0143-Vitamin D Assay Testing: Medical Necessity and Documentation Requirements

Description

Vitamin D lab assay is only reimbursable under Medicare when it meets the indications under the applicable LCD and not as a routine screening according to 42 CFR 410.32(a)

Affected Code(s)

82306, 82652

Applicable Policy References

1.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3.    42 CFR §405.929- Post-Payment Review
4.    42 CFR §405.930- Failure to Respond to Additional Documentation Request
5.    42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6.    42 CFR §405.986- Good Cause for Reopening  
7.    42 CFR §410.32(a) Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.
8.    42 CFR §411.15(k)(1)- Particular services excluded from coverage
9.    Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.1- 3.6.6
10.    Medicare Program Integrity Manual, Chapter 13, §13.5.4 Reasonable and Necessary Provision in an LCD
11.    Medicare Benefit Policy Manual, Chapter 6- Hospital Services Covered Under Part B, Section 20.4.4- Coverage of Outpatient Diagnostic Services Furnished on or After January 1, 2010
12.    Noridian, LCD L36692 (JE) Vitamin D Assay Testing, Effective 02/03/2017, Revised 12/01/2019
13.    Noridian LCA A57718 (JE) Vitamin D Assay Testing, Effective 12/01/2019 Revised Date 10/01/2022
14.    Noridian, LCD L34051 (JF) Vitamin D Assay Testing, Effective 10/01/2015, Revised 12/01/2019
15.    Noridian LCA A57719 (JF) Vitamin D Assay Testing, Effective 12/01/2019, Revised Date 10/01/2022
16.    American Medical Association (AMA) Current Procedural Terminology (CPT) Codebook