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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
The rules say that the term heavy metal testing is historically used to describe elements such as lead, arsenic, 
mercury, cadmium, and chromium. In general, all of the heavy metals in inorganic form cause GI irritation, 
resulting in nausea, vomiting, abdominal pain and diarrhea. The next most consistent toxicity for the heavy 
metals as a group, but not for every heavy metal, is renal toxicity. A further generalization is that each member 
of the heavy metal group tends to cause multi-organ toxicity. Many metals cause cutaneous abnormalities, such 
as irritant and allergic contact dermatitis, urticaria, keratoses, and premalignant and malignant lesions. Several 
of the heavy metals produce central and peripheral nervous system toxicity. Other metals cause pulmonary 
illness. 
 
However, before any testing for heavy metal is ordered, a detailed medical history of the patient must be 
obtained, including a careful documentation of occupational and avocational exposure to these toxins. A 
complete physical examination must be done. While classified as heavy metals, this policy does not include 
iron or lithium since the former is typically tested for anemia issues, discussed in National Coverage 
Determination 110.10 (Intravenous Iron Therapy), and the latter is typically tested for monitoring of 
medications. In addition, iron testing is covered under the National Coverage Determination 190.18 (Serum 
Iron Studies). 
 
1. Aluminum. Serum aluminum testing is payable for beneficiaries who have been on dialysis with evidence 
suggesting aluminum toxicity, or for beneficiaries with chronic industrial exposure history 
2. Antimony. Serum and/or urine antimony testing is payable for beneficiaries with documented treatment in 
the past with antileishmaniasis agents or with documented chronic antimony industrial exposure history. 
3. Arsenic. Serum and whole blood and/or urine arsenic testing is payable for beneficiaries with unexplained peripheral neuropathies, industrial exposure to arsenic, histories of arsenic pesticide exposure, unexplained 
encephalopathies, unexplained weight loss, chronic glomerulonephritis, bone marrow hypoplasia, or melanosis 
of skin, unexplained chronic diarrhea, persistent abdominal pain, or nausea and vomiting. 
4. Barium. Serum and or/urine barium testing is payable for beneficiaries with pulmonary disease with 
industrial exposure to barium or unexplained flaccid paralysis. 
5. Beryllium. Serum and/or urine beryllium testing is payable for beneficiaries with pulmonary disease with 
industrial exposure to beryllium. 
6. Bismuth. Serum and/or urine bismuth testing is payable for beneficiaries with bismuth lines on their gums, 
methemoglobinemia, unexplained pathological fractures, or a history of bismuth medicine abuse. 
7. Cadmium. Serum and whole blood and/or urine cadmium testing is payable for beneficiaries with an 
exposure to cadmium with evidence of pulmonary disease or unexplained renal failure. 
8. Chromium. Serum chromium testing is payable for beneficiaries with an industrial exposure to chromium 
with evidence of pulmonary disease. 
9. Cobalt. Serum cobalt testing is payable for beneficiaries with an industrial exposure to cobalt with evidence 
of pulmonary disease 
10. Copper. Serum copper testing is payable for beneficiaries with an industrial exposure to copper with 
evidence of pulmonary disease, for beneficiaries with Wilson's Disease, unexplained cardiomyopathy, 
unexplained renal failure, polycythemia. unexplained myelodysplastic syndrome or known ingestion of zinc. 
11. Lead. Blood (serum and whole) and/or urine lead testing is covered if there is documented industrial 
exposure to lead, documented avocation exposure to lead, retained bullet fragments at or near joints, a blue 
gum line, a history of moonshine abuse, unexplained peripheral neuropathies, evidence of lead contaminated 
drinking water, paint stripping, lead lines on bones on radiographs, or basophilic stippling of red blood cells. 
12. Manganese. Serum manganese testing is covered for beneficiaries with documented industrial exposure to 
manganese. 
13. Mercury. Serum, whole blood, and/or urine mercury testing is covered for beneficiaries with documented 
industrial exposure to mercury, with a blue line in their mouth, those with a history of laxative abuse, with a 
history of pesticide exposure, mercury spillage with vacuuming of the liquid metal, unexplained renal failure, 
or a history of skin lightening treatments. 
14. Molybdenum. Serum molybdenum testing is covered for beneficiaries with documented industrial exposure 
to molybdenum. 
15. Nickel. Serum and/or urine nickel testing is covered for beneficiaries with documented industrial exposure 
to nickel, unexplained renal failure, unexplained pulmonary disease. 
16. Selenium. Serum and/or urine selenium testing is covered for beneficiaries with documented industrial 
exposure to selenium or on chronic renal dialysis. 
17. Thallium. Serum thallium testing is covered for beneficiaries with documented industrial exposure to 
thallium and unexplained ataxia. 
18. Tin. Serum tin testing is covered for beneficiaries with documented industrial exposure to tin. 
19. Titanium. Serum titanium testing is covered for beneficiaries with documented industrial exposure to 
titanium. 
20. Zinc. Serum zinc and/or urine testing is covered for beneficiaries with documented industrial exposure to 
zinc, on chronic renal dialysis, with malabsorption syndromes, Crohn's disease, unexplained myelodysplastic 
syndrome or known ingestion of zinc. Zinc testing is not covered for the assessment and supplementation for 
the treatment of depression. 
21. Testings for the following metals are non-covered: Boron, Phosphorous, Silica, Strontium, Sulfur, 
Uranium, Vanadium 
 
Documented recent, long-term total parenteral nutrition (TPN) with clinical trace element deficiency evidence 
is an acceptable medical indication for testing for copper, manganese, and zinc. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Heavy Metal Testing 
(L35074). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.