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• Distinguish between primary and secondary hypothyroidism
• Confirm or rule out primary hypothyroidism
• Monitor thyroid hormone levels (i.e. patients with goiter, thyroid nodules, or thyroid cancer)
• Monitor drug therapy in patients with primary hypothyroidism
• Confirm or rule out primary hyperthyroidism
• Monitor therapy in patients with hyperthyroidism

Thyroid function testing may be medically necessary in patients with disease or neoplasm of the thyroid and other endocrine glands.

Thyroid function testing may also be medically necessary in patients with metabolic disorders; malnutrition; hyperlipidemia; certain types of anemia; psychosis and non-psychotic personality disorders; unexplained depression; ophthalmologic disorders; various cardiac arrhythmias; disorders of menstruation; skin conditions; myalgias; and a wide array of signs and symptoms, including alterations in consciousness; malaise; hypothermia; symptoms of the nervous and musculoskeletal system; skin and integumentary system; nutrition and metabolism; cardiovascular; and gastrointestinal system.

Thyroid testing may be considered medically necessary up to two times a calendar year in clinically stable patients.

More frequent thyroid testing may be considered medically necessary for patients whose thyroid therapy has been altered or in whom signs or symptoms of hyperthyroidism or hypothyroidism are present.

Follow-up thyroid testing may be considered medically necessary in patients with a personal history of malignant neoplasm of the endocrine system and patients on long term thyroid drug therapy.

The coverage guidelines outlined in this Medical Policy should not be used in lieu of the Member's specific benefit plan language.

9/28/2009: Code reference section updated. New ICD-9 diagnosis codes 279.41, 279.49, 784.42, 784.43, 784.44, 784.51, 784.59 and 799.21, 799.22, 799.23 and 799.29 added to covered table. Added deleted statement to ICD-9 code 279.4, 784.5 and 799.2. Description revised for ICD-9 codes 784.49 and 793.99

12/01/2009: Policy Statement Section revised to define year as a calendar year for the statement, thyroid testing may be considered medically necessary up to two times a year in clinically stable patients.

01/15/2010:  Typographical error corrected, changed V57.00 to V67.00

11/18/2010:  Added the following ICD-9 codes to the Covered Codes table: 150.0 - 150.9, 151.0 - 151.9, 152.0 - 152.9, 153.0 - 153.9, 277.7, 530.0 - 530.9, 531.00 - 531.91, 532.00 - 532.91, 533.00 - 533.91, 534.00 - 534.91, 535.00 - 535.71, 555.0 - 555.9, 558.1 - 558.9, 560.0 - 560.9, 562.00 - 562.13, 564.00 - 564.9, 626.0 - 626.9, 780.2, 796.2, V10.03, V10.04, V10.05, and V10.43.

01/14/2011: Added ICD-9 codes 708.0 - 708.9 to the Covered Codes table.

01/24/2011: Added the following ICD-9 codes to the Covered Codes table: 627.0 - 627.9, 783.41, and 783.43.

02/23/2011: Added ICD-9 codes 346.00 - 346.93, 374.32, and 611.6 to the Covered Codes table.

05/09/2011: Added ICD-9 codes 259.0, 259.1, 314.00, and 314.01 to the Covered Codes table. 

06/16/2011: Added ICD-9 codes 234.8, 194.0 - 194.9, and 227.0 - 227.9 to the Covered Codes table. 

08/11/2011: Added ICD-9 codes 252.00 - 252.08 and 783.40 to the Covered Codes table. 

12/13/2011:  Added the following ICD-9 codes to the Covered Codes table:  268.9, 733.91, 611.1, 140.0 -165.9, 170.0 -176.9, 179 - 199.2, 200.00 - 208.98, 209.00 - 209.79, 230.0 - 234.9, and  V10.0 - V10.91.

05/08/2012:  Added 287.5, 374.55, and 567.82 to the Covered Codes table.

07/13/2012:  Added 070.54, 274.00 - 274.9, 333.94, and 701.2  to the Covered Codes table.

This is not intended to be a comprehensive list of codes. Some covered procedure codes have multiple descriptions.

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.

Covered Codes

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