SUPERCEDED LCD: Centers for Medicare & Medicaid Services

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Contractor Information

Contractor Name ^{back to top}

Palmetto GBA
Contractor Number ^{back to top}
00380
Contractor Type ^{back to top}
FI

LCD Information

LCD ID Number ^{back to top}

L26125

LCD Title ^{back to top}
Vitamin B12 (Cyanocobalamin) Chemistry Test

Contractor's Determination Number ^{back to top}
07A-0008-L

AMA CPT / ADA CDT Copyright Statement ^{back to top}
CPT codes, descriptions and other data only are copyright 2009 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy ^{back to top}
Title XVIII of the Social Security Act, §1862(a)(7) excludes routine physical examinations. Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. CMS Manual System, Pub 100-08, Medicare Program Integrity, Transmittal 63, dated January 23, 2004, Change Request 3010

Primary Geographic Jurisdiction ^{back to top}
South Carolina

Oversight Region ^{back to top}
Region IV

Original Determination Effective Date ^{back to top}
For services performed on or after 01/07/2008

Original Determination Ending Date ^{back to top}


Revision Effective Date ^{back to top}
For services performed on or after 02/12/2009

Revision Ending Date ^{back to top}
10/22/2009

Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
The serum cyanocobalamin is a quantitative analysis of serum Vitamin B12 levels. It is generally indicated in the evaluation of megaloblastic anemias whose cause is unknown, and in patients with malabsorptive states. Cyanocobalamin testing is indicated when a macrocytic anemia is suspected using blood indices, especially when the MCV (mean corpuscular volume) is increased above 110fL (femtolitres). Testing is indicated only for megaloblastic anemias, and in dementias or neuropathies thought to be secondary to B12 deficiencies. Sequential cyanocobalamin testing is usually unnecessary to monitor the effects of Vitamin B12 therapy. Since cyanocobalamin is given to treat the macrocytic anemia, tests normally used to monitor anemia such as hemoglobin or hematocrit should be used.

Coding Information

Bill Type Codes: ^{back to top}

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

12x	Hospital-inpatient or home health visits (Part B only)
13x	Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)
14x	Non-Patient Laboratory Specimens
18x	Hospital-swing beds
21x	SNF-inpatient, Part A
22x	SNF-inpatient or home health visits (Part B only)
23x	SNF-outpatient (HHA-A also)
71x	Clinic-rural health
73x	Clinic-independent provider based FQHC (eff 10/91)
85x	Special facility or ASC surgery-rural primary care hospital (eff 10/94)

Revenue Codes: ^{back to top}

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

030X	Laboratory-general classification

CPT/HCPCS Codes ^{back to top}

82607 CYANOCOBALAMIN (VITAMIN B-12);

ICD-9 Codes that Support Medical Necessity ^{back to top}

123.4	DIPHYLLOBOTHRIASIS INTESTINAL
151.0 - 151.9	MALIGNANT NEOPLASM OF CARDIA - MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE
266.2	OTHER B-COMPLEX DEFICIENCIES
269.9	UNSPECIFIED NUTRITIONAL DEFICIENCY
270.4	DISTURBANCES OF SULPHUR-BEARING AMINO-ACID METABOLISM
281.0	PERNICIOUS ANEMIA
281.1	OTHER VITAMIN B12 DEFICIENCY ANEMIA
281.3	OTHER SPECIFIED MEGALOBLASTIC ANEMIAS NOT ELSEWHERE CLASSIFIED
281.9	UNSPECIFIED DEFICIENCY ANEMIA
285.9	ANEMIA UNSPECIFIED
289.6	FAMILIAL POLYCYTHEMIA
294.10 - 294.11	DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITHOUT BEHAVIORAL DISTURBANCE - DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITH BEHAVIORAL DISTURBANCE
354.8 - 354.9	OTHER MONONEURITIS OF UPPER LIMB - MONONEURITIS OF UPPER LIMB UNSPECIFIED
355.8 - 355.9	MONONEURITIS OF LOWER LIMB UNSPECIFIED - MONONEURITIS OF UNSPECIFIED SITE
356.9	UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY
357.4	POLYNEUROPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE
458.0	ORTHOSTATIC HYPOTENSION
529.0	GLOSSITIS
529.4	ATROPHY OF TONGUE PAPILLAE
529.6	GLOSSODYNIA
535.10 - 535.11	ATROPHIC GASTRITIS (WITHOUT HEMORRHAGE) - ATROPHIC GASTRITIS WITH HEMORRHAGE
555.0 - 555.9	REGIONAL ENTERITIS OF SMALL INTESTINE - REGIONAL ENTERITIS OF UNSPECIFIED SITE
564.2	POSTGASTRIC SURGERY SYNDROMES
577.1	CHRONIC PANCREATITIS
579.0 - 579.9	CELIAC DISEASE - UNSPECIFIED INTESTINAL MALABSORPTION
751.1	CONGENITAL ATRESIA AND STENOSIS OF SMALL INTESTINE
780.09	ALTERATION OF CONSCIOUSNESS OTHER
780.4	DIZZINESS AND GIDDINESS
780.93	MEMORY LOSS
781.3	LACK OF COORDINATION
782.0	DISTURBANCE OF SKIN SENSATION
V44.2	ILEOSTOMY STATUS
V44.4	STATUS OF OTHER ARTIFICIAL OPENING OF GASTROINTESTINAL TRACT
V45.3	POSTSURGICAL INTESTINAL BYPASS OR ANASTOMOSIS STATUS
V45.89	OTHER POSTSURGICAL STATUS

Diagnoses that Support Medical Necessity ^{back to top}

N/A

ICD-9 Codes that DO NOT Support Medical Necessity ^{back to top}

N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation ^{back to top}

Diagnoses that DO NOT Support Medical Necessity ^{back to top}

N/A

General Information

Documentation Requirements ^{back to top}

Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record, and must be made available to the Intermediary upon request.

Appendices ^{back to top}

N/A

Utilization Guidelines ^{back to top}

N/A

Sources of Information and Basis for Decision ^{back to top}

Teitz N. The Clinical Guide to Laboratory Tests. 2nd ed.

Davis FA. Wildmann’s Clinical Interpretation of Laboratory Tests. 10th ed.

Clinical Laboratory Tests: Values and Implications. Springhouse Corp. 2nd ed. 1995.

Local Coverage Determination, 98NC-002-L, Vitamin B12 (Cyanocobalamin) Chemistry Test, FI, North Carolina

Advisory Committee Meeting Notes ^{back to top}

This policy does not reflect the sole opinion of the Contractor or Contractor Medical Director. Although the final decision rests with the Intermediary, this policy was developed in cooperation with advisory groups, which include representatives from the affected provider community. Advisory Committee Meeting Date: N/A.

Start Date of Comment Period ^{back to top}

08/23/2007

End Date of Comment Period ^{back to top}

10/08/2007

Start Date of Notice Period ^{back to top}

11/21/2007

Revision History Number ^{back to top}

Revision #3, 02/12/2009
Revision #2, 08/28/2008
Revision #1, 01/07/2008

Revision History Explanation ^{back to top}

Revsion #3, 02/12/2009
Under ICD-9 Codes That Support Medical Necessity section ICD-9 code 780.93 has been added. This revision becomes effective on 02/12/2009.

Revision #2, 08/28/2008
This LCD has had its annual validation. No changes were made. This revision becomes effective on 08/28/2008.

Revision #1, 01/07/2008
Under AMA/CPT & ADA/CDT Copyright Statement changed the copyright date from 2006 to 2007. No comments were received during the comment period. The notice period becomes effective 11/21/2007. This policy becomes effective 01/07/2008.

Reason for Change ^{back to top}

ICD9 Addition/Deletion
Maintenance (annual review with new changes, formatting, etc.)

Last Reviewed On Date ^{back to top}

02/02/2009

Medicare Coverage Database

LCD for Vitamin B12 (Cyanocobalamin) Chemistry Test (L26125)