DISCLAIMER

Highmark Health Options medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.

POLICY STATEMENT

Highmark Health Options may provide coverage under medical surgical benefits of the Company’s Medicaid products for medically necessary. Refer to the Noncovered Services policy for more information.

This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.

The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the West Virginia Department of Health and Human Resources (DHHR) and all applicable state and federal regulations.

Purpose 

This medical policy outlines Highmark Health Options services for  Assays for Vitamins and Metabolic Function.

Definitions

Highmark Health Options Duals (HHO Duals) – Highmark Health Options Duals is designed for people with both Medicare and Medicaid. Our D-SNP Medicare Advantage HMO coverage offers the same benefits as Original Medicare, plus extra benefits, like prescription drug coverage and vision and dental care.

Prior Authorization

Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool

https://wv.highmarkhealthoptions.com/providers/prior-authorization-code-lookup.html

Procedures

Please review the specific National Coverage Determination (NCD), Local Coverage Determination (LCD), and/or Local Coverage Article information, as well as other CMS sources, using the links below.

Post-payment Audit Statement The medical record must include documentation that reflects the medical necessity criteria and is subject to audit by HHO Duals at any time pursuant to the terms of your provider agreement

Place of Service The proper place of service for Vitamin D deficiency screening can be inpatient, outpatient, skilled nursing (inpatient and outpatient), clinical, ambulatory surgery center, and critical access hospital.

Coverage Determination and Links

HHO Duals follows the coverage determinations made by CMS as outlined in either the NCD the state-specific LCD, and/or the LCA.

CMS Link

CMS Website

NCD/LCD Link

·       NCD: There are currently no NCDs related to this topic.

·       LCD: Assays for Vitamins and Metabolic Function (L34914)

Article Link

·       Billing and Coding: Assays for Vitamins and Metabolic Function (A56416)