HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
L-63-011
Topic:
Vitamin D Assay
Section:
Laboratory
Effective Date:
October 1, 2018
Issued Date:
October 1, 2018
Last Revision Date:
April 2018
Annual Review:
April 2018
 
 

Vitamin D metabolites are used to assess serum vitamin D level and metabolism. Specifically, 25-hydroxy vitamin D, referred to as 25(OH)D, and 1,25-dihydroxyvitamin D. The 25 (OH)D metabolite  has an estimated half- life of approximately two (2) to three (3) weeks, and provides a measure of the vitamin D originating from both dietary/supplement sources and from cutaneous(e.g. sun exposure) production. Vitamin D stored in other body tissues are, however, not reflected in the serum 25(OH)D levels. Serum levels of the active vitamin D metabolite, 1,25-dihydroxyvitamin D, may not accurately indicate the individual’s vitamin D status due to its short half-life (15 hours). Since it’s closely regulated by parathyroid hormone and the intake of calcium and phosphate, serum levels of 1,25-dihydroxyvitamin D may appear normal in individuals with vitamin D deficiency.

Vitamin D deficiency is defined as a 25(OH)D below 20 ng/ml (50 nmol/liter), and vitamin D insufficiency as a 25(OH)D of 21–29 ng/ml(525–725 nmol/liter).

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

Measurement of cholecalciferol 25-hydroxyvitamin D [25 (OH) D] levels may be considered medically necessary for individuals with (not all inclusive):

 

  • Clinically documented underlying disease that is specifically associated with vitamin D deficiency, decreased bone density; or
  • Individuals considered at high risk for vitamin D deficiency (see list below) and vitamin D supplementation is being taken per the recommended daily amounts; or
    • African-American and Hispanic children and adults
    • Pregnant and lactating women
    • Older adults greater than 65 years with history of falls or non-traumatic fractures
    • Obesity; children and adults (BMI greater than or equal to 30)
  • Chronic kidney disease (CKD), stage 3 or greater; or
  • Granuloma forming diseases; or
    • Sarcoidosis
    • Tuberculosis
    • Histoplasmosis
    • Coccidiomycosis
    • Berylliosis
  • Hepatic disease or failure; or
  • Hyperparathyroidism; or
  • Long term use of anticonvulsants, glucocorticoids, rifampicin, acquired immune deficiency syndrome (aids) medications, antifungals, cholestyramine  and other medications known to lower vitamin d levels; or
  • Malabsorption states; or
    • Cystic fibrosis 
    • Inflammatory bowel disease (i.e. Crohn’s disease, Ulcerative colitis)
    • Bariatric surgery
    • Radiation enteritis
  • Individuals receiving hyperalimentation; or
  • Osteomalacia; or
  • Osteoporosis or at risk for osteoporosis; or
  • Osteogenesis imperfecta; or
  • Rickets; or
  • Vitamin D deficiency on replacement therapy; to monitor the efficacy of treatment

25-OH Vitamin D-3 may be tested up to four (4) times per year for Vitamin D deficiencies when the above criteria are met.

Testing and screening for vitamin D deficiency with 25-hydroxyvitamin D [25(OH)D] serum testing is considered not medically necessary for all other indications.

 

82306


Measurement of 1,25(OH)2D may be considered  medically necessary for evaluation of patients with a clinically documented underlying disease or condition associated with increased or decreased 1,25(OH)2D, including:

  • Chronic kidney disease; or
  • Hypercalcemia with a low parathyroid hormone; or
  • Acquired and/or inherited disorders in the metabolism of 25(OH)D and phosphate; or
  • Tumor induced osteomalacia (oncogenic osteomalacia); or 
  • Hereditary phosphate-losing disorders; or
  • Vitamin D-dependent rickets type 1 (also known as pseudo-vitamin d deficient rickets); or
  • Vitamin D-resistant rickets; or
  • Chronic granuloma-forming disorders; or
  • Lymphomas.

Measurement of 1,25(OH)2D may be tested up to four (4) times per year for Vitamin D deficiencies when the above criteria is met.

With exception in very complex cases (e.g. hypercalcemia with reportedly low endogenous levels of 25-hydroxy vitamin D), there are rarely indications for ordering both 25-hydroxy vitamin D and1,25-dihydroxy vitamin D on the same specimen at the same time.  In the presence of renal disease, 1,25-dihdroxy vitamin D levels may be needed to adequately assess vitamin D status.

Testing and screening for vitamin D deficiency with 1,25 dihydroxyvitamin D [1,25(OH)2D] serum testing is considered not medically necessary for all other indications.

82652


Professional Statements and Societal Positions Guidelines

Guidelines are in accordance with The Endocrine Society’s Clinical Practice Guidelines: Treatment, and prevention of Vitamin D Deficiency.  The Endocrine Society recommends screening for vitamin D deficiency in individuals at risk for deficiency.  The society does not recommend population screening for vitamin D deficiency in individuals who are not at risk.  It is recommended using the serum circulating 25-hydroxyvitamin D [25(OH)D] level, measured by a reliable assay to evaluate Vitamin D status in patients who are at risk for vitamin D deficiency. The society recommends using the serum 1,25-dihydroxyvitamin D [1,25(OH)2D] assay in monitoring certain conditions, such as acquired and inherited disorders of vitamin D and phosphate metabolism.

American Society for Clinical Pathology and Choosing Wisely recommends not performing population based screening for 25-OH-Vitanin D deficiency. Vitamin D deficiency is common in many populations, particularly in patients at higher latitudes, during winter months and in those with limited sun exposure. Over the counter Vitamin D supplements and increased summer sun exposure are sufficient for most otherwise healthy patients. Laboratory testing is appropriate in higher risk patients when results will be used to institute more aggressive therapy (e.g., osteoporosis, chronic kidney disease, malabsorption, some infections, obese individuals).


Covered Diagnosis Codes for Procedure Code 82306

A15.0

A15.4

A15.5

A15.6

A15.7

A15.8

A17.0

A17.1

A17.81

A17.82

A17.83

A17.89

A18.09

A18.14

A18.16

A18.2

A18.4

A18.53

A18.54

A18.6

A18.7

A18.82

A18.84

A18.01

A18.02

A18.03

A18.11

A18.12

A18.13

A18.15

A18.17

A18.31

A18.32

A18.39

A18.51

A18.52

A18.59

A18.81

A18.83

A18.85

A18.89

A19.0

A19.1

A19.2

A19.8

A19.9

B38.0

B38.1

B38.2

B38.3

B38.4

B38.7

B38.81

B38.89

B39.0

B39.1

B39.3

B39.5

D86.0

D86.1

D86.2

D86.3

D86.9

D86.81

D86.82

D86.83

D86.84

D86.85

D86.86

D86.89

E20.0

E20.1

E.20.8

E20.9

E21.0

E21.1

E21.2

E21.3

E44.0

E46

E55.0

E55.9

E64.3

E66.8

E66.01

E66.09

E67.2

E67.8

E68

E83.00

E83.30

E83.31

E83.32

E83.39

E83.51

E83.52

E83.59

E84.0

E84.8

E84.9

E84.19

G73.7

J63.0

J63.1

J63.2

J63.3

J63.4

J63.5

J63.6

K50.00

K50.10

K50.011

K50.012

K50.013

K50.014

K50.018

K50.019

K51.00

K51.90

K52.0

K50.80

K50.90

K50.111

K50.112

K50.113

K50.114

K50.118

K50.119

K50.811

K50.812

K50.813

K50.814

K50.818

K50.819

K50.911

K50.912

K50.913

K50.914

K50.918

K50.919

K51.20

K51.30

K51.80

K51.011

K51.012

K51.013

K51.014

K51.018

K51.019

K51.211

K51.212

K51.213

K51.214

K51.218

K51.219

K51.311

K51.312

K51.313

K51.314

K51.318

K51.319

K70.0

K70.10

K70.11

K70.2

K70.30

K70.31

K70.40

K70.41

K70.9

K71.10

K71.11

K71.4

K71.50

K71.51

K71.6

K72.00

K72.01

K72.10

K72.11

K72.90

K72.91

K73.0

K73.1

K73.2

K73.8

K73.9

K74.0

K74.60

K74.69

K75.4

K74.1

K74.2

K74.3

K74.4

K74.5

K75.81

K76.0

K76.9

K76.89

K77

K83.01

K83.09

K83.1

K83.2

K83.3

K83.4

K83.5

K83.8

K83.9

K86.0

K86.1

K90.0

K90.1

K90.2

K90.3

K90.9

K90.41

K90.49

K90.81

K90.89

K91.2

M32.0

M32.8

M32.9

M32.10

M32.11

M32.12

M32.13

M32.14

M32.15

M32.19

M33.00

M33.01

M33.02

M33.03

M33.09

M33.10

M33.11

M33.12

M33.13

M33.19

M33.90

M33.91

M33.92

M33.93

M33.99

M60.80

M60.9

M60.88

M60.89

M62.81

M80.00XA

M80.00XD

M80.00XG

M80.00XK

M80.00XP

M80.00XS

M80.011A

M80.011D

M80.011G

M80.011K

M80.011P

M80.011S

M80.012A

M80.012D

M80.012G

M80.012K

M80.012P

M80.012S

M80.019A

M80.019D

M80.019G

M80.019K

M80.019P

M80.019S

M80.021A

M80.021D

M80.021G

M80.021K

M80.021P

M80.021S

M80.022A

M80.022D

M80.022G

M80.022K

M80.022P

M80.022S

M80.029A

M80.029D

M80.029G

M80.029K

M80.029P

M80.029S

M80.031A

M80.031D

M80.031G

M80.031K

M80.031P

M80.031S

M80.032A

M80.032D

M80.032G

M80.032K

M80.032P

M80.032S

M80.039A

M80.039D

M80.039G

M80.039K

M80.039P

M80.039S

M80.041A

M80.041D

M80.041G

M80.041K

M80.041P

M80.041S

M80.042A

M80.042D

M80.042G

M80.042K

M80.042P

M80.042S

M80.049A

M80.049D

M80.049G

M80.049K

M80.049P

M80.049S

M80.051A

M80.051D

M80.051G

M80.051K

M80.051P

M80.051S

M80.052A

M80.052D

M80.052G

M80.052K

M80.052P

M80.052S

M80.059A

M80.059D

M80.059G

M80.059K

M80.059P

M80.059S

M80.061A

M80.061D

M80.061G

M80.061K

M80.061P

M80.061S

M80.062A

M80.062D

M80.062G

M80.062K

M80.062P

M80.062S

M80.069A

M80.069D

M80.069G

M80.069K

M80.069P

M80.069S

M80.071A

M80.071D

M80.071G

M80.071K

M80.071P

M80.071S

M80.072A

M80.072D

M80.072G

M80.072K

M80.072P

M80.072S

M80.079A

M80.079D

M80.079G

M80.079K

M80.079P

M80.079S

M80.08XA

M80.08XD

M80.08XG

M80.08XK

M80.08XP

M80.08XS

M80.80XA

M80.80XD

M80.80XG

M80.80XK

M80.80XP

M80.80XS

M80.811A

M80.811D

M80.811G

M80.811K

M80.811P

M80.811S

M80.812A

M80.812D

M80.812G

M80.812K

M80.812P

M80.812S

M80.819A

M80.819D

M80.819G

M80.819K

M80.819P

M80.819S

M80.821A

M80.821D

M80.821G

M80.821K

M80.821P

M80.821S

M80.822A

M80.822D

M80.822G

M80.822K

M80.822P

M80.822S

M80.829A

M80.829D

M80.829G

M80.829K

M80.829P

M80.829S

M80.831A

M80.831D

M80.831G

M80.831K

M80.831P

M80.831S

M80.832A

M80.832D

M80.832G

M80.832K

M80.832P

M80.832S

M80.839A

M80.839D

M80.839G

M80.839K

M80.839P

M80.839S

M80.841A

M80.841D

M80.841G

M80.841K

M80.841P

M80.841S

M80.842A

M80.842D

M80.842G

M80.842K

M80.842P

M80.842S

M80.849A

M80.849D

M80.849G

M80.849K

M80.849P

M80.849S

M80.851A

M80.851D

M80.851G

M80.851K

M80.851P

M80.851S

M80.852A

M80.852D

M80.852G

M80.852K

M80.852P

M80.852S

M80.859A

M80.859D

M80.859G

M80.859K

M80.859P

M80.859S

M80.861A

M80.861D

M80.861G

M80.861K

M80.861P

M80.861S

M80.862A

M80.862D

M80.862G

M80.862K

M80.862P

M80.862S

M80.869A

M80.869D

M80.869G

M80.869K

M80.869P

M80.869S

M80.871A

M80.871D

M80.871G

M80.871K

M80.871P

M80.871S

M80.872A

M80.872D

M80.872G

M80.872K

M80.872P

M80.872S

M80.879A

M80.879D

M80.879G

M80.879K

M80.879P

M80.879S

M80.88XA

M80.88XD

M80.88XG

M80.88XK

M80.88XP

M80.88XS

M81.0

M81.6

M81.8

M83.0

M83.1

M83.2

M83.3

M83.4

M83.5

M83.8

M83.9

M85.80

M85.811

M85.812

M85.819

M85.821

M85.822

M85.829

M85.831

M85.832

M85.839

M85.841

M85.842

M85.849

M85.851

M85.852

M85.859

M85.9

M85.88

M85.89

M85.861

M85.862

M85.869

M85.871

M85.872

M85.879

M89.9

M94.9

N18.3

N18.4

N18.5

N18.6

P37.0

P71.0

P71.1

P71.2

P71.3

P71.4

P71.8

P71.9

Q78.0

Q78.2

Z34.82

Z68.30

Z68.31

Z68.32

Z68.33

Z68.34

Z68.35

Z68.36

Z68.37

Z68.38

Z68.39

Z68.41

Z68.42

Z68.43

Z68.44

Z68.45

Z68.54

Z79.51

Z79.52

Z79.899

Z98.84

 

Covered Diagnosis Codes for Procedure Code 82652

A15.0

A15.4

A15.5

A15.6

A15.7

A15.8

A17.0

A17.1

A17.9

A17.81

A17.82

A17.89

A18.2

A18.4

A18.6

A18.7

A18.01

A18.02

A18.03

A18.10

A18.11

A18.12

A18.13

A18.15

A18.17

A18.31

A18.32

A18.39

A18.50

A18.51

A18.52

A18.59

A18.81

A18.83

A18.85

A18.89

A19.0

A19.1

A19.2

A19.8

A19.9

B38.0

B38.1

B38.2

B38.7

B38.9

B38.89

B39.4

C81.00

C81.01

C81.02

C81.04

C81.05

C81.06

C81.07

C81.08

C81.09

C81.10

C81.11

C81.12

C81.13

C81.14

C81.15

C81.16

C81.17

C81.18

C81.19

C81.20

C81.21

C81.22

C81.23

C81.24

C81.25

C81.26

C81.27

C81.28

C81.29

C81.30

C81.31

C81.32

C81.33

C81.34

C81.36

C81.37

C81.38

C81.40

C81.41

C81.42

C81.44

C81.45

C81.46

C81.47

C81.48

C81.49

C81.70

C81.71

C81.72

C81.73

C81.74

C81.75

C81.76

C81.77

C81.78

C81.79

C81.90

C81.91

C81.92

C81.93

C81.94

C81.95

C81.96

C81.97

C81.98

C81.99

C82.00

C82.01

C82.02

C82.03

C82.04

C82.05

C82.06

C82.07

C82.08

C82.13

C82.14

C82.15

C82.16

C82.17

C82.18

C82.22

C82.23

C82.24

C82.25

C82.26

C82.27

C82.28

C82.31

C82.32

C82.33

C82.34

C82.35

C82.36

C82.37

C82.38

C82.41

C82.42

C82.43

C82.44

C82.45

C82.46

C82.47

C82.48

C82.50

C82.51

C82.52

C82.53

C82.54

C82.55

C82.56

C82.58

C82.59

C82.60

C82.61

C82.62

C82.63

C82.64

C82.65

C82.66

C82.67

C82.68

C82.69

C82.80

C82.81

C82.82

C82.83

C82.84

C82.85

C82.86

C82.87

C82.88

C82.89

C82.90

C82.92

C82.91

C82.93

C82.94

C82.95

C82.96

C82.97

C82.98

C82.99

C83.00

C83.01

C83.02

C83.03

C83.04

C83.05

C83.06

C83.07

C83.08

C83.09

C83.10

C83.11

C83.12

C83.13

C83.14

C83.15

C83.16

C83.17

C83.18

C83.19

C83.30

C83.31

C83.32

C83.33

C83.34

C83.35

C83.36

C83.37

C83.38

C83.39

C83.50

C83.51

C83.52

C83.53

C83.54

C83.55

C83.56

C83.57

C83.58

C83.59

C83.70

C83.71

C83.72

C83.73

C83.74

C83.75

C83.76

C83.77

C83.78

C83.79

C83.80

C83.81

C83.82

C83.83

C83.84

C83.85

C83.86

C83.87

C83.88

C83.89

C83.90

C83.91

C83.92

C83.93

C83.94

C83.95

C83.96

C83.97

C83.98

C83.99

C84.00

C84.01

C84.02

C84.03

C84.04

C84.05

C84.07

C84.08

C84.09

C84.10

C84.11

C84.12

C84.13

C84.14

C84.15

C84.16

C84.17

C84.18

C84.19

C84.40

C84.43

C84.44

C84.45

C84.47

C84.48

C84.49

C84.65

C84.66

C84.67

C84.68

C84.75

C84.76

C84.77

C84.78

C84.79

C84.90

C84.91

C84.92

C84.93

C84.94

C84.95

C84.96

C84.98

C84.99

C84.A0

C84.A1

C84.A2

C84.A3

C84.A4

C84.A5

C84.A6

C84.A7

C84.A8

C84.A9

C84.Z0

C84.Z1

C84.Z2

C84.Z3

C84.Z4

C84.Z5

C84.Z6

C84.Z7

C84.Z8

C84.Z9

C85.10

C85.11

C85.12

C85.13

C85.14

C85.16

C85.18

C85.19

C85.20

C85.21

C85.22

C85.23

C85.24

C85.25

C85.26

C85.27

C85.28

C85.29

C85.80

C85.81

C85.82

C85.83

C85.84

C85.85

C85.86

C85.88

C85.89

C85.90

C85.91

C85.92

C85.93

C85.94

C85.95

C85.96

C85.98

C85.99

C86.0

C86.2

C86.3

C86.4

C86.5

C86.6

C88.4

C91.40

C91.41

C91.42

C96.0

C96.2

C96.21

C96.22

C96.29

C96.4

C96.9

C96.A

C96.Z

D71

E55.0

E55.9

E83.00

E83.30

E83.31

E83.32

E83.39

E83.50

E83.51

E83.52

E83.59

M83.0

M83.1

M83.2

M83.4

M83.5

M83.8

M83.9

N18.3

N18.4

N18.5

N18.6

 

 

 


Place of Service: Outpatient

A vitamin D assay is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Quantity level limits or quantity of supplies that exceed the frequency guidelines listed in the policy will be denied as not medically necessary.



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

    Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.




    Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

    Discrimination is Against the Law
    The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.