Medical Necessity of Vitamin D Assay Testing: Top Denials and How to Prevent Them

Learn how to prevent common denials for Vitamin D Assay Testing (CPT Code 82306):

1. Testing may not be used for routine or other screening.

There must be documentation to support medical necessity of the Vitamin D assay test. Vitamin D assay tests billed for routine screening will be denied.

2. Documentation submitted must include a covered indication/diagnosis.

The documentation submitted must support that the beneficiary has one or more of the covered indications listed in LCD L37535: Vitamin D Assay Testing. If the documentation does not indicate that the patient has one of the covered indications, the claim will be denied as not medically necessary. Note: Use of the E55.9 diagnosis code without support of the diagnosis of Vitamin D deficiency in the medical records will be denied as not medically necessary.

The covered indications include:

• Chronic kidney disease stage III or greater
• Cirrhosis
• Hypocalcemia
• Hypercalcemia
• Hypercalciuria
• Hypervitaminosis D
• Parathyroid disorders
• Malabsorption states
• Obstructive jaundice
• Osteomalacia
• Osteoporosis if:
  • T score on DEXA scan <-2.5 or
  • History of fragility fractures or
  • FRAX> 3% 10-year probability of hip fracture or 20% 10-year probability of other major osteoporotic fracture or
  • FRAX> 3% (any fracture) with T-score <-1.5 or
  • Initiating bisphosphanate therapy (Vitamin D level and serum calcium levels should be determined and managed as necessary before bisphosphonate is initiated.)
• Osteosclerosis/petrosis
• Rickets
  • Vitamin D deficiency on replacement therapy related to a condition listed above; to monitor the efficacy of treatment.

3. Denials related to medical necessity. Example: Documentation supports that the patient has an established diagnosis of Vitamin D deficiency and is taking a Vitamin D supplement. The previous vitamin D level was between 20 and 50 ng/dl. The documentation does not indicate why repeat testing was necessary.

When a patient with a diagnosis of Vitamin D deficiency has had a Vitamin D assay test within 12 months and the Vitamin D level is between 20 – 50 ng/ml, the patient is considered clinically stable. There needs to be clear documentation to support why a Vitamin D Assay test is needed when the previous Vitamin D level was stable. If there is not a documented clinical reason for the Vitamin D Assay Test, then the claim will be denied as medically unnecessary.

If the patient wants a Vitamin D Assay Test but it is not medically necessary based on Medicare Regulations, the provider can issue an ABN, bill with an appropriate ABN modifier, and include the ABN with submitted documentation, if selected for review.

Related Content

• Local Coverage Determination - Vitamin D Assay Testing (L37535)
• Article - Billing and Coding: Vitamin D Assay Testing (A57736)

Reviewed 6/18/2024