Medicare Carrier Proposes No Pay for Vitamin D Test

Proposal restricts coverage for Vitamin D tests to four diseases and no allowance for screening

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CEO SUMMARY: Medicare contractor NGS wants to end payment to labs and physicians for routine Vitamin D testing. In a proposed local coverage determination (LCD), the Medicare carrier says it would cover Vitamin D testing only for patients with chronic kidney disease, osteomalacia, hypercalcemia, and rickets. All other testing for Vitamin D would be denied. Endocrinologists responded by labeling the NGS proposal as “flawed and incomplete, a factor that would shortchange current medical practice.”

EARLIER THIS MONTH, a Medicare carrier published a proposed plan to deny payment for routine Vitamin D testing. If implemented, this carrier would begin denying claims for routine testing for Vitamin D deficiency as early as June 1, 2009.

The proposal generated an immediate response in opposition from the American Clinical Laboratory Association (ACLA), based in Washington, DC. ACLA is concerned that this proposal from one Medicare carrier could spread. “We would like to put a stop to this idea before any other Medicare carriers adopt it,” said ACLA President Alan Mertz.

Medicare Contractor

National Government Services (NGS), one of the nation’s largest Medicare contractors, proposed the policy. The NGS proposal would effectively end payment to labs and physicians for routine testing for Vitamin D deficiency for Medicare patients. In its proposed local coverage determination (LCD), NGS said it would cover Vitamin D testing only for patients with chronic kidney disease, osteomalacia, hypercalcemia, and rickets. Other testing for Vitamin D would be denied.

The draft LCD, dated February 6, was posted on the NGS Web site and asked for comments through February 21. If accepted as proposed, denials for routine Vitamin D testing would begin on June 1. NGS noted in the draft that LCDs are not necessarily a reflection of the current policies or practices, meaning not all Medicare providers would be affected by the LCD that NGS posted. NGS serves 200,000 providers and suppliers, along with 24.5 million Medicare beneficiaries in 25 states and five U.S. territories.

According to Mertz, ACLA is preparing a response to the proposal. In addition, the American Association of Clinical Endocrinologists (AACE) wrote to the Medicare carrier criticizing the proposal as being based on 1980s medical research.

When a Medicare carrier adopts a change in reimbursement policy, other Medicare carriers and private payers typically follow suit. Therefore, any proposal to deny payment for routine testing for Vitamin D deficiency is a concern for all labs and physicians nationwide.

“Measurement of Vitamin D levels is indicated for patients with chronic kidney disease, osteomalacia, hypercalcemia, and rickets,” stated the draft LCD published by NCG. “Measurement of Vitamin D levels is not indicated for screening. Measurement of any other Vitamin D metabolites (CPT codes 82307 & 82652) is not indicated, and will be denied. An excess of Vitamin D is unusual, but may lead to hypercalcemia. Vitamin D deficiency may lead to a variety of disorders, the most infamous of which is rickets. Treatment of Vitamin D deficiency is relatively straightforward, negating the need for measuring Vitamin D levels in many cases. Evaluating patients’ Vitamin D levels is accomplished by measuring the level of 25- hydroxyvitamin D. Measurement of other metabolites is not medically necessary.”

Doubling of Test Volume

Over the past 24 to 36 months, the volume of Vitamin D testing nationally has exploded. (See TDR, July 28, 2009.) One reason is that patients and physicians are responding to news reports and published scientific papers about the widespread rate of Vitamin D deficiency, as well as new findings about the role Vitamin D plays in an expanding number of diseases and health conditions.

Evidence is that a substantial portion of the American population does not have adequate levels of Vitamin D. For example, about 30% of those tested at ARUP Laboratories in Salt Lake City, Utah, have a Vitamin D deficiency, according to A. Wayne Meikle, M.D., medical director of ARUP’s Encocrinology and Automated Endocrinology Laboratory.

John J. Cannell, M.D., a psychiatrist who founded The Vitamin D Council, a nonprofit organization in Atascadero, California, said, “This rule change flies in the face of an enormous amount of research, some of it published in the last few months. For example, several weeks ago, the British Journal of Cancer reported that in men with prostate cancer, those with highest Vitamin D blood levels, were seven times more likely to survive than were men with the lowest levels.”

THE DARK REPORT observes that, should this Medicare contractor successfully implement its proposed policy to deny coverage for routine testing for Vitamin D deficiency, it will likely be copied by other Medicare carriers and private health insurers. As that happens, laboratories will be placed in the position of being the gatekeeper for managing physician utilization of Vitamin D testing. The laboratory profession has been down that road before with other types of testing and it is an unsatisfactory development for labs, physicians, and patients.

Endocrinologists Act To Stop A Bad Idea

IN ITS LETTER to National Government Services (NGS) on the proposal to deny coverage for routine testing for Vitamin D deficiency, the American Association of Clinical Endocrinologists (AACE) blasted the idea as outdated thinking.

“The measurement of Vitamin D is a very important test which research offers evidence supporting expanded applications and a relationship to many disease states with readily identifiable treatment and improved prognosis,” wrote Daniel S. Duick, M.D., President of AACE. “This policy, if it goes through with its list of covered diagnosis codes that is flawed and incomplete, would undeniably short- change current medical practice, and patients who need the test will lose.

“Indeed, it appears that the draft LCD is based upon sound medical practice in the 1980s, not the 21st century,” continued Duick. “For all of these reasons, we encourage you to further review and revise the draft LCD, so the list of acceptable medical conditions is complete and includes historically accepted conditions, such as osteoporosis.”

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