CurrentOscar HealthPolicy N/A

Folate Testing — Coverage Criteria

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Defines coverage and limitations for serum, red blood cell (RBC), urinary, and folate receptor autoantibody testing for folate (vitamin B9) for Oscar Health members. Applies to providers submitting claims to Oscar and governs medical necessity and reimbursement guidance.

Policy Summary

PayerOscar Health

PolicyFolate Testing — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2026

Last ReviewJun 16, 2026

Next Review DateJun 16, 2026

Key ActionDocument and submit clinical evidence of megaloblastic/macrocytic anemia or bariatric surgery status when ordering serum folate to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Covered indications

Not coveredRBC folate

Not coveredFRAT®

2CPT codes listed

Annual

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CurrentOscar HealthPolicy N/A

Folate Testing — Coverage Criteria

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Policy Summary

PayerOscar Health

PolicyFolate Testing — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2026

Last ReviewJun 16, 2026

Next Review DateJun 16, 2026

Key ActionDocument and submit clinical evidence of megaloblastic/macrocytic anemia or bariatric surgery status when ordering serum folate to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Covered indications

Not coveredRBC folate

Not coveredFRAT®

2CPT codes listed

Annual

Recommended monitoring

Coverage Criteria for Folate Testing

inv-01: Serum folate — medically necessary indications

Covered when ANY of the following are met for measurement of serum folate concentration:

Covered indications for serum folate: Individuals with megaloblastic or macrocytic anemia.

Serum folate measurement meets criteria for evaluation of megaloblastic or macrocytic anemia.

Covered indications for serum folate: Individuals who have undergone or who are scheduled for bariatric procedures such as Roux-en-Y gastric bypass, sleeve gastrectomy, or biliopancreatic diversion/duodenal switch.

Serum folate measurement meets criteria for pre- or post-bariatric surgery assessment.

inv-02: Serum folate — not medically necessary

Not covered (does not meet criteria):

Not indicated scenarios: Measurement of serum folate for all indications not described as covered in this policy does not meet criteria.

Policy explicitly states serum folate DOES NOT MEET CRITERIA for indications other than megaloblastic/macrocytic anemia and pre/post-bariatric surgery.

inv-03: Tests not medically necessary

Tests explicitly not covered:

RBC folate: Measurement of red blood cell (RBC) folate DOES NOT MEET CRITERIA for all indications.

Policy-wide exclusion for RBC folate testing; Choosing Wisely/ASCP recommends not ordering RBC folate levels in adults.

Folate receptor autoantibody testing (FRAT): Folate receptor autoantibody testing DOES NOT MEET CRITERIA for all situations due to lack of published scientific literature confirming required clinical benefit.

FRAT® is specifically called out as not meeting criteria.

The policy explicitly states that measurement of red blood cell (RBC) folate and folate receptor autoantibody testing (FRAT®) DO NOT MEET CRITERIA and are excluded from coverage for all indications. Providers should not expect coverage for claims submitted for RBC folate or folate receptor autoantibody testing under this policy.

Routine measurement of red blood cell (RBC) folate is not necessary in many adults because serum folate generally provides equivalent information in most clinical situations. National guidance (e.g., BCSH) and Choosing Wisely/ASCP advise against routine RBC folate testing and recommend considering folate supplementation instead of routine testing in adults with macrocytic anemia.

Measurement of serum folate is considered medically necessary only for the covered indications specified in this policy. Specifically, testing does not meet criteria for indications other than evaluation of megaloblastic/macrocytic anemia or for patients pre- or post-bariatric surgery. Ordering serum folate for other indications may be denied as not medically necessary.

Ordering RBC folate routinely in adults without a specific clinical indication is discouraged and may be unnecessary. Professional societies (ASCP/Choosing Wisely and BCSH) note the low yield of routine RBC folate measurement in populations with folic acid–fortified food supplies and recommend supplementation or serum testing strategies rather than routine RBC folate testing.

inv-04: Indications supported by clinical guidelines

Covered or indicated testing scenarios per referenced clinical guidelines (grouped as distinct clinical indications):

Macrocytic or unexplained anemia: Testing for folate (serum and/or RBC) is indicated in patients with macrocytic or unexplained anemia; assessment is commonly performed alongside vitamin B12 and other anemia workup.

BCSH, NCCN, and other organizations list folate testing in anemia evaluation; ASCP/Choosing Wisely suggests supplementation may be considered instead of routine testing in adults.

CKD with anemia: In people with anemia and chronic kidney disease in whom initial tests do not reveal the cause, consider an expanded panel that includes folate.

KDIGO recommends considering folate as part of an expanded panel when initial testing is non-diagnostic.

Pre- and post-bariatric surgery: Preoperative nutritional screening for bariatric surgery candidates should include folate; post-operative surveillance (including trimester screening if pregnant after surgery) is recommended.

AACE/ASMBS perioperative guidelines recommend folate screening preoperatively and surveillance post-op, with specific attention for malabsorptive procedures.

Specific Covered Indications

inv-32: Megaloblastic or macrocytic anemia

Covered when ALL of the following are met:

Megaloblastic or macrocytic anemia: Serum folate measurement is requested to evaluate documented megaloblastic or macrocytic anemia (e.g., macrocytosis on CBC or clinical concern for megaloblastic processes).

Serum folate measurement meets criteria for evaluation of megaloblastic or macrocytic anemia.

inv-33: Pre- or post-bariatric surgery

Covered when ANY of the following are met:

Pre- or post-bariatric surgery assessment: Individual is undergoing preoperative nutritional screening for bariatric surgery or requires post-operative nutritional surveillance related to a prior bariatric procedure.

AACE/ASMBS guidelines recommend folate screening in pre-op and post-op bariatric patients; policy lists bariatric procedures (Roux-en-Y, sleeve gastrectomy, biliopancreatic diversion/duodenal switch) as covered contexts.

Tests and Indications Not Covered

Red blood cell (RBC) folate testing and folate receptor autoantibody testing are not covered for any indication. The policy explicitly states that measurement of RBC folate does not meet criteria for all indications, and that folate receptor autoantibody testing (including proprietary FRAT®) does not meet criteria due to lack of confirmed clinical benefit in published literature.

Procedure codes associated with these tests that appear in the coding section for reference include CPT 82747 (Folic acid; RBC) and the proprietary folate receptor antibody assay (FRAT® by Religen Inc) described under the procedure code listing; these codes may be used for administrative reference but the policy stance is exclusion for coverage.

Claims for RBC folate or folate receptor autoantibody testing may be denied or subject to recoupment if submitted for payment because these tests are explicitly excluded from coverage under this policy. If local, state, or federal regulations (including Medicare/Medicaid) differ, applicable government policy will govern the final determination.

Routine RBC folate testing in adults without a specific clinical indication is discouraged and may be considered unnecessary. Professional guidance (ASCP/Choosing Wisely and AAFP–endorsed recommendations) advises against ordering RBC folate levels routinely and suggests considering folate supplementation instead of routine serum or RBC folate testing for adults with macrocytic anemia.

The policy emphasizes that serum folate generally provides equivalent clinical information in many settings and that RBC folate testing historically used as a surrogate for tissue folate status usually does not change diagnosis or management in fortified populations. Providers should document a covered clinical indication (e.g., megaloblastic/macrocytic anemia or pre/post-bariatric surgery) when ordering folate testing; otherwise, testing may be considered not medically necessary.

For administrative reference only, listed procedure codes include CPT 82746 (Folic acid; serum) and CPT 82747 (Folic acid; RBC). Even when codes are listed, routine RBC folate without indication remains discouraged per clinical guidance and this policy.

Procedure Codes and Coding Notes

Listed CPT Codes for Folate TestingCPT

82746	Folic acid; serum.
82747	Folic acid; RBC.

Proprietary/Other Testsmixed

FRAT proprietary test

Folate Receptor Antibody Test — detection of anti-human folate receptor IgG-binding antibody and blocking autoantibodies by ELISA; functional blocking assay for IgG or IgM, quantitative; proprietary test FRAT® (Religen Inc).

Applicable CPT CodesCPT

82746	Folic acid; serum.
82747	Folic acid; RBC.

Note

Procedure codes are for reference only

Procedure codes in this policy are provided only as a general reference and may not be all-inclusive; they should not be interpreted as an exhaustive or definitive code list for billing.

Billing Rule

Procedure codes and proprietary test referenced

The policy lists CPT codes 82746 (folic acid; serum) and 82747 (folic acid; RBC) and names the proprietary FRAT® (Folate Receptor Antibody Test) by manufacturer for reference.

CPT 82746 — Folic acid; serum.
CPT 82747 — Folic acid; RBC.
FRAT® (Religen Inc) — proprietary folate receptor antibody test (ELISA and functional blocking assay described).

Provider Actions and Billing Guidance

Prior Authorization

Verify prior authorization and member benefits

Services must meet authorization and medical necessity guidelines and coverage depends on the member's benefit coverage and applicable state/federal regulations at the time of request.

Prior Authorization

Prior authorization not specified for listed CPTs

No explicit prior authorization requirement for CPT codes 82746 (serum folic acid) or 82747 (RBC folic acid) is stated in this document excerpt.

Confirm member-specific authorization requirements with payer prior to ordering, as this policy does not itself impose an authorization mandate for these CPTs.

Step Therapy

Consider folate supplementation before testing (ASCP/Choosing Wisely)

Ordering and Authorization Requirements

Documentation Required

Document clinical indication and verify member benefits before ordering

Ordering provider must document a clinical indication consistent with the policy's covered situations; coverage also depends on member benefits and applicable regulations.

Document the specific covered indication in the medical record when ordering.
Verify member benefits and any prior authorization requirements before ordering.

Note

Order tests per clinician role and guideline context

Ordering responsibilities may be clinician-specific: Registered Dietitian Nutritionists should evaluate and recommend biochemical testing for adult oncology patients; specialists managing celiac disease, IBD, CKD, or bariatric surgery patients should order folate testing as clinically indicated.

RDNs: include folate in nutritional anemia profiles for oncology patients when indicated.
Specialists: order folate testing for disease-specific monitoring per guideline recommendations.

Monitoring Frequency and Limits

Frequency limits — general

Frequency limits specifiedNone specified in this document portion

Frequency limits — specific populations

Recommended minimal monitoring frequencyAt least annually for serum folate (or combined folate/B12 monitoring) in certain populations (e.g., bladder cancer follow-up, IBD)

Populations referencedMuscle-invasive bladder cancer follow-up (post‑radical cystectomy)

Populations referencedPatients with inflammatory bowel disease or small bowel disease (and those with small bowel resection)

Guideline source examplesNICE (bladder cancer), ECCO (IBD) recommend annual testing in these contexts

Definitions and Key Terms

Folate (vitamin B9)

DefinitionA water‑soluble vitamin involved in single‑carbon transfers, nucleic acid biosynthesis, and methionine/homocysteine metabolism; includes natural polyglutamate forms and synthetic folic acid.

Biochemical roleCofactor in one‑carbon metabolism; linked to vitamin B12 (cobalamin) cycle and required for formation of 5,10‑methylene tetrahydrofolate.

SourcesOccurs naturally as polyglutamates in foods; synthetic form is folic acid (monoglutamate) used in supplements and fortification.

Megaloblastic anemia

DefinitionA macrocytic anemia due to defects in nucleic acid metabolism causing nuclear‑cytoplasmic dyssynchrony and abnormal erythroid precursors, often from folate and/or vitamin B12 deficiency.

Clinical features

Background and Rationale

Folate (vitamin B9) is a water-soluble vitamin essential for one-carbon transfers, nucleic acid biosynthesis, and methionine/homocysteine metabolism and is biochemically linked with vitamin B12. Folate deficiency can result in megaloblastic/macrocytic anemia and is associated with increased risk of neural tube defects; population-level folic acid supplementation and food fortification have markedly reduced deficiency prevalence in many countries.

Evidence Summary and References

FRAT® (Folate Receptor Antibody Test) is a proprietary assay (Religen Inc) described in this policy. Folate receptor antibody testing methods referenced include ELISA detection of anti-human folate receptor IgG-binding antibodies and functional blocking assays that quantify blocking autoantibodies. The policy notes FRAT® by name and describes its intended use for evaluation of suspected cerebral folate deficiency, but also indicates that folate receptor autoantibody testing does not meet coverage criteria.

No additional explicit tests or indications are listed as not covered in this segment beyond the named exclusions for RBC folate and folate receptor autoantibody testing.

Policy Summary

PayerOscar Health

PolicyFolate Testing — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2026

Last ReviewJun 16, 2026

Next Review DateJun 16, 2026

Key ActionDocument and submit clinical evidence of megaloblastic/macrocytic anemia or bariatric surgery status when ordering serum folate to support medical necessity.

SourceLink

On This Page

IBD and small bowel disease: Patients with inflammatory bowel disease or small bowel resection should have serum folate measured at least annually or if macrocytosis is present; higher-risk patients need closer surveillance.

ECCO guidance advises annual measurement or when macrocytosis is present; closer surveillance for small bowel disease or resection.

Celiac disease: People with newly diagnosed celiac disease should undergo testing for micronutrient deficiencies including folic acid as part of baseline assessment; follow-up testing individualized.

ACG recommends baseline micronutrient testing including folic acid and individualized follow-up.

Oncology nutrition assessment: Registered Dietitian Nutritionists and oncology teams should include folate in nutritional anemia profiles for adult oncology patients when clinically indicated.

Academy of Nutrition and Dietetics supports inclusion of folate in nutritional assessments for oncology patients.

Neurologic suspicion (cerebral folate deficiency): Specialized testing for folate receptor antibodies (e.g., FRAT) may be used in evaluation of suspected cerebral folate deficiency.

Proprietary FRAT test is referenced by guideline documents for neurologic assessment, though policy excludes FRAT from coverage.

inv-34: Preconception and pregnancy risk management, anemia evaluation, bariatric surgery assessment, IBD and celiac disease monitoring, initial MDS/cytopenia workup

Covered when ANY of the following guideline-supported scenarios apply:

Preconception and pregnancy risk management: Individuals of reproductive age planning pregnancy or with prior NTD-affected pregnancy where folate status assessment is part of risk management or supplementation planning.

CDC recommends daily folic acid supplementation for reproductive-age individuals (400 mcg) and higher dose (4,000 mcg) for those with prior NTD-affected pregnancy; testing may be part of preconception management.

Anemia evaluation (initial cytopenia/MDS workup): Measurement of serum or RBC folate as part of initial evaluation for cytopenias or suspected myelodysplastic syndromes to rule out folate deficiency as a contributory cause.

NCCN recommends measurement of serum or RBC folate in initial evaluation for suspected MDS/cytopenia.

Bariatric surgery assessment: Preoperative and postoperative assessment of folate as part of nutritional screening and surveillance for bariatric surgery patients.

AACE/ASMBS guidance supports folate testing in bariatric surgery care pathways.

IBD monitoring: Annual (or sooner if macrocytosis present) measurement of serum folate in patients with inflammatory bowel disease or small bowel disease/resection; higher-risk patients require closer surveillance.at least annually

ECCO recommends measuring folate at least annually or when macrocytosis is present.

Celiac disease monitoring: Baseline and individualized follow-up testing for micronutrient deficiencies including folic acid in newly diagnosed celiac disease.

ACG recommends testing for folic acid as part of baseline evaluation for celiac disease.

inv-35: Serum folic acid testing (82746), RBC folic acid testing (82747), and folate receptor antibody testing (FRAT®) for evaluation of folate status or suspected cerebral folate deficiency.

Guidance on test methods and coverage stance for folate-related assays:

Serum folic acid (CPT 82746): Serum folic acid testing (CPT 82746) is the listed procedure for folate measurement and is indicated per covered situations in this policy.

82746 is enumerated in the CPT code list.

RBC folic acid (CPT 82747) — excluded from coverage: Red blood cell (RBC) folate testing (CPT 82747) does not meet criteria for coverage and is excluded for all indications.

Policy explicitly states RBC folate measurement DOES NOT MEET CRITERIA.

Folate receptor antibody testing (FRAT) — excluded from coverage: Folate receptor antibody testing (proprietary FRAT®) does not meet criteria for coverage due to insufficient published evidence of clinical benefit.

FRAT® is a proprietary test (Religen Inc) referenced in the CPT/HCPCS section but excluded by policy.

Laboratory-developed tests (LDTs): Laboratory-developed folate-related assays must be validated and performed in-house under CLIA '88 high-complexity rules.

LDTs are regulated by CMS under CLIA '88 and are not FDA-approved or -cleared; validation and CLIA compliance required.

There are no additional tests or indications specifically listed as covered or not covered beyond those already stated; however, the policy reiterates that RBC folate measurement and folate receptor autoantibody testing (FRAT®) do not meet criteria and therefore may be denied for any indication.

Procedure codes are provided in the policy as a general reference and may not be all-inclusive; the coding list includes CPT 82746 (Folic acid; serum), CPT 82747 (Folic acid; RBC), and a description of the proprietary FRAT® (Folate Receptor Antibody Test) by Religen Inc. Providers should follow coding and billing guidelines and submit appropriate documentation to support medical necessity for any covered serum folate testing.

If laboratories offer laboratory‑developed versions of folate receptor antibody assays or other non‑FDA cleared tests, those laboratory‑developed tests (LDTs) must be validated and performed under CLIA '88 high‑complexity rules; LDTs remain regulated by CMS and are not automatically considered to meet clinical benefit or coverage absent supporting evidence and documentation.

Denial Risk

RBC folate and folate receptor antibody testing do not meet criteria (may be denied)

Red blood cell (RBC) folate measurement and folate receptor autoantibody testing (e.g., FRAT®) are explicitly designated as not meeting criteria and may be denied when submitted for coverage.

Procedure codes referenced in this policy include CPT 82747 (RBC folic acid) and the proprietary FRAT® folate receptor antibody test (Religen Inc) — these tests are listed in the policy and are subject to the exclusion for RBC folate and folate receptor antibody testing.
Laboratory-developed tests (LDTs) such as proprietary FRAT® assays must be validated and performed in-house under CLIA '88 high-complexity rules; lack of appropriate validation or CLIA compliance can contribute to denial.
Claims for RBC folate (82747) or folate receptor autoantibody testing that do not meet the policy’s exclusion criteria or lack required clinical documentation may be denied or recouped.

ASCP/Choosing Wisely recommends considering folate supplementation instead of routine serum or RBC folate testing in adults with macrocytic anemia.

In adults with macrocytic anemia, consider empiric folate supplementation rather than routine serum or RBC folate measurement.

Step Therapy

Consider supplementation before testing (AAFP/Choosing Wisely)

Clinical guidance (Choosing Wisely/ASCP and AAFP-endorsed recommendations) advises considering folate supplementation instead of routine serum or RBC folate testing in patients with macrocytic anemia.

Documentation Required

Submit required clinical documentation to support medical necessity

Providers must submit documentation supporting medical necessity for serum folate testing, such as evidence of megaloblastic or macrocytic anemia or documentation of bariatric surgery or planned bariatric procedure.

Include clinical indication (e.g., megaloblastic/macrocytic anemia) in the medical record.
Document prior or planned bariatric procedures when testing is ordered for that indication.

Denial Risk

Coding and documentation compliance to avoid denials

Claims may be denied or recouped if coding/billing guidelines or current reimbursement policies are not followed and appropriate documentation is not submitted.

Code claims according to industry-standard coding guidelines and payer rules.
Retain supporting clinical documentation in the medical record.

Note

Follow government coverage determinations when they differ

If government (Medicare/Medicaid) policies conflict with this policy, the applicable government policy (LCD/NCD or state Medicaid) will be used for coverage determinations.

Check applicable Medicare or state Medicaid coverage guidance when ordering for beneficiaries.

Documentation Required

LDT validation and CLIA '88 compliance required

Laboratory-developed tests (LDTs) must be validated and performed in-house and are regulated by CMS as high-complexity tests under CLIA '88; they are not FDA-approved/cleared but may be used clinically after validation.

Ensure LDT validation and CLIA high-complexity compliance when offering proprietary folate receptor antibody tests.

Documentation Required

Laboratory responsibility for LDT validation and performance

LDTs are regulated by CMS under CLIA '88 as high-complexity tests and must be validated and performed in-house by laboratories before clinical use.

Denial Risk

Non-indicated serum folate testing may be denied

Measurement of serum folate for indications other than megaloblastic/macrocytic anemia or pre/post-bariatric surgery does not meet criteria and may be denied.

Do not order serum folate for indications not described as covered in this policy unless supported by separate payer authorization.

Note

No explicit provider-type ordering restrictions stated

This document does not impose explicit ordering restrictions by provider type; follow standard practice and payer-specific rules when ordering.

Macrocytosis with large RBCs; symptoms include fatigue, weakness, difficulty concentrating, irritability, headache, palpitations, and shortness of breath.

Relation to folateMegaloblastic changes are principal manifestations of folate deficiency.

FRAT® (proprietary test)

Test nameFRAT® — Folate Receptor Antibody Test (proprietary, Religen Inc)

PurposeDetection of anti‑human folate receptor IgG‑binding antibodies and blocking autoantibodies for evaluation of cerebral folate deficiency (neurology use).

Methodology describedELISA for IgG‑binding antibodies and functional blocking assays for IgG or IgM (reported qualitative/quantitative as applicable).

LDT (Laboratory‑Developed Test)

DefinitionLaboratory‑developed test (LDT): a test developed and validated by a laboratory and regulated by CMS under CLIA ’88 as a high‑complexity test.

Regulatory statusLDTs are not approved or cleared by the FDA but are regulated by CMS/CLIA and must be validated and performed in‑house.

Laboratory responsibilityLaboratories must validate LDTs and follow CLIA ’88 high‑complexity requirements for clinical use.

FRAT® (Folate Receptor Antibody Test)

Test nameFRAT® (Folate Receptor Antibody Test) — proprietary assay by Religen Inc

Clinical contextReferenced for evaluation of neurological/cerebral folate deficiency and detection of folate receptor autoantibodies.

Assay typesDescribed methods include ELISA for IgG‑binding antibodies and functional blocking assays; reported as positive/not detected or quantitative as appropriate.