Vitamin D Testing AHS – G2005 Notification

Vitamin D is a precursor to steroid hormones and plays a key role in calcium absorption and mineral metabolism. Vitamin D promotes enterocyte differentiation and the intestinal absorption of calcium. Other effects include a lesser stimulation of intestinal phosphate absorption, suppression of parathyroid hormone (PTH) release, regulation of osteoblast function, osteoclast activation, and bone resorption (Pazirandeh & Burns, 2017).

Vitamin D is present in nature in two major forms. Ergocalciferol, or vitamin D2, is found in fatty fish (e.g., salmon and tuna) and egg yolks, although very few foods naturally contain significant amounts of vitamin D. Cholecalciferol, or vitamin D3, is synthesized in the skin via exposure to ultraviolet radiation present in sunlight. Some foods are also fortified with vitamin D, most notably milk and cereals (Sahota, 2014). 

BCBSNC will provide coverage for Vitamin D Testing when it is determined to be medically necessary because the medical criteria and guidelines shown below are met.

This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this medical policy. 

1. 25-hydroxyvitamin D serum testing is considered medically necessary in individuals with an underlying disease or condition which is specifically associated with vitamin D deficiency or decreased bone density (see Guideline 1 below). 
2. Testing for D2 and D3 fractions of 25-hydroxyvitamin D is considered medically necessary as part of the total 25-hydroxyvitamin D analysis. 
3. Repeat testing for serum 25-hydroxyvitamin D is considered medically necessary in individuals who have documented vitamin D deficiency, at least 12 weeks after initiation of vitamin D supplementation therapy. 
   1. Repeat testing for monitoring of supplementation therapy should not exceed 2 testing instances per year until the therapeutic goal is achieved. 
   2. Once therapeutic range has been reached, annual testing, meets coverage criteria. 
4. 1,25-dihydroxyvitamin D serum testing is considered medically necessary in the evaluation or treatment of conditions that are associated with defects in vitamin D metabolism (see Guideline 2 below).

Guideline 1: Indications that support coverage criteria for serum measurement of 25 hydroxyvitamin D are as follows:

1. Biliary cirrhosis and other specified disorders of the biliary tract
2. Blind loop syndrome
3. Celiac Disease
4. Coronary artery disease in individuals where risk of disease progression is being considered against benefits of chronic vitamin D and calcium therapy
5. Dermatomyositis 
6. Hypercalcemia, hypocalcemia or other disorders of calcium metabolism
7. Hyperparathyroidism or hypoparathyroidism 
8. Hypervitaminosis of vitamin D
9. Individuals receiving hyperalimentation
10. Intestinal malabsorption
11. Liver cirrhosis
12. Long term use of anticonvulsants, glucocorticoids and other medications known to lower vitamin D levels
13. Lymphoma 
14. Malnutrition 
15. Myalgia and other myositis not specified
16. Myopathy related to endocrine diseases
17. Obesity 
18. Osteogenesis imperfecta 
19. Osteomalacia
20. Osteopetrosis
21. Osteoporosis 
22. Pancreatic steatorrhea 
23. Primary or miliary tuberculosis
24. Psoriasis 
25. Regional enteritis
26. Renal, ureteral or urinary calculus
27. Rickets 
28. Sarcoidosis
29. Stage III-V Chronic Kidney Disease and End Stage Renal Disease
30. Systemic lupus erythematosus

Guideline 2: Indications that support medical necessity for serum testing of 1,25 dihydroxyvitamin D are as follows:

1. Disorders of calcium metabolism 
2. Familial hypophosphatemia
3. Fanconi syndrome 
4. Hyperparathyroidism or hypoparathyroidism 
5. Individuals receiving hyperalimentation
6. Neonatal hypocalcemia 
7. Osteogenesis imperfecta 
8. Osteomalacia
9. Osteopetrosis
10. Primary or miliary tuberculosis
11. Renal, ureteral or urinary calculus 
12. Rickets 
13. Sarcoidosis
14. Stage III-V Chronic Kidney Disease and End Stage Renal Disease

1,25-dihydroxyvitamin D serum testing for testing and screening of vitamin D deficiency is considered not medically necessary.

Routine screening for vitamin D deficiency with serum testing is considered investigational.

The vitamin D that is consumed or formed in the skin must then be activated, via addition of hydroxyl groups, in order to be used in metabolic processes. Two forms of activated vitamin D are found in human circulation: 25-hydroxyvitamin D (calcidiol or 25OHD) and 1,25- dihydroxyvitamin D (calcitriol). 25-hydroxyvitamin D is the predominant and most stable form, but 1,25-dihydroxyvitamin D is the metabolically active form. The initial activation step occurs in the liver, where 25OHD is synthesized, and the second hydroxyl group is added in the kidney, creating the fully activated 1,25-dihdroxy form (Sahota, 2014).

25OHD has a half-life of 15 days in the circulation, whereas 1,25-dihydroxyvitamin D has a much shorter, 15 hour, circulating half-life; consequently, measurement of serum 25OHD is generally accepted as the preferred test to evaluate an individual’s vitamin D status despite lack of standardization between methods and laboratories (Glendenning & Inderjeeth, 2012; Sahota, 2014; Scott et al., 2015).

Vitamin D deficiency typically is defined as a serum 25OHD level less than 20 ng/ml, and certain organizations consider <30 ng/ml as insufficient. Trials of vitamin D supplementation (Chapuy et al., 2002; B. Dawson-Hughes, Harris, Krall, & Dallal, 1997; Sanders et al., 2010; Trivedi, Doll, & Khaw, 2003) and the Institute of Medicine (IOM) systematic review (Ross et al., 2011) recommend maintaining the serum 25OHD concentration between 20 and 40 ng/mL (50 to 100 nmol/L), whereas other experts favor maintaining 25OHD levels between 30 and 50 ng/mL (75 to 125 nmol/L). Experts agree that levels lower than 20 ng/mL are suboptimal for skeletal health. The optimal serum 25OHD concentrations for extraskeletal health have not been established (Bess Dawson-Hughes, 2017). Approximately 15% of the U.S. pediatric population suffers from either vitamin D deficiency or insufficiency. Limited sun exposure and the use of sunscreen that prohibits creation of vitamin D by sunlight radiation in the skin contribute to low vitamin D levels (Madhusmita, 2018). Also, “vitamin D deficiency has been reported in darkskinned immigrants from warm climates to cold climates in North America and Europe (Drezner, 2017).” For example, a study by Awumey and colleagues found that Asian Indians who immigrated to the U.S. still were considered vitamin D insufficient or deficient even after the administration of 25OHD. “Thus, Asian Indians residing in the U.S. are at risk for developing vitamin D deficiency, rickets, and osteomalacia (Awumey, Mitra, Hollis, Kumar, & Bell, 1998).”

Vitamin D deficiency has been associated with important short and long-term health effects such as rickets, osteomalacia and the risk of osteoporosis (Sahota, 2014). Rickets in children can result in skeletal deformities. In adults, osteomalacia, can result in muscular weakness in addition to weak bones and osteoporosis, creating increased risk for falls and fractures (Granado-Lorencio, Blanco-Navarro, & Perez-Sacristan, 2016).

A role for vitamin D has been suggested in several other conditions and metabolic processes, such as cancer, cardiovascular disease, hypertension, diabetes, and preeclampsia, as well as others. However, conclusive evidence for vitamin D’s role in these conditions is not available (Aspray et al., 2014; Ross et al., 2011).

Certain other conditions may impact an individual’s ability to absorb or activate vitamin D, thereby resulting in vitamin D deficiency. These include, but are not limited to, celiac disease, liver cirrhosis, chronic kidney disease, and bariatric surgery. Vitamin D is fat soluble, so anything that impacts fat absorption or storage may have an effect on circulating vitamin D levels (Drezner, 2017).

According to the Institute of Medicine (IOM), routine dietary supplementation with vitamin D is recommended for most individuals. The IOM recommends a dietary allowance of 600 IU for males and females 1 - 70 years of age and 800 IU for adults 71 years and older (Ross et al., 2011), although these recommendations have been met with some criticism as being too low to adequately impact vitamin D levels in some individuals. The USPSTF recommends against daily supplementation with 400 IU or less of vitamin D3 and 1000 mg or less of calcium for the primary prevention of fractures in noninstitutionalized postmenopausal women (Moyer, 2013).

Vitamin D toxicity is very rare and occurs only when levels of 25 hydroxy-vitamin D as >500 nmol/L [>200 ng/mL], well above the level considered to be sufficient. Vitamin D toxicity may cause hypercalciuria, hypercalcemia, renal stones, renal calcification with renal failure (Moyer, 2013).

Analytical Validity

Serum or plasma concentration of 25OHD can be measured using a number of assays, including ELISA, radioimmunoassay (RIA), mass spectrometry, and HPLC. Assays using LC-MS/MS can differentiate between D2 and D3. These methods “can individually quantitate and report both analytes, in addition to providing a total 25-hydroxyvitamin D concentration (Krasowski, 2011).” RIA-based assays for 25OHD can have intra- and interassay variations of 8 – 15%, and the IDSdeveloped RIA has a reported 100% specificity for D3 and 75% for D2 (Holick, 2009). “For most HPLC and LC-MS/MS methods extraction and procedural losses are corrected for by the inclusion of an internal standard which, in part, may account for higher results compared to immunoassay (Wallace, Gibson, de la Hunty, Lamberg-Allardt, & Ashwell, 2010).” Even though LC-MS/MS is considered to be the gold standard of measuring 25OHD and its metabolites, only approximately 20% of labs report using it (Avenell, Bolland, & Grey, 2018). One study reports that 46% of samples measured using LC-MS/MS were classified as vitamin D-deficient whereas, when the samples were measured using an immunoassay method, 69% were vitamin D-deficient (<30 nmol/L) (Annema, Nowak, von Eckardstein, & Saleh, 2018).

Clinical validity and utility

A retrospective study of 32,363 tests of serum 25OHD found that “A significant proportion of the requests was unjustified by clinical or biochemical criteria”, and “that clinical and biochemical criteria may be necessary to justify vitamin D testing but not sufficient to indicate the presence of vitamin D deficiency” (Granado-Lorencio et al., 2016).

The table below lists the criteria used for vitamin D testing in the study by Granado-Lorencio et al. 

Clinical conditions

• Differential diagnosis (i.e. hypercalcemia)
• Undernourished subjects
• Malabsorption syndromes (i.e. celiac disease, Chron's disease, radiation enteritis)
• Eating disorders (i.e. morbid obesity, anorexia and bulimia)
• Candidates for bariatric surgery
• Conditions associated with altered calcium, phosphorus or vitamin D metabolism (i.e. osteroperosis, rickets, renal disease, liver failure, multiple mieloma, sarcoidosis, hyper/hypoparathyroidism, liver and kidney transplants)
• Diseases related to low or null sun exposure (i.e. lupus, prophyria)
• Vitamin-D related inborn errors of metabolism

Therapeutic criteria

• Pharmacotherapy associated with increased vitamin D catabolism (i.e. antiseizure drugs, glucocorticoids)
• Treatment for AIDS and tuberculosis
• Monitorization of vitamin D treatment

Biochemical indicators

• Alterations of serum or urine levels of calcium and phosphorus
• Elevation of alkaline phosphatase (in the absence of altered liver enzymes or growth)
• Serum levels of parathyroid hormone out of the reference range (14-72 pg/mL)
• Previous (<6 months) serum values of 25-OH-vitamin D out of the reference interval (<37.5 or >160 nmol/L)

A meta-analysis study by Bolland and colleagues of 81 randomized controlled trials with a combined total of 53,537 participants measured the effects, if any, vitamin D supplementation had on fractures, falls, and bone density. They found that there was no clinically relevant difference in bone mineral density at any site between the control and experimental groups; moreover, “for total fracture and falls, the effect estimate lay within the futility boundary for relative risks of 15%, 10%, 7·5%, and 5% (total fracture only), suggesting that vitamin D supplementation does not reduce fractures or falls by these amounts… Our findings suggest that vitamin D supplementation does not prevent fractures or falls, or have clinically meaningful effects on bone mineral density. There were no differences between the effects of higher and lower doses of vitamin D. There is little justification to use vitamin D supplements to maintain or improve musculoskeletal health. This conclusion should be reflected in clinical guidelines (Bolland, Grey, & Avenell, 2018).”

State and Federal Regulations, as applicable

A search of the FDA Device database on 10/25/2018 for “vitamin D” yielded 39 results. Additionally, many labs have developed specific tests that they must validate and perform in house. These laboratory-developed tests (LDTs) are regulated by the Centers for Medicare and Medicaid (CMS) as high-complexity tests under the Clinical Laboratory Improvement Amendments of 1988 (CLIA ’88). As an LDT, the U. S. Food and Drug Administration has not approved or cleared this test; however, FDA clearance or approval is not currently required for clinical use.

Guidelines and Recommendations

The Endocrine Society (Holick et al., 2011)

The Endocrine Society recommends serum testing of 25-hydroxyvitamin D for evaluation of vitamin D status in individuals who are at risk of deficiency, including those with osteoporosis, obesity, or a history of falls. 1,25-dihydroxyvitamin D testing is not recommended for screening of at-risk individuals, due to its very short half-life in circulation, but is recommended for a few conditions in which formation of the 1,25-dihdroxy form may be impaired (Holick et al., 2011). 

Institute of Medicine (Ross et al., 2011)

After an extensive evaluation of published studies and testimony from investigators, the Institute of Medicine determined that supplementation with vitamin D is appropriate; however, guidelines regarding the use of serum markers of vitamin D status for medical management of individual patients and for screening were beyond the scope of the Committee’s charge, and evidence-based consensus guidelines are not available (Ross et al., 2011).

National Osteoporosis Society (Aspray et al., 2014)

The National Osteoporosis Society recommends the measurement of serum 25 (OH) vitamin D (25OHD) to estimate vitamin D status in the following clinical scenarios: bone diseases that may be improved with vitamin D treatment; bone diseases, prior to specific treatment where correcting vitamin D deficiency is appropriate; musculoskeletal symptoms that could be attributed to vitamin D deficiency. The guideline also states that routine vitamin D testing is unnecessary where vitamin D supplementation with an oral antiresorptive treatment is already planned and sets the following serum 25OHD thresholds: <30 nmol/l is deficient; 30-50 nmol/l may be inadequate in some people; >50 nmol/l is sufficient for almost the whole population (Aspray et al., 2014).

United States Preventive Services Task Force (LeFevre, 2015; Moyer, 2013; USPSTF, 2018)

The USPSTF recently issued the guideline Vitamin D, Calcium, or Combined Supplementation for the Primary Prevention of Fractures in Community-Dwelling Adults, which recommends the following:

“The USPSTF concludes that the current evidence is insufficient to assess the balance of the benefits and harms of vitamin D and calcium supplementation, alone or combined, for the primary prevention of fractures in community-dwelling, asymptomatic men and premenopausal women. (I statement) The USPSTF concludes that the current evidence is insufficient to assess the balance of the benefits and harms of daily supplementation with doses greater than 400 IU of vitamin D and greater than 1000 mg of calcium for the primary prevention of fractures in communitydwelling, postmenopausal women. (I statement) The USPSTF recommends against daily supplementation with 400 IU or less of vitamin D and 1000 mg or less of calcium for the primary prevention of fractures in community-dwelling, postmenopausal women. (D recommendation) These recommendations do not apply to persons with a history of osteoporotic fractures, increased risk for falls, or a diagnosis of osteoporosis or vitamin D deficiency (USPSTF, 2018).”

In the 2013 update to the USPSTF recommendation concerning the use of vitamins for the primary prevention of cardiovascular disease and cancer, they concluded that there was insufficient evidence to assess the efficacy of multivitamins, including those containing vitamin D, in the prevention of cardiovascular disease or cancer (Moyer, 2013).

The USPSTF published their recommendation concerning screening of vitamin D deficiency in asymptomatic community-dwelling, nonpregnant adults in 2015. “The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for vitamin D deficiency in asymptomatic adults. (I statement) (LeFevre, 2015)” It should be noted that this guideline is currently undergoing review in 2018.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic and Bariatric Surgery (Mechanick et al., 2013)

Minimal daily nutritional supplementation for patients with RYGB and LSG all in chewable form initially should be at least 3000 international units of vitamin D (titrated to therapeutic 25- hydroxyvitamin D levels >30 ng/ml). Minimal daily nutritional supplementation for patients with LAGB should include at least 3000 international units of vitamin D (titrated to therapeutic 25- dihydroxyvitamin D levels). “Alternatively, in lieu of routine screening with relatively costly biochemical testing, the above routine micronutrient supplementation may be initiated preoperatively (Mechanick et al., 2013).”

American Academy of Pediatrics (Golden & Abrams, 2014)

“Evidence is insufficient to recommend universal screening for vitamin D deficiency… In the absence of evidence supporting the role of screening healthy individuals at risk for vitamin D deficiency in reducing fracture risk and the potential costs involved, the present AAP report advises screening for vitamin D deficiency only in children and adolescents with conditions associated with reduced bone mass and/or recurrent low-impact fractures. More evidence is needed before recommendations can be made regarding screening of healthy black and Hispanic children or children with obesity. The recommended screening is measuring serum 25-OH-D concentration, and it is important to be sure this test is chosen instead of measurement of the 1,25-OH2-D concentration, which has little, if any, predictive value related to bone health (Golden & Abrams, 2014).”

American College of Obstetricians and Gynecologists (ACOG, 2011) (and reaffirmed in 2017)

“At this time, there is insufficient evidence to support a recommendation for screening all pregnant women for vitamin D deficiency. For pregnant women thought to be at increased risk of vitamin D deficiency, maternal serum 25-hydroxyvitamin D levels can be considered and should be interpreted in the context of the individual clinical circumstance (ACOG, 2011).”

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable service codes: 82606, 82652

ACOG. (2011). ACOG Committee Opinion No. 495: Vitamin D: Screening and supplementation during pregnancy. Obstet Gynecol, 118(1), 197-198. doi:10.1097/AOG.0b013e318227f06b

Annema, W., Nowak, A., von Eckardstein, A., & Saleh, L. (2018). Evaluation of the new restandardized Abbott Architect 25-OH Vitamin D assay in vitamin D-insufficient and vitamin Dsupplemented individuals. J Clin Lab Anal, 32(4), e22328. doi:10.1002/jcla.22328

Aspray, T. J., Bowring, C., Fraser, W., Gittoes, N., Javaid, M. K., Macdonald, H., Francis, R. M. (2014). National Osteoporosis Society vitamin D guideline summary. Age Ageing, 43(5), 592- 595. doi:10.1093/ageing/afu093

Avenell, A., Bolland, M. J., & Grey, A. (2018). 25-Hydroxyvitamin D - Should labs be measuring it? Ann Clin Biochem, 4563218796858. doi:10.1177/0004563218796858

Awumey, E. M., Mitra, D. A., Hollis, B. W., Kumar, R., & Bell, N. H. (1998). Vitamin D metabolism is altered in Asian Indians in the southern United States: a clinical research center study. J Clin Endocrinol Metab, 83(1), 169-173. doi:10.1210/jcem.83.1.4514

Bolland, M. J., Grey, A., & Avenell, A. (2018). Effects of vitamin D supplementation on musculoskeletal health: a systematic review, meta-analysis, and trial sequential analysis. Lancet Diabetes Endocrinol. doi:10.1016/s2213-8587(18)30265-1 

Chapuy, M. C., Pamphile, R., Paris, E., Kempf, C., Schlichting, M., Arnaud, S., Meunier, P. J. (2002). Combined calcium and vitamin D3 supplementation in elderly women: confirmation of reversal of secondary hyperparathyroidism and hip fracture risk: the Decalyos II study. Osteoporos Int, 13(3), 257-264. doi:10.1007/s001980200023

Dawson-Hughes, B. (2017). Vitamin D deficiency in adults: Definition, clinical manifestations, and treatment - UpToDate. In J. Mulder (Ed.), UpToDate. Waltham, MA: UptoDate. Retrieved from https://www.uptodate.com/contents/vitamin-d-deficiency-in-adults-definition-clinicalmanifestations-and-treatment?source=see_link.

Dawson-Hughes, B., Harris, S. S., Krall, E. A., & Dallal, G. E. (1997). Effect of calcium and vitamin D supplementation on bone density in men and women 65 years of age or older. N Engl J Med, 337(10), 670-676. doi:10.1056/nejm199709043371003

Drezner, M. (2017, 10/23/2017). Causes of vitamin D deficiency and resistance - UpToDate. UpToDate. Retrieved from https://www.uptodate.com/contents/causes-of-vitamin-d-deficiencyand-resistance

Glendenning, P., & Inderjeeth, C. A. (2012). Vitamin D: methods of 25 hydroxyvitamin D analysis, targeting at risk populations and selecting thresholds of treatment. Clin Biochem, 45(12), 901-906. doi:10.1016/j.clinbiochem.2012.04.002

Golden, N. H., & Abrams, S. A. (2014). Optimizing bone health in children and adolescents. Pediatrics, 134(4), e1229-1243. doi:10.1542/peds.2014-2173

Granado-Lorencio, F., Blanco-Navarro, I., & Perez-Sacristan, B. (2016). Criteria of adequacy for vitamin D testing and prevalence of deficiency in clinical practice. Clin Chem Lab Med, 54(5), 791-798. doi:10.1515/cclm-2015-0781

Holick, M. F. (2009). Vitamin D status: measurement, interpretation, and clinical application. Ann Epidemiol, 19(2), 73-78. doi:10.1016/j.annepidem.2007.12.001

Holick, M. F., Binkley, N. C., Bischoff-Ferrari, H. A., Gordon, C. M., Hanley, D. A., Heaney, R. P., . . . Weaver, C. M. (2011). Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab, 96(7), 1911-1930. doi:10.1210/jc.2011-0385

Krasowski, M. D. (2011). Pathology Consultation on Vitamin D Testing. American Journal of Clinical Pathology $V 136(4), 507-514.

LeFevre, M. L. (2015). Screening for vitamin D deficiency in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med, 162(2), 133-140. doi:10.7326/m14-2450

Madhusmita, M. (2018, 08/24/2018). Vitamin D insufficiency and deficiency in children and adolescents. UpToDate. Retrieved from https://www.uptodate.com/contents/vitamin-dinsufficiency-and-deficiency-in-children-and-adolescents

Mechanick, J. I., Youdim, A., Jones, D. B., Garvey, W. T., Hurley, D. L., McMahon, M. M., Brethauer, S. (2013). Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery. Endocr Pract, 19(2), 337-372. doi:10.4158/ep12437.gl

Moyer, V. A. (2013). Vitamin D and calcium supplementation to prevent fractures in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med, 158(9), 691-696. doi:10.7326/0003-4819-158-9-201305070-00603

Pazirandeh, S., & Burns, D. (2017). Overview of vitamin D - UpToDate. In J. Mulder (Ed.), UpToDate. Waltham, MA: UptoDate. Retrieved from https://www.uptodate.com/contents/overview-of-vitamin-d?source=history_widget.

Ross, A. C., Manson, J. E., Abrams, S. A., Aloia, J. F., Brannon, P. M., Clinton, S. K., . . . Shapses, S. A. (2011). The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. J Clin Endocrinol Metab, 96(1), 53- 58. doi:10.1210/jc.2010-2704

Sahota, O. (2014). Understanding vitamin D deficiency. In Age Ageing (Vol. 43, pp. 589-591). England.

Sanders, K. M., Stuart, A. L., Williamson, E. J., Simpson, J. A., Kotowicz, M. A., Young, D., & Nicholson, G. C. (2010). Annual high-dose oral vitamin D and falls and fractures in older women: a randomized controlled trial. Jama, 303(18), 1815-1822. doi:10.1001/jama.2010.594

Scott, M. G., Gronowski, A. M., Reid, I. R., Holick, M. F., Thadhani, R., & Phinney, K. (2015). Vitamin D: the more we know, the less we know. Clin Chem, 61(3), 462-465. doi:10.1373/clinchem.2014.222521

Trivedi, D. P., Doll, R., & Khaw, K. T. (2003). Effect of four monthly oral vitamin D3 (cholecalciferol) supplementation on fractures and mortality in men and women living in the community: randomised double blind controlled trial. Bmj, 326(7387), 469. doi:10.1136/bmj.326.7387.469

USPSTF. (2018). Vitamin D, calcium, or combined supplementation for the primary prevention of fractures in community-dwelling adults: US preventive services task force recommendation statement. Jama, 319(15), 1592-1599. doi:10.1001/jama.2018.3185

Wallace, A. M., Gibson, S., de la Hunty, A., Lamberg-Allardt, C., & Ashwell, M. (2010). Measurement of 25-hydroxyvitamin D in the clinical laboratory: current procedures, performance characteristics and limitations. Steroids, 75(7), 477-488. doi:10.1016/j.steroids.2010.02.012 

1/1/19 New policy developed. BCBSNC will provide coverage for Vitamin D Testing when it is determined to be medically necessary because the medical criteria and guidelines are met. Medical Director review 1/1/2019. Policy noticed 1/1/2019 for effective date 4/1/2019. (an)