Clinical UM Guideline

This document addresses routine testing of serum vitamin D levels in adults and children, in the absence of clinical signs and symptoms of vitamin D deficiency or intoxication or conditions for which vitamin D supplementation may be recommended. Vitamin D testing is a non-invasive blood test which can aid in the identification and clinical management of individuals at-risk for vitamin D deficiency. This document does not address testing for vitamin D in individuals who exhibit clinical manifestations or risk factors of vitamin D deficiency or toxicity.

Not Medically Necessary:

Testing vitamin D levels in individuals with no known signs or symptoms of vitamin D deficiency or intoxication nor conditions for which vitamin D treatment is recommended is considered not medically necessary.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Not Medically Necessary:
When the code describes a procedure specified in the Clinical Indications section as not medically necessary.

Vitamin D is normally an endogenously produced, fat-soluble vitamin; endogenous synthesis is prompted by ultraviolet rays on the skin which triggers synthesis of this essential vitamin. Vitamin D is naturally present in a limited number of foods and is available as a dietary supplement. Whether obtained from food, supplements, or exposure to ultraviolet rays, vitamin D must undergo further synthesis in the liver and kidneys to be converted from an inert form to an activated form useful for the body’s vital functions, aiding functions in calcium absorption for bone strengthening, modulation of cell growth, and neuromuscular and immune functions. Due to the complexity in the synthesis of vitamin D, there is misunderstanding in the medical community regarding the best indicators for vitamin D deficiency. For instance, measurement of 1,25-dihydroxyvitamin, or calcitriol (produced by the kidneys), is commonplace for vitamin D deficiency testing; however, it is a poor indictor due to its efficient regulation by other vitamin and hormone levels as well as its relatively short half-life (15 hours). Generally, calcitriol levels do not decrease markedly unless an individual has a severe deficiency in vitamin D. Conversely, serum measurement of 25-hydroxyvitamin D, or calcidiol (produced by the liver), is a much more reliable indicator of vitamin D status. Although levels of calcidiol also do not correlate significantly with Vitamin D stores, it is a reflection of serum circulating levels of cutaneously produced and ingested vitamin D with a half-life averaging 15 days. Unfortunately, there is considerable disagreement regarding the serum levels of calcidiol (25-hydroxyvitamin D) that are indicative of deficiency warranting intervention, such as dietary supplementation. Further complicating medical management of Vitamin D deficiency, is the wide variability that exists in laboratory analysis methods. There are also health risks associated with excessive vitamin D levels and vitamin D toxicity, such as anorexia, weight loss, polyuria, kidney stones, and heart arrhythmias. Toxicity is most likely to result from over-supplementation (National Institutes of Health [NIH], 2016).

Despite the uncertainty that remains in clinical practice regarding not only the clinical benefit of vitamin D serum testing, but even the definition of vitamin D deficiency, screening of asymptomatic, average-risk individuals (e.g., non-pregnant, community dwelling adults without osteoporosis or chronic kidney disease), remains commonplace. A study evaluating data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey found that diagnosis for vitamin D deficiency more than tripled between 2008 and 2010 (383 in 2008 vs. 1177 visits per 100,000 population in 2010) (Huang, 2014).

The U.S. Preventive Services Task Force (USPSTF) has rated the current medical evidence insufficient to assess the balance of benefits and harms of screening for vitamin D deficiency in asymptomatic adults. This recommendation is specified to be applicable to “community-dwelling, non-pregnant adults aged 18 years or older who are seen in primary care settings and are not known to have signs or symptoms of vitamin D deficiency or conditions for which vitamin D treatment is recommended” (USPSTF, 2021).

The Endocrine Society published clinical practice guideline recommendations in 2011, which contain the following statement related to screening for vitamin D deficiency in both children and adults, “We recommend screening for vitamin D deficiency in individuals at risk for deficiency. We do not recommend population screening for vitamin D deficiency in individuals who are not at risk.” This recommendation is based on the Endocrine Society’s highest level of evidence and the rating denoted as ‘strong’, meaning the Task Force has confidence that individuals who receive care according to the recommendation “will derive, on average, more good than harm” (Holick, 2011).

The American Society of Clinical Pathology (ASCP, 2020) contributed the following recommendation to Choosing Wisely^®:

Vitamin D deficiency is common in many populations, particularly in patients at higher latitudes, during winter months and in those with limited sun exposure. Over the counter Vitamin D supplements and increased summer sun exposure are sufficient for most otherwise healthy patients. Laboratory testing is appropriate in higher risk patients when results will be used to institute more aggressive therapy (e.g., osteoporosis, chronic kidney disease, malabsorption, some infections, obese individuals).

In summary, there are a number of conditions, some of which are aforementioned, that would place individuals at risk for development of vitamin D deficiency and merit testing of vitamin D levels for screening and management. According to the Endocrine Society’s (Holick, 2011) recommendations, infants who may be at risk for vitamin D deficiency include those who are breast-fed without vitamin D supplementation, have darker pigmented skin, and those with maternal vitamin D deficiency. Adults may be at higher risk for vitamin D deficiency if their outdoor activities are greatly limited (for example, those who are institutionalized or the elderly), if they practice aggressive sun protection measures or if living in an area considered high risk. Pregnancy, lactation, obesity and certain medication regiments are additional circumstances that may place individuals at high risk for vitamin D deficiency and may warrant screening, supplementation and on-going clinical management. However, based on the current evidence and consensus recommendations, screening for vitamin D deficiency in average-risk, asymptomatic adults and children, is not recommended.

Endogenous: To be produced or synthesized within an organism or system.

Screening: Examination of a group to separate well persons from those who have an undiagnosed pathologic condition or who are at high risk.

Peer Reviewed Publications:

1. Huang KE, Milliron BJ, Davis SA, Feldman SR. Surge in US outpatient vitamin D deficiency diagnoses: National Ambulatory Medical Care Survey analysis. South Med J. 2014; 107(4):214-217.
2. LeBlanc ES, Zakher B, Daeges M, et al. Screening for vitamin D deficiency: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2015; 162(2):109-122.
3. Rockwell M, Kraak V, Hulver M, Epling J. Clinical management of low vitamin D: a scoping review of physicians' practices. Nutrients. 2018. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5946278/. Accessed on June 19, 2023.
4. Yayla Ç, Kurek M, Turan I, et al. Association between maternal circulating 25 hydroxyvitamin D concentration and placental volume in the first trimester. J Matern Fetal Neonatal Med. 2017; 30(24):2944-2950.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Society for Clinical Pathology. Choosing Wisely: Fifteen things physicians and patients should question. Updated September 2020. Available at: https://www.ascp.org/content/docs/default-source/get-involved-pdfs/istp_choosingwisely/ascp-35-things-list_2020_final.pdf. Accessed on June 19, 2023. 
2. Endocrine Society. Choosing Wisely: Five things physicians and patients should question. Reviewed 2017. Available at: https://www.mainlinehealth.org/-/media/files/pdf/basic-content/physicians/mlhpp/choosing-wisely/endocrine-society--choosing-wisely.pdf?la=en. Accessed on June 19, 2023.
3. Holick MF, Binkley NC, Bischoff-Ferrari HA, et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011; 96(7):1911-1130.
4. Kahwati LC, LeBlanc E, Weber RP, et al. Screening for Vitamin D Deficiency in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2021; 325(14):1443-1463.
5. US Preventive Services Task Force, Krist AH, Davidson KW, et al. Screening for Vitamin D Deficiency in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2021; 325(14):1436-1442.

1. National Institutes of Health (NIH) Office of Dietary Supplements. Vitamin D: Fact sheet for health professionals. Updated on June 02, 2022. Available at: https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/. Accessed on June 19, 2023.

This Clinical UM Guideline is intended to provide assistance in interpreting Healthy Blue’s standard Medicaid benefit plan. When evaluating insurance coverage for the provision of medical care, federal, state and/or contractual requirements must be referenced, since these may limit or differ from the standard benefit plan. In the event of a conflict, the federal, state and/or contractual requirements for the applicable benefit plan coverage will govern. Healthy Blue reserves the right to modify its Policies and Guidelines as necessary and in accordance with legal and contractual requirements. This Clinical UM Guideline is provided for informational purposes. It does not constitute medical advice. Healthy Blue may also use tools and criteria developed by third parties, to assist us in administering health benefits. Healthy Blue’s Policies and Guidelines are intended to be used in accordance with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.