Vitamin D Testing

Reimbursement Policy:
Vitamin D Testing

Effective Date:
June 15, 2020

Purpose:
Provide guidelines for coverage and reimbursement of Vitamin D testing to prevent overutilization and misuse.

Scope:
All products are included, except:

Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
COB
Flex Link
MPL
ITS Home
FEP
ITS Host
Medicare Advantage

Administrative Services Only (ASO) accounts will be included as an Opt-In option on an account by account basis.

Policy:
Horizon BCBSNJ shall consider for reimbursement Vitamin D testing for patients with risk factors at a limit of up to four (4) per year. The limit includes initial measurement of 25(OH)D and subsequent measurement 3-4 months later to assess dose adequacy as per the American Association of Clinical Endocrinologists and The American College of Endocrinology.

The procedure codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:
Horizon BCBSNJ shall consider for reimbursement one test per day for procedure codes 82306, 82652, and 0038U with a limit of up to four tests per year when submitted with vitamin D deficiency and/or the appropriate high risk ICD-10 diagnosis code.

Horizon BCBSNJ shall deny the following:

Vitamin D tests billed beyond the four (4) per year limit when billed with the appropriate ICD-10 diagnosis code
All Vitamin D tests billed with an inappropriate ICD-10 diagnosis code

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

Group or Individual benefit
Provider Participation Agreement
Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
Mandated or legislative required criteria will always supersede.

History:
7/22/2019: Policy approved

Policy129_v1.0_07222020