applicable

Billing, Documentation, and Ordering Requirements

Prior Authorization

Verify medical necessity and authorization

All services must be medically necessary to qualify for reimbursement. Providers must verify eligibility, coverage and any plan-specific prior authorization requirements prior to rendering services. For prior authorization details, refer to Neighborhood's plan-specific Prior Authorization Reference page and Clinical Medical Policies. Contact Provider Services at 1-800-963-1001 with questions.

Refer to National Coverage Determination (NCD) and Local Coverage Determination (LCD) when applicable.
Accept industry-accepted criteria such as InterQual and Rhode Island EOHHS recommendations.

Billing Rule

Claim submission and coding

Providers are required to submit complete claims within contractual timely filing guidelines. Coding must follow CPT, ICD-10-CM, and HCPCS Level II standards.

Submit complete claims with CPT/ICD-10/HCPCS-compliant coding.
Billable services are subject to contractual agreements where applicable.

Documentation Required

Documentation and record retention

Neighborhood reserves the right to request medical records for any service billed. Documentation must support the service(s) billed and the medical necessity of those services. Neighborhood follows CMS standards for proper documentation requirements.

Maintain medical record documentation that supports billed service(s).
Lack of documentation supporting medical necessity may result in claim denial.

Denial Risk

Support diagnosis on claim

When billing CPT 82652 or CPT 82306, ensure the diagnosis code on the claim matches one of the acceptable diagnosis codes listed by Neighborhood. Claims may be denied for diagnosis code mismatch.

Documentation should support the listed acceptable diagnosis codes when billing for CPT 82652.
Claims for CPT 82306 may be denied if submitted with diagnosis codes not listed among the acceptable diagnosis codes.

Note

Provider verification reminder

Providers should be prepared to verify eligibility, coverage and prior authorization requirements before providing services.

Ordering and Authorization Notes

Prior Authorization

Ordering: verify eligibility and follow prior authorization processes

Providers must verify member eligibility and any plan-specific authorization requirements before ordering; follow Neighborhood's prior authorization processes where applicable.

Consult Neighborhood's Prior Authorization Reference page and Clinical Medical Policies prior to testing when required by the member's plan.

Note

Ordering: provider type not specified in excerpt

The extract does not specify which provider types are authorized to order these tests (for example, primary care versus specialists); providers should follow standard ordering privileges and plan-specific rules.

When in doubt, confirm ordering privileges with the member's plan or the provider's contract.

Services Not Supported by This Policy

Any testing that does not meet the medical necessity criteria outlined in this policy or that lacks supporting clinical documentation in the member’s medical record may be denied. The policy does not guarantee reimbursement and adjudication remains subject to plan coverage rules and claims processing.

Tests billed with diagnosis codes that are not included in the acceptable lists for CPT 82306 or CPT 82652 (the extensive ICD-10 mappings shown in the policy extract) are not supported by this extract and may be denied when submitted without an acceptable code.