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Are you billing a covered diagnosis for these tests?
October 27, 2023

This article is for physicians, clinicians, and their office staff who order:

  • Vitamin B-12 testing
  • Respiratory pathogen panels

And for clinical and hospital laboratories that conduct these tests.

Please share with your biller or billing agency.

In September, we notified you of medical policy changes that will take effect on December 1, 2023. We’re reminding you of these changes so our members receive the recommended testing.

  • Vitamin B-12 Testing medical policy 061 (new policy)
  • Pathogen Panel Testing medical policy 045 (revised policy)

Medical necessity is based on a covered diagnosis

The tests listed below aren’t covered routinely. Members must have a diagnosis that is listed in our medical policy for us to consider the tests medically necessary. If a claim is submitted for one of the tests and includes a non-covered diagnosis, the claim will deny.

Criteria and diagnosis codes

Type of test

Is considered medically necessary You can find covered diagnosis codes by
Vitamin B-12 testing For commercial and Medicare Advantage members with these conditions:
  • Inadequate intake of B-12 (malnutrition)
  • Insufficient absorption of B-12 (malabsorption)
  • Metabolic causes
  • Symptoms suggesting B-12 deficiency.
Referring to Vitamin B-12 Testing medical policy 061.

Note: This policy will be posted on December 1, 2023.
Respiratory pathogen panel tests For commercial members with these conditions when the panel has:
  • No more than 5 respiratory pathogens and
  • The individual has signs/symptoms of a respiratory infection and
  • Results will be used to guide or alter clinical management.

For Medicare Advantage members, we already use CMS’ local coverage determination criteria.

Referring to Pathogen
Panel Testing medical policy 045.

Note: This revised policy will be posted on December 1, 2023.

Thank you

Thank you for helping our members to avoid additional costs by ordering covered tests.