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    v1.0.30
    OpenPayerPolicy UpdatesLaboratory/PathologyProvidence Serum Iron Studies Coverage | OpenPayer
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    CurrentProvidence Health PlanPolicy 322

    Serum Iron Studies

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    Medicare coverage and billing requirements for serum iron studies, including ferritin, iron, iron-binding capacity, and transferrin testing. Coverage depends on Medicare NCD 190.18 criteria and medically necessary ICD-10-CM coding.

    Policy Summary
    PayerProvidence Health Plan
    PolicySerum Iron Studies
    Policy CodePolicy 322
    Change TypeRevised
    Effective DateOct 1, 2026
    Last ReviewSep 1, 2026
    Next Review DateSep 1, 2027
    Key ActionBill the applicable CPT code with a current Medicare medically necessary ICD-10-CM diagnosis code.
    SourceLink
    POLICY UPDATE CHANGES

    The policy updated its ICD-10 configuration to align with CMS Change Request 14536 for the current policy cycle.

    Medicare onlyProduct and benefit application
    NCD 190.18Applicable CMS coverage reference
    4Listed covered CPT laboratory codes
    NoPrior authorization for listed services

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Audit subject
    Utilization

    Medicare Coverage Criteria

    Medicare coverage criteria

    Covered according to Medicare guidelines when all of the following requirements are met:

    Medicare coverage requirements

    • Coverage and medical necessity

      • The serum iron study must meet the applicable Medicare guidelines and NCD 190.18 requirements.
      • The service must be billed with an ICD-10-CM diagnosis code that Medicare has identified as medically necessary in the current NCD Coding Policy Manual and Change Report.

        Use the version corresponding to the date the service was or will be rendered.

      • All applicable NCD 190.18 criteria must be met.

        Inclusion of a diagnosis code on the Medicare list does not by itself guarantee coverage.

    Services or items that are direct exclusions under Medicare or the member’s benefit plan are not covered. This includes services considered cosmetic, not medical in nature, or not medically reasonable and necessary under Title XVIII of the Social Security Act, Section 1862(a)(1)(A).

    Serum iron studies are not covered when they do not satisfy Medicare requirements for medical reasonableness and medical necessity, including the applicable criteria under NCD 190.18.

    Covered Serum Iron Studies

    Covered serum iron studies

    Serum iron studies are covered when all of the following requirements are met:

    Covered serum iron study requirements

    • The service is a Medicare-covered serum iron study under applicable NCD 190.18 criteria.
    • The service is billed with an ICD-10-CM diagnosis code identified by Medicare as medically necessary in the current CMS Lab NCD ICD-10-CM code list.

      Select the code-list version that aligns with the date services were or will be rendered.

    • All applicable NCD 190.18 medical-necessity and coverage requirements are met.

      The policy does not enumerate separate clinical indications; consult the applicable NCD and current CMS coding guidance.

    Billing Codes

    Covered CPT CodesCPTCovered
    82728Ferritin
    83540Iron
    83550Iron binding capacity
    84466Transferrin
    HCPCS CodesHCPCS
    No codes listed

    Authorization, Billing, and Denial Guidance

    Prior Authorization

    No prior authorization for listed tests

    The listed serum iron study services do not require prior authorization. All NCD 190.18 criteria must still be met, and utilization may be subject to audit.

    • CPT 82728 (Ferritin)
    • CPT 83540 (Iron)
    • CPT 83550 (Iron binding capacity)
    • CPT 84466 (Transferrin)
    Prior Authorization

    Recommended authorization for unlisted codes

    For an unlisted code submitted for a potentially covered service addressed by this policy, prior authorization is recommended to help avoid post-service denial.

    Non-Covered Services

    Serum iron studies that are cosmetic, not medical in nature, or not medically reasonable and necessary under Medicare requirements are not covered.

    Policy Summary
    PayerProvidence Health Plan
    PolicySerum Iron Studies
    Policy CodePolicy 322
    Change TypeRevised
    Effective DateOct 1, 2026
    Last ReviewSep 1, 2026
    Next Review DateSep 1, 2027
    Key ActionBill the applicable CPT code with a current Medicare medically necessary ICD-10-CM diagnosis code.
    SourceLink
    On This Page
    Medicare Coverage CriteriaCovered Serum Iron StudiesBilling CodesAuthorization, Billing, and Denial GuidanceNon-Covered Services
    Billing Rule

    Submit current Medicare diagnosis coding

    Bill the applicable CPT code with an ICD-10-CM diagnosis code included as medically necessary in the current CMS Lab NCD ICD-10-CM code list for NCD 190.18. Use the version corresponding to the date the service was or will be rendered.

    Documentation Required

    Support medical necessity for audit

    Consult the applicable NCD for additional test-coverage and utilization limitations, and retain documentation supporting medical necessity because utilization may be audited.

    Denial Risk

    NCD criteria and medical necessity not met

    Claims may be denied when the billed serum iron study is not supported by an ICD-10-CM code that Medicare identifies as medically necessary under NCD 190.18, when NCD criteria are not met, or when the service is not otherwise medically reasonable and necessary. Inclusion of a diagnosis code on the Medicare list does not guarantee coverage.

    Denial Risk

    Unlisted-code denial risk

    Unlisted codes submitted for non-covered services addressed by the policy will be denied as not covered. Potentially covered services submitted with an unlisted code may be subject to post-service denial if prior authorization was not obtained.