L-91-008

HIGHMARK MEDICARE ADVANTAGE MEDICAL POLICY - PENNSYLVANIA

Medical Policy:

L-91-008

Topic:

Assays for Vitamins and Metabolic Function

Section:

Laboratory

Effective Date:

October 1, 2021

Issued Date:

November 16, 2021

Last Revision Date:

November 2021

Most vitamin deficiencies are suggested by specific clinical findings. The presence of those specific clinical findings may prompt laboratory testing for evidence of a deficiency of that specific vitamin. Certain other clinical states may also lead to vitamin deficiencies (malabsorption syndromes, etc).

Policy Position

To view specific LCD and NCD information, as well as other CMS sources, please refer to the LINKS section at the bottom of this policy page.

82180	82306	82379	82607	82652	82746	83090
83698	84207	84252	84425	84446	84590	84597
84999	85385	86352

Covered Diagnosis Codes for Procedure Codes 82306 and 82652

A15.0	A15.4	A15.5	A15.6	A15.7	A15.8	A15.9
A17.0	A17.1	A17.81	A17.82	A17.83	A17.89	A17.9
A18.01	A18.02	A18.03	A18.09	A18.10	A18.11	A18.12
A18.13	A18.14	A18.15	A18.16	A18.17	A18.18	A18.2
A18.31	A18.32	A18.39	A18.4	A18.50	A18.51	A18.52
A18.53	A18.54	A18.59	A18.6	A18.7	A18.81	A18.82
A18.83	A18.84	A18.85	A18.89	A19.0	A19.1	A19.2
A19.8	A19.9	B38.1	B38.2	B38.3	B38.4	B38.7
B38.81	B38.89	B38.9	B39.1	B39.2	B39.3	B39.4
B39.5	B39.9	C82.00	C82.01	C82.02	C82.03	C82.04
C82.05	C82.06	C82.07	C82.08	C82.09	C82.10	C82.11
C82.12	C82.13	C82.14	C82.15	C82.16	C82.17	C82.18
C82.19	C82.20	C82.21	C82.22	C82.23	C82.24	C82.25
C82.26	C82.27	C82.28	C82.29	C82.30	C82.31	C82.32
C82.33	C82.34	C82.35	C82.36	C82.37	C82.38	C82.39
C82.40	C82.41	C82.42	C82.43	C82.44	C82.45	C82.46
C82.47	C82.48	C82.49	C82.50	C82.51	C82.52	C82.53
C82.54	C82.55	C82.56	C82.57	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	C82.91
C82.92	C82.93	C82.94	C82.95	C82.96	C82.97	C82.98
C82.99	D86.0	D86.1	D86.2	D86.3	D86.81	D86.82
D86.83	D86.84	D86.85	D86.86	D86.87	D86.89	D86.9
E20.0	E20.8	E20.9	E21.0	E21.1	E21.2	E21.3
E55.0	E55.9	E67.3	E67.8	E68	E83.30	E83.31
E83.32	E83.39	E83.51	E83.52	E83.59	E84.0	E84.19
E84.8	E89.2	G73.7	J63.2	K50.00	K50.011	K50.012
K50.013	K50.014	K50.018	K50.019	K50.10	K50.111	K50.112
K50.113	K50.114	K50.118	K50.119	K50.80	K50.811	K50.812
K50.813	K50.814	K50.818	K50.819	K50.90	K50.911	K50.912
K50.913	K50.914	K50.918	K50.919	K51.00	K51.011	K51.012
K51.013	K51.014	K51.018	K51.019	K51.20	K51.211	K51.212
K51.213	K51.214	K51.218	K51.219	K51.30	K51.311	K51.312
K51.313	K51.314	K51.318	K51.319	K51.40	K51.411	K51.412
K51.413	K51.414	K51.418	K51.419	K51.50	K51.511	K51.512
K51.513	K51.514	K51.518	K51.519	K51.80	K51.811	K51.812
K51.813	K51.814	K51.818	K51.819	K51.90	K51.911	K51.912
K51.913	K51.914	K51.918	K51.919	K52.0	K70.2	K70.30
K70.31	K74.00	K74.01	K74.02	K74.3	K74.4	K74.5
K74.60	K74.69	K83.5	K83.8	K87	K90.0	K90.1
K90.2	K90.3	K90.49	K90.81	K90.89	K90.9	K91.2
L40.0	L40.1	L40.2	L40.3	L40.4	L40.50	L40.51
L40.52	L40.53	L40.54	L40.59	L40.8	L40.9	M32.0
M32.10	M32.11	M32.12	M32.13	M32.14	M32.15	M32.19
M32.8	M32.9	M33.00	M33.01	M33.02	M33.09	M33.10
M33.11	M33.12	M33.19	M33.20	M33.21	M33.22	M33.29
M33.90	M33.91	M33.92	M33.99	M36.0	M60.80	M60.811
M60.812	M60.819	M60.821	M60.822	M60.829	M60.831	M60.832
M60.839	M60.841	M60.842	M60.849	M60.851	M60.852	M60.859
M60.861	M60.862	M60.869	M60.871	M60.872	M60.879	M60.88
M60.89	M60.9	M79.11	M79.12	M79.18	M79.7	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
M85.9	M89.9	M94.9	N18.30	N18.31	N18.32	N18.4
N18.5	N18.6	N25.81	Q78.0	Q78.2	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	Z79.3
Z79.51	Z79.52	Z79.891	Z79.899	Z98.0	Z98.84

Covered Diagnosis Codes for Procedure Code 82379

D63.1	E71.40	E71.41	E71.42	E71.43	E71.440	E71.448
I95.3

Covered Diagnosis Codes for Procedure Codes 82607, 82746, and 83090

D51.0	D51.1	D51.2	D51.3	D51.8	D51.9	D52.0
D52.1	D52.8	D52.9	D53.1	D53.9	D69.6	D81.818
D81.819	E41	E43	E45	E46	E53.8	E64.0
E72.10	E72.11	E72.12	E72.19	F03.90	F03.91	F10.20
G25.70	G25.71	G25.79	G25.89	G25.9	G26	G30.0
G30.1	G30.8	G30.9	G60.3	G60.9	K14.0	K14.6
K31.83	K50.00	K50.011	K50.012	K50.013	K50.014	K50.018
K50.019	K50.10	K50.111	K50.112	K50.113	K50.114	K50.118
K50.119	K50.80	K50.811	K50.812	K50.813	K50.814	K50.818
K50.819	K50.90	K50.911	K50.912	K50.913	K50.914	K50.918
K50.919	K90.0	K90.1	K90.2	K90.3	K90.49	K90.81
K90.89	K90.9	K91.2	R20.0	R20.1	R20.2	R20.3
R20.8	R20.9	R26.0	R26.1	R26.81	R26.89	R26.9
R27.0	R27.8	R27.9	R41.1	R41.2	R41.3	R41.82
R41.9	R45.84	Z51.11	Z79.3	Z79.891	Z79.899	Z86.39
Z98.0	Z99.2

Covered Diagnosis Codes for Procedure Code 84207

D64.0	D64.1	D64.2	D64.3	E53.1	E67.2	E83.39
G25.70	G25.71	G25.79	G25.89	G25.9	G26	G60.9
K14.0	R74.8

Covered Diagnosis Codes for Procedure Code 85385

D47.3	D65	D68.2	D68.32	D68.4	D69.3	D69.41
D69.42	D69.49	D69.51	D69.59	D69.6	R79.1

Covered Diagnosis Codes for Procedure Code 86352

D81.4	D82.0	D82.1	D83.1	T86.00	T86.01	T86.02
T86.03	T86.09	T86.10	T86.11	T86.12	T86.13	T86.19
T86.20	T86.21	T86.22	T86.23	T86.290	T86.298	T86.30
T86.31	T86.32	T86.33	T86.39	T86.40	T86.41	T86.42
T86.43	T86.49	T86.5	T86.810	T86.811	T86.812	T86.818
T86.819	T86.850	T86.851	T86.852	T86.858	T86.859	T86.890
T86.891	T86.892	T86.898	T86.899	Z48.21	Z48.22	Z48.23
Z48.24	Z48.280	Z48.290	Z94.0	Z94.1	Z94.2	Z94.3
Z94.4	Z94.81	Z94.82	Z94.83

Covered Diagnosis Codes for Procedure Code 83698

E11.65	E11.9	E13.9	E78.00	E78.01	E78.1	E78.2
E78.3	E78.49	I25.10

Related Policies

Refer to Medicare Advantage medical policy N-107 Levocarnitine for Use in the Treatment of Carnitine Deficiency in ESRD Patients – NCD 230.19 for additional information.

The policy position applies to all Medicare Advantage lines of business

Links

Link to Provider Resource Center for the Medical Policy Update

10/2016, New Policy Established For Assays for Vitamins and Metabolic Function

CMS Links

CMS Website

Article Links

Article Link

LCD Links

LCD Link

References

Novitas Solutions, Inc., LCD L34914. Revised 07/01/2020 (R14).
Novitas Solutions, Inc., LCA A56416. Revised 10/01/2021 (R6).

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.

This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.