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).

Vitamin assay panels (more than one vitamin assay) are considered a screening procedure and therefore, non-covered. Similarly, assays for micronutrient testing for nutritional deficiencies that include multiple tests for vitamins, minerals, antioxidants and various metabolic functions are never necessary. Reimbursement is made for covered clinical laboratory studies that are reasonable and necessary for the diagnosis or treatment of an illness. Many vitamin deficiency problems can be determined from a comprehensive history and physical examination. Any diagnostic evaluation should be targeted at the specific vitamin deficiency suspected and not a general screen. Most vitamin deficiencies are nutritional in origin and may be corrected with supplemented vitamins.

Utilization Guidelines

More than one test per year is not covered, per member except as noted below.

Certain tests may exceed the stated frequencies, when accompanied by a diagnosis fitting the exception description for exceeding the once per annum maximum.

• Carnitine (82379) may be tested up to three times per year to account for baseline assay followed by evaluations at six-month increments (adapted from “Levocarnitine” NCD).
  
  
• Vitamin B-12 (82607) and folate (82746) can each be tested up to four times per year for malabsorption syndromes or deficiency disorders.
  
  
• Vitamin B-12 (82607) can only be tested more frequently than four times per year for postsurgical malabsorption.
  
  
• 25-OH Vitamin D-3 (82306) may be tested up to four times per year for Vitamin D deficiencies.
  
• Fibrinogen, antigen (85385) may be tested up to four times per year for low platelet diagnoses.
  
  
• More than two high-sensitivity C-reactive protein (86141) tests per year per member are not covered. This allows for baseline testing and six-month follow-up tests for statin therapeutic management.
  
  
• The same frequency edit (two tests per year per member) will be applied to Lipoprotein-associated phospholipase A2 (Lp-PLA2) (83698) used in the management of patients with coronary artery disease.
  
  
• Lymphocyte transformation assays (86353) will not be subjected to any frequency edits.

Tests exceeding the frequency listed above will deny as not medically necessary. Tests reported without a covered diagnosis code will deny as not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Limitations

For Medicare members, screening tests are governed by statute (Social Security Act 1861(nn)). Vitamin testing may not be used for routine screening.

Once a member has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors.

Assays of selenium (84255), functional intracellular analysis (84999) or total antioxidant function (84999) are non-covered services. Assays of vitamin testing, not otherwise classified (84591), are not covered since all clinically relevant vitamins have specific assays. A provider can bill the member for the non-covered procedure. 

The following are pertinent laboratory tests for which frequency limitations will be specified [note this should be all the CPT codes in the list below, except for those that are non-covered]:

• Vitamins and metabolic function assays: 25-OH Vitamin D-3, Carnitine, Vitamin B-12, Folic Acid (Serum), Homocystine, Vitamin B-6, Vitamin B-2, Vitamin B-1, Vitamin E, Fibrinogen, High-Sensitivity C-Reactive Protein and Lipoprotein-associated phospholipase A 2 (Lp-PLA 2); Vitamin A; Vitamin K; and Ascorbic acid.
  
  
• Additional inclusion of Vitamin D (with limited coverage not otherwise specified).

Documentation Requirements

Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available upon request.

Provider News

4/2012, Medicare Advantage classifies assays for vitamins and metabolic function as screening procedure

Covered Diagnosis Codes

The following is limited coverage for CPT codes 82306 and 82652

The following is limited coverage for CPT code 82379

The following is limited coverage for CPT codes 82607, 82746 and 83090

*Note: Use code 780.99 to identify altered mental status.

**Effective 10/01/2011

The following is limited coverage for CPT code 84207

The following is limited coverage for CPT code 85385

The following limited coverage for CPT codes 86352 and 86353

The following is limited coverage for CPT code 86141, and 83698

*Effective 10/01/2011