L30868-LCD

Automated World Health

Local Coverage Determination (LCD) for Vitamin D; 25 hydroxy, includes fraction(s), if performed (L30868)

Contractor Information

Contractor Name

First Coast Service Options, Inc. opens in new window

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L30868

LCD Title Vitamin D; 25 hydroxy, includes fraction(s), if performed

Contractor's Determination Number 82306

Primary Geographic Jurisdiction opens in new window Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 06/07/2010

Original Determination Ending Date

Revision Effective Date

For services performed on or after 06/07/2010

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determination (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represent quotation from one or more of the following CMS sources: Medicare Claims Processing Manual, Chapter 16, Section 120

Indications and Limitations of Coverage and/or Medical Necessity

Vitamin D, a group of fat-soluble prohormones, is an essential vitamin. There are two major types of Vitamin D (Vitamin D2 and Vitamin D3) which are collectively known as calciferol. They are essential for promoting calcium absorption and maintaining adequate serum calcium and phosphate concentrations to enable mineralization of bone and prevent hypocalcemic conditions. Vitamin D2 (ergocalciferol) is obtained from foods of plant origin and vitamin D3 (cholecalciferol) is obtained from foods of animal origin and ultraviolet light-stimulated conversion of 7

-dehydrocholestral in the skin. Vitamin D is stored in the human body as calcidiol (25-hydroxyvitamin D). Serum concentration of 25(OH) D is the best indicator of vitamin D status.

Vitamin D deficiencies are the result of dietary inadequacy, impaired absorption and use, increased requirement, or increased excretion. Vitamin D deficiency can occur when usual intake is lower than recommended levels over a period of time, or when exposure to sunlight is limited. Vitamin D deficiency can also result from the inability of the kidneys to convert the vitamin D to its active form. Vitamin D toxicity can cause symptoms including nausea, vomiting, poor appetite, constipation, weakness, and weight loss as well as elevation in the blood level of calcium which in turn can lead to mental status changes, and heart rhythm abnormalities.

Indications

FCSO Medicare will consider the measurement of 25(OH)D Vitamin D levels medically reasonable and necessary for patients with any of the following conditions:

• Chronic kidney disease stage III or greater;

• Hypercalcemia;

• Hypocalcemia;

• Hyperparathyroidism;

• Hypoparathyroidism;

• Osteomalacia;

• Osteoporosis;

• Osteopenia;

• Rickets; or

• Vitamin D deficiency to monitor the efficacy of replacement therapy

• Malabsorption states

• Cirrhosis

Limitations

Vitamin D assay testing is not covered for routine screening, therefore, preventive care is not recognized as a covered indication for Vitamin D serum testing. Tests that are performed in the absence of signs, symptoms, complaints, personal history of disease, or injury are not covered by Medicare except when there is a statutory provision that explicitly covers tests for screening as described in the manual.

This LCD outlines the indications for vitamin D, 25-hydroxy (CPT code 82306). This test is appropriate for assessment of vitamin D deficiency. Vitamin D, 1,25-dihydroxy (CPT code 82652) is primarily indicated during patient evaluations for hypercalcemia and renal failure. It should not be ordered in addition to vitamin D, 25- hydroxy for vitamin D deficiency testing.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes

82306 VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED

ICD-9 Codes that Support Medical Necessity

252.1 HYPERPARATHYROIDISM, UNSPECIFIED

252.2 PRIMARY HYPERPARATHYROIDISM

252.3 SECONDARY HYPERPARATHYROIDISM, NON-RENAL

252.08 OTHER HYPERPARATHYROIDISM

252.1 HYPOPARATHYROIDISM

268.0 RICKETS ACTIVE

268.2 OSTEOMALACIA UNSPECIFIED

268.9 UNSPECIFIED VITAMIN D DEFICIENCY

275.3 DISORDERS OF PHOSPHORUS METABOLISM

275.41 HYPOCALCEMIA

275.42 HYPERCALCEMIA

278.4 HYPERVITAMINOSIS D

571.2 ALCOHOLIC CIRRHOSIS OF LIVER

571.5 CIRRHOSIS OF LIVER WITHOUT ALCOHOL

571.6 BILIARY CIRRHOSIS

579.0 - 579.9 opens in new window CELIAC DISEASE - UNSPECIFIED INTESTINAL MALABSORPTION

585.3 CHRONIC KIDNEY DISEASE, STAGE III (MODERATE)

585.4 CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE)

585.5 CHRONIC KIDNEY DISEASE, STAGE V

585.6 END STAGE RENAL DISEASE

588.81 SECONDARY HYPERPARATHYROIDISM (OF RENAL ORIGIN)

733.1 OSTEOPOROSIS UNSPECIFIED

733.2 SENILE OSTEOPOROSIS

733.3 IDIOPATHIC OSTEOPOROSIS

733.4 DISUSE OSTEOPOROSIS

733.09 OTHER OSTEOPOROSIS

733.90 DISORDER OF BONE AND CARTILAGE UNSPECIFIED

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity XX000 Not Applicable

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation must support the medical necessity of vitamin D testing. The results of the vitamin D testing and the resulting treatment regimen must be documented in the patient’s medical record. This information includes, but is not limited to relevant medical history, physical examination, and results of pertinent

diagnostic tests or procedures usually found in hospital/office progress notes and written laboratory reports.

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated in current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

For vitamin D deficiency, further testing may be medically reasonable and necessary in some cases, when utilized to ensure adequate replacement has been accomplished for the vitamin deficiency, however, other parameters are generally measured.

Sources of Information and Basis for Decision

Bishoff-Ferrari, H.A., Dawson-Hughes, B., Willet, W., et al. Effect of vitamin D on falls: a meta-analysis JAMA. April 2004; 291:16:1999-2006. Retrieved December 29, 2009 from www.jama.com

Bishoff-Ferrari, H.A., Willett, W., Wong, J., Giovannucci, E., Eietrich, T., Dawson-Hughes, B. Fracture prevention with vitamin D supplementation: a meta-analysis of randomized controlled trials. JAMA. May 2005; 293:18:2257- 2264. Retrieved December 29, 2009 from www.jama.com

Clinician’s Guide to Prevention and Treatment of Osteoporosis. (2008). National Osteoporosis Foundation. Retrieved October 26, 2009 from www.nof.org

Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease. (2004). National Kidney Foundation. Retrieved October 26, 2009 from www.kidney.org/professionals

Nichols, J. The controversy surrounding vitamin D lab testing. Washington G-2 Reports. (2008). Retrieved October 22, 2009 from www.g2reports.com/issues/advisory/advisory/james_nichols/422-1.html

Office of Dietary Supplements, National Institutes of Health: Dietary Supplement Fact Sheet: Vitamin D. (2005) Retrieved December 23, 2009 from www.ods.od.nih.gov/factsheets/vitamind.asp

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with advisory groups, which includes representatives from numerous societies.

Florida Contractor Advisory Committee meeting February 13, 2010

Puerto Rico/U.S. Virgin Islands Contractor Advisory Committee meeting February 25, 2010

Start Date of Comment Period 02/04/2010

End Date of Comment Period 03/20/2010

Start Date of Notice Period 04/23/2010

Revision History Number Original

Revision History Explanation Revision Number:Original Start Date of Comment Period:02/04/2010

Start Date of Notice Period:04/23/2010 Original Effective Date:06/07/2010

LCR B2010 - 042

April 2010 Update

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

82306 descriptor was changed in Group 1

Reason for Change