CAM 126

Vitamin D Testing

Category:Laboratory   Last Reviewed:January 2020
Department(s):Medical Affairs   Next Review:January 2021
Original Date:January 2016    

Description
The vitamin D that is consumed or formed in the skin must then be activated, via addition of hydroxyl groups, in order to be used in metabolic processes.  Two forms of activated vitamin D, 25 hydroxy- (calcidol) and 1,25 dihydroxy-vitamin D (calcitriol) are found in human circulation. Twenty-five hydroxy-vitamin D is the predominant and most stable form, but 1,25 dihydroxy-vitamin D is the metabolically active form.  The initial activation step occurs in the liver, where the 25 hydroxy form is synthesized, and the second hydroxyl group is added in the kidney, creating the fully activated 1,25 dihdroxy form. 

Twenty-five hydroxy-vitamin D has a half-life of 15 days in the circulation, whereas 1,25 dihydroxy-vitamin D has a much shorter, 15 hour, circulating half-life.  Therefore, it is widely accepted that measurement of 25 hydroxy-vitamin D levels is the best way to evaluate an individual’s vitamin D status.

Vitamin D deficiency is a known cause of rickets and osteomalacia. Rickets in children can result in skeletal deformities.  In adults, osteomalacia can result in muscular weakness, in addition to weak bones and osteoporosis, creating increased risk for falls and fractures. 

A role for vitamin D has been suggested in several other conditions and metabolic processes, such as cancer, cardiovascular disease, hypertension, diabetes and pre-eclampsia, as well as others.  However, conclusive evidence for vitamin D’s role in these conditions is not available.  

Certain other conditions may impact an individual’s ability to absorb or activate vitamin D, thereby resulting in vitamin D deficiency.  These include, but are not limited to, celiac disease, liver cirrhosis, chronic kidney disease and bariatric surgery.  Vitamin D is fat soluble, so anything that impacts fat absorption or storage may have an effect on circulating vitamin D levels.

Vitamin D deficiency typically is defined as a serum 25 hydroxy-vitamin D level less than 20 ng/ml, and some organizations consider <30 ng/ml as insufficient.  Available serum assays can yield widely variable results, depending on the technology used for analysis. Efforts to standardize vitamin D measurements across technologies and laboratories are ongoing.

Most children and adults in the United States are considered to be vitamin D insufficient or deficient for several reasons.  Limited sun exposure for much of the country over much of the year, and the use of sunscreen that prohibits creation of vitamin D by sunlight radiation in the skin, contribute to low vitamin D levels. 

Routine dietary supplementation with vitamin D is recommended for most individuals.  The Institute of Medicine recommends a dietary allowance of 600 IU for males and females 1 - 70 years of age and 800 IU for adults 71 years and older, although these recommendations have been met with some criticism as being too low to adequately impact vitamin D levels in some individuals.

Vitamin D toxicity is very rare and occurs only when levels of 25 hydroxy-vitamin D are >150 ng/ml. Vitamin D toxicity may cause hypercalciuria, hypercalcemia, renal stones, renal calcification with renal failure and even death.

Background 
Vitamin D is a precursor to steroid hormones, and plays a key role in calcium absorption and mineral metabolism.  Vitamin D helps maintain calcium and phosphorus concentrations in blood, thereby serving an essential role in normal bone development and maintenance.  Vitamin D has also been associated with other metabolic roles, including neuromuscular and immune function.

Vitamin D is present in nature in two major forms.  Ergocalciferol, or vitamin D2, is found in fatty fish (e.g., salmon and tuna) and egg yolks, although very few foods naturally contain significant amounts of vitamin D.   Cholecalciferol, or vitamin D3, is synthesized in the skin via exposure to ultraviolet radiation present in sunlight.   Some foods are also fortified with vitamin D, most notably milk and cereals.

Testing is available for the determination of circulating blood levels of 25 hydroxy-vitamin D and 1,25 dihydroxy-vitamin D, for purposes of detecting deficiency or toxicity. 

Policy 

  1. Twenty-five hydroxy-vitamin D serum testing is MEDICALLY NECESSARY in individuals with an underlying disease or condition that is specifically associated with vitamin D deficiency or decreased bone density (see Guideline 1 below). 
  2. Testing for D2 and D3 fractions of 25 hydroxy-vitamin D is considered MEDICALLY NECESSARY as part of the total 25 hydroxy-vitamin D analysis.
  3. Repeat testing for serum 25 hydroxy-vitamin D is MEDICALLY NECESSARY in individuals who have documented vitamin D deficiency, at least 12 weeks after initiation of vitamin D supplementation therapy.   
    • Repeat testing for monitoring of supplementation therapy should not exceed 2 testing instances per year until the therapeutic goal is achieved.  
    • Once therapeutic range has been reached, annual testing meets coverage criteria.
  4. One,25 dihydroxy-vitamin D serum testing is MEDICALLY NECESSARY in the evaluation or treatment of conditions that are associated with defects in vitamin D metabolism (see Guideline 2 below).
  5. The following testing is considered NOT MEDICALLY NECESSARY:
    • One,25 dihydroxy-vitamin D serum testing for testing and screening of vitamin D deficiency.
    • Routine screening for vitamin D deficiency with serum testing in asymptomatic individuals and/or during general encounters.  

Policy Guidelines 
Indications that support coverage criteria for serum measurement of 25 hydroxy-vitamin D are:

  1. Biliary cirrhosis and other specified disorders of the biliary tract
  2. Blind loop syndrome
  3. Celiac disease
  4. Coronary artery disease in individuals where risk of disease progression is being considered against benefits of chronic vitamin D and calcium therapy
  5. Dermatomyositis
  6. Eating disorders
  7. Hypercalcemia, hypocalcemia or other disorders of calcium metabolism
  8. Hyperparathyroidism or hypoparathyroidism
  9. Hypervitaminosis of vitamin D
  10. Individuals receiving hyperalimentation
  11. Intestinal malabsorption
  12. Liver cirrhosis
  13. Long-term use of anticonvulsants, glucocorticoids and other medications known to lower vitamin D levels
  14. Lymphoma
  15. Malnutrition
  16. Myalgia and other myositis not specified
  17. Myopathy related to endocrine diseases
  18. Obesity
  19. Osteogenesis imperfecta
  20. Osteomalacia
  21. Osteopetrosis
  22. Osteoporosis
  23. Pancreatic steatorrhea
  24. Primary or miliary tuberculosis
  25. Psoriasis
  26. Regional enteritis
  27. Renal, ureteral or urinary calculus
  28. Rickets
  29. Sarcoidosis
  30. Stage III-V Chronic Kidney Disease and End Stage Renal Disease
  31. Systemic lupus erythematosus

Indications that support medical necessity for serum testing of 1,25 dihydroxy-vitamin D are:

  1. Disorders of calcium metabolism
  2. Familial hypophosphatemia
  3. Fanconi syndrome
  4. Hyperparathyroidism or hypoparathyroidism
  5. Individuals receiving hyperalimentation
  6. Neonatal hypocalcemia
  7. Osteogenesis imperfecta
  8. Osteomalacia
  9. Osteopetrosis
  10. Primary or miliary tuberculosis
  11. Renal, ureteral or urinary calculus
  12. Rickets
  13. Sarcoidosis
  14. Stage III-V Chronic Kidney Disease and End Stage Renal Disease

Rationale 
There are no evidence-based clinical practice guidelines to recommend routine screening for vitamin D deficiency.  Dietary supplementation is considered an adequate approach to addressing potential vitamin D deficiency or insufficiency in the general population.  Existing guidelines focus on individuals with conditions that are associated with the risk of decreased bone density/osteoporosis.

The Endocrine Society recommends serum testing of 25 hydroxy-vitamin D for evaluation of vitamin D status in individuals who are at risk of deficiency, including those with osteoporosis, obesity or a history of falls.  One,25 dihdroxy-vitamin D testing is not recommended for screening of at-risk individuals, due to its very short half-life in circulation, but is recommended for a few conditions in which formation of the 1,25 dihdroxy form may be impaired. 

After an extensive evaluation of published studies and testimony from investigators, the Institute of Medicine determined that supplementation with vitamin D is appropriate, but did not make a recommendation for routine vitamin D testing.

The National Osteoporosis Foundation defines vitamin D insufficiency as serum 25 hydroxy-vitamin D of < 30 ng/ml (75 nmol/L).  Its guidelines state: “Patients with recent fractures, multiple fractures or very low BMD should be evaluated for secondary etiologies and, when considering osteomalacia or vitamin D insufficiency, a serum 25(OH)D level should be obtained.”  Consistent with other organizations, the guidelines recommend adequate intake of calcium and vitamin D, and suggest weight-bearing exercise and lifestyle modifications that promote good bone health.

The United States Preventive Services Task Force (USPSTF) is currently reviewing and updating its statement on screening for vitamin D deficiency.  Among the questions being addressed are:

  1. “Is there direct evidence that screening for vitamin D deficiency results in improved health outcomes?”
  2. “What are the harms of screening (e.g., risk of procedure, false-positive or false-negative results)?”

The USPSTF recently issued a guideline, Prevention of Falls in Community-Dwelling Older Adults, which determined that vitamin D supplementation has a “moderate net benefit in preventing falls in older adults aged 65 years or older who are at risk for falls.”  As a result, vitamin D supplementation is included as one of the preventive services addressed in the Affordable Care Act.  However, testing for vitamin D deficiency is not included as a preventive service.

The U.S. Preventive Services Task Force (USPSTF) “concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for Vitamin D deficiency in asymptomatic adults. (I statement)." 

References 

  1. Agency for Healthcare Research and Quality, Recommendations for the diagnosis and management of vitamin D deficiency in adults.  Accessed 12/9/13 at http://www.guideline.gov/content.aspx?id=14868
  2. Institute of Medicine of the National Academies. Dietary Reference Intakes for Calcium and Vitamin D. November 2010. Accessed 12/9/13 at: http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D.aspx
  3. Holick, MF, Binkley, NC, Bischoff-Ferrari, HA, et al. Evaluation, treatment, and prevention of vitamin d deficiency: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2011 Jul;96(7):1911-30.  PMID: 21646368 
  4. USPSTF, Final Research Plan:  Screening for Vitamin D Deficiency.  Accessed on 12/9/13 at: http://www.uspreventiveservicestaskforce.org/uspstf13/vitddefic/vitddeficfinalresplan.htm
  5. USPSTF, Vitamin D and Calcium Supplementation to Prevent Fractures. February, 2013. Accessed on 12/9/13 at:  http://www.uspreventiveservicestaskforce.org/uspstf/uspsvitd.htm
  6. “Vitamin D and Bone Health:  A Practical Clinical Guide for Patient Management,” National Osteoporosis Society.  Accessed 1.2014 at www.nos.org.uk/document.doc?id=1352
  7. “Vitamin D Deficiency: Beyond the Basics”  Up to Date.  Accessed 1.2014 at http://www.uptodate.com/contents/vitamin-d-deficiency-beyond-the-basics
  8. “Vitamin D Assay Testing”  National Government Services, Inc., Medicare LCD (L29510), effective 10.25.13
  9. Screening for Vitamin D Deficiency in Adults: U.S. Preventive Services Task Force Recommendation Statement, Michael L. LeFevre, MD, MSPH, on behalf of the U.S. Preventive Services Task Force Accessed at www.annals.org. Vol. 162 No. 2 January 20 2015. 

Coding Section 

Code Number Description
CPT 82306 Vitamin D; 25 hydroxy
  82652 Vitamin D; 1, 25 dihydroxy
  0038U  Vitamin D, 25 hydroxy D2 and D3, by LC-MS/MS, serum microsample, quantitative
Proprietary test: Sensieva™ Droplet 25OH Vitamin D2/D3 Microvolume LC/MS Assay
Lab/Manufacturer: InSource Diagnostics
ICD-10-CM  A15.0-A15.9  Tuberculosis 
  A19.0-A19.9  Military Tuberculosis 
  A15.7, A19.0 - A19.9 Primary or miliary tuberculosis
  C81.00-C84.99  Other Lymphoma 
  C81.00 - C96.9 Lymphoma
  C85.10-C85.99  Unspecified B-cell lymphoma 
  C85.20-C85.29  Unspecified B-cell lymphoma 
  C85.80-C85.89  Other specified types of non-Hodgkin lymphoma 
  C85.90-C85.99  Non-Hodgkin lymphoma, unspecified, unspecified site 
  D61.09 Fanconi's anemia
  E66.01-E66.09 Obesity
  D86.0 - D86.85 Sarcoidosis
  D86.86  Sarcoid arthropathy 
  D86.87  Sarcoid myositis 
  D86.89  Sarcoidosis of other sites 
  D86.9    Sarcoidosis, unspecified   
  E20.0 Idiopathic hypoparathyroidism
  E20.1 Pseudohypoparathyroidism
  E20.8  Other hypoparathyroidism 
  E20.9  Hypoparathyroidism, unspecified 
  E21.0  Primary hyperparathyroidism 
  E21.1  Secondary hyperparathyroidism, not elsewhere classified 
  E21.2  Other hyperparathyroidism 
  E21.3  Hyperparathyroidism, unspecified 
  E21.4  Other specified disorders of parathyroid gland 
  E40 - E46 Malnutrition
  E64.3 Sequelae of rickets
  E67.3 Hypervitaminosis, D
  E72.09 Fanconi syndrome
  E83.50 Unspecified disorder of calcium metabolism
  E83.51 Hypocalcemia
  E83.52 Hypercalcemia
  E83.59 Other disorders of calcium metabolism
  E84.0-E84.9 Cystic fibrosis
 

E89.2

Postprocedural hypoparathyroidism 
  E55.0, E83.31-E83.32, K90.0, N25.0 Rickets
  E55.9 Vitamin D deficiency, unspecified
  E66.01-E66.09 Obesity
  E83.31 Familial hypophosphatemia
  E83.50 - E83.59 Disorders of calcium metabolism
  G73.7 Myopathy in diseases classified elsewhere
  I25.1 - I25.119 Coronary artery disease
  K74.3 - K74.5 Primary biliary cirrhosis
  K74.60 Cirrhosis (of liver) NOS
  K74.69 Other cirrhosis of liver
  K90.2, Q43.8 Blind loop syndrome, NOS
  K90.3 Pancreatic steatorrhea
  K90.9 Intestinal malabsorption, unspecified
 

K83.8

Other specified diseases of biliary tract 
  K90.0 Celiac disease
  K91..2  Postsurgical malabsorption, not elsewhere classified. 
  K90.1 - K90.4, K90.81 - K90.9 Intestinal malabsorption
  K90.3 Pancreatic steatorrhea
  L40.0 - L40.9 Psoriasis
  K50.90 - K50.919 Regional enteritis
  M33.10 Other dermatomyositis, organ involvement unspecified
  M60.9 Myositis, unspecified
  M81.0 Age-related osteoporosis without current pathological fracture
  M81.6  Localized osteoporosis (Lequesne) 
  M81.8  Other osteoporosis without current pathological fracture 
  M83.0 - M83.3 Osteomalacia
  M383.5-M83.9  Other Osteomalacia 
  M32.0 - M32.9 Systemic lupus erythematosus
  Q78.0 Osteogenesis imperfecta
  Q78.2 Osteopetrosis
  N20.0 - N22, N13.2 Renal, ureteral, urinary calculus
  N18.3 - N18.6 Chronic Kidney Disease III-V, ESRD
  N25.0  Renal osteodystrophy 
  P71.0 - P71.1 Neonatal hypocalcemia
  Q78.0 Osteogenesis imperfecta
  Q78.2 Osteopetrosis
  Z33.1-Z33.3 Pregnant state, incidental
  Z3A.00-Z3A.49  Weeks of gestation 
  Z34.00-Z34.93  Encntr for suprvsn of normal first pregnancy, unsp trimester (Encounter for supervision of normal first pregnancy, unspecified trimester) 
  Z79.899 Other long term (current) drug therapy

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2016 Forward     

01/06/2020 

Annual review, updating guidelines and coding. No change to policy intent. 

05/23/2019 

Corrected typo in coding 

01/08/2019 

Annual review, no change to policy intent. Updating ICD coding. 

01/22/2018 

Annual review, no change to policy intent. 

08/21/2017 

Updated coding. No other changes. 

08/09/2017 

Updated coding. No other changes. 

06/19/2017 

Updated coding section. No other changes. 

04/26/2017 

Updated category to Laboratory. No other changes made. 

01/04/2017 

Annual review, no change to policy intent. 

01/05/2016

NEW POLICY


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