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DESCRIPTIONCalcium and phosphate are two minerals that are essential for normal bone formation. Throughout childhood, the body uses these minerals to produce bones. If the body does not get enough calcium, or if the body does not absorb enough calcium from the diet, bone production and bone tissues may suffer. Vitamin D is an essential nutrient that plays an important role in calcium homeostasis and bone health. Vitamin D helps the body absorb calcium.
Sunlight and ultraviolet light photoisomerize provitamin D to vitamin D3 (cholecalciferol) in the skin; they are then bound by the vitamin D binding proteins (DBP) and transported via blood to target organs for metabolism and activity. Intestinal absorption is the other major source of vitamin D. As part of the diet, vitamin D is found in fortified milk, fatty fish, cod-liver oil and, to a lesser extent, eggs. In the United States, milk fortified with vitamin D2 (ergocalciferol, a plant steroid) or vitamin D3 (cholecalciferol) is the principal source of dietary vitamin D. In other parts of the world, cereals and bread products are often fortified with vitamin D.
Vitamin D deficiency or resistance is caused by one of four mechanisms:
Vitamin D deficiency can lead to osteoporosis in adults. Severe deficiency of vitamin D causes rickets and/or hypocalcemia in infants and children and osteomalacia in adults or adolescents after epiphysial closure; severe vitamin D deficiency may also be associated with hypocalcemia, which may cause tetany or seizures. These disorders occur with the highest frequency among children in malnourished populations and in children with chronic illnesses. Rickets also occurs in children in developed nations if sufficient vitamin D intake is not ensured through the use of supplements and fortified foods, particularly if exposure to sunlight is limited.
The Clinical Guidelines Subcommittee of the Endocrine Society appointed a Task Force to formulate evidence-based recommendations for Vitamin D evaluation, treatment, and prevention. The Task Force recommends screening for vitamin D deficiency in individuals at risk for deficiency using the serum circulating 25-hydroxyvitamin D [25(OH)D] level, measured by a reliable assay, to evaluate vitamin D status in patients who are at risk for vitamin D deficiency. In individuals who are in the high risk groups, it is appropriate to measure serum 25OHD, to supplement with the amount estimated to be needed to reach the target 25OHD level, and then to remeasure three to four months later to verify that the target has been achieved. Although healthy adults initiating vitamin D supplementation (600 to 800 units daily) do not require an initial or follow-up serum 25OHD measurement after starting supplementation, patients being treated specifically for vitamin D deficiency require a repeat 25OHD measurement approximately three to four months after initiating therapy. Ergocal has a ½ life of 21 days, so more frequent testing after initiation of therapy is not indicated.
The Task Force does not recommend population screening for vitamin D deficiency in individuals who are not at risk. Normal risk adults do not need assessment, but all adults who do not have regular effective sun exposure year round should consume at least 600 to 800 international units (units) of daily. In the general population, it is not necessary to perform broad-based screening of serum Vitamin D levels.
POLICYSerum measurement of vitamin D [25-hydroxyvitamin D [25(OH)D] is considered medically necessary up to four (4) times per calendar year for the following conditions:
Routine serum vitamin D testing is considered not medically necessary when performed for screening purposes in asymptomatic patients (absence of signs, symptoms, or disease).
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
10/01/2013: New policy added.
08/14/2015: Medical policy revised to add ICD-10 codes.
06/07/2016: Policy number L.2.04.423 added. Policy Guidelines updated to add medically necessary definition.
09/08/2016: Code Reference section updated to make correction: ICD-10 diagnosis code E70.00 should be E70.0.
09/30/2016: Code Reference section updated to add new ICD-10 diagnosis code K90.41.
10/18/2016: Code Reference section updated to make correction: ICD-10 diagnosis code K90.41 should be K90.49.
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.