84591
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Clinical documentation supporting suspicion of micronutrient deficiency (history, signs/symptoms, risk factors).
- Serum laboratory results using standardized reference values demonstrating deficient or abnormal levels for the specific micronutrient(s) tested.
- Specification of which micronutrient(s) are being tested when multinutrient panels are ordered.
- Laboratory documentation demonstrating CLIA certification for high-complexity testing.
Key Coverage Criteria
- None — Intracellular micronutrient analysis (functional intracellular/essential metabolic analysis) is considered experimental, investigational and/or unproven and not covered.
- Screening for nutritional deficiencies by measuring intracellular levels of micronutrients in otherwise healthy individuals.
- Evaluation to aid diagnosis of nutritional deficiencies or related disease in patients with chronic illness or nonspecific symptoms.
- Serum testing of individual micronutrients to confirm suspected clinical micronutrient deficiency states (e.g., vitamins A, B1, B12, C, D, selenium).
- Commercial laboratory vitamin/mineral panels using serum analysis when clinical suspicion warrants multinutrient assessment.
- Intracellular micronutrient testing is medically relevant when it provides information that leads to a clinical management decision that improves the net health outcome.
5 Active Policies
MED207.088 — Intracellular Micronutrient Analysis
BCBSIL-MED207.088 — Intracellular Micronutrient Analysis
BCBSMT-MED207.088 — Intracellular Micronutrient Analysis
BCBSNM-MED207.088 — Intracellular Micronutrient Analysis
BCBSOK-MED207.088 — Intracellular Micronutrient Analysis
Related Codes
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