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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 state that Vitamin D is a hormone, synthesized by the skin, the liver, and then metabolized by the 
kidney to an active hormone, calcitriol. An excess of vitamin D may lead to hypercalcemia. Vitamin D 
deficiency may lead to a variety of disorders. This LCD identifies the indications and limitations of Medicare 
coverage and reimbursement for these services. 
 
Vitamin D is called a "vitamin" because of its availability from an exogenous source, predominantly from oily 
fish in the form of cholecalciferol, vitamin D3. Plant-based vitamin D is in the form of ergocalciferol, Vitamin 
D2. It is really a hormone, as it is synthesized by the skin, metabolized by the liver, and converted by the 
kidney to an active hormone, calcitriol. Calcitriol in its classical action, absorbs calcium from the intestine, and 
promotes bone mineralization. 
 
In the skin, 7-dehydrocholesterol is converted to vitamin D3 in response to sunlight, a process that is inhibited 
by sunscreen with a skin protection factor (SPF) of 8 or greater. Once in the blood, vitamin D2 or D3 from diet, 
or D3 from skin production are carried by an alpha-2-globulin, vitamin D binding protein, and are carried to the 
liver where they are hydroxylated to yield 25-hydroxyvitamin D (25OHD; calcidiol). 25OHD then is converted 
in the kidney to 1, 25(OH)2D (calcitriol) by the action of 25OHD-1-alpha hydroxylase (CYP27B1). The 
CYP27B1 in the kidney is regulated by nearly every hormone involved in calcium homeostasis, and its activity 
is stimulated by PTH, estrogen, calcitonin, prolactin, growth hormone, low calcium levels, and low phosphorus 
levels. Its activity is inhibited by calcitriol, thus providing the feedback loop that helps regulates its synthesis. 
 
An excess of vitamin D is unusual but may lead to hypercalcemia. Vitamin D deficiency may lead to a variety 
of disorders; the well-described is rickets in growing children or osteomalacia in adults. Evaluating the status of 
a patients vitamin D sufficiency is accomplished by measuring the level of 25-hydroxyvitamin D. 
Measurement of other metabolites is generally not necessary outside of several unusual metabolic bone 
disorders or in chronic kidney disease-mineral bone disorder (CKD-MBD). 
 Indications: 
Measurement of vitamin D levels is indicated for patients with: 
 chronic kidney disease stage III or greater; 
 osteoporosis; 
 osteomalacia; 
 osteopenia; 
 osteogenesis imperfecta; 
 osteosclerosis; 
 hypocalcemia; 
 hypercalcemia; 
 hypoparathyroidism; 
 hyperparathyroidism; 
 rickets; 
 vitamin D deficiency to monitor the efficacy of replacement therapy; 
 fibromyalgia; 
 granuloma forming diseases; 
 hypovitaminosis D; 
 hypervitaminosis D; 
 long term use of anticonvulsants or glucocorticoids and other medications known to lower - vitamin D 
levels; 
 malabsorption states; 
 obstructive jaundice; 
 cirrhosis; 
 psoriasis; 
 Pagets disease of bone; 
 gastric bypass; 
 obesity. 
Limitations: 
For Medicare beneficiaries, screening tests are governed by statute (Social Security Act 1861 {nn}). Vitamin D 
testing may not be used for routine screening. 
 
Assays of calcitriol need not be performed for each of the above conditions. The most common type of vitamin 
D deficiency is that of 25 OH Vitamin D. 
 
The 1,25-dihydroxy form of vitamin D is generally only required to assist in the diagnosis of certain cases of 
rare endocrine disorders (primary hyperparathyroidism, hypothyroidism, pseudohypoparathyroidism), or for 
diagnosing and treating renal osteodystrophy and vitamin D-dependent and vitamin D resistant rickets, or in 
cases of unknown causes of hypercalcemia, including sarcoidosis. Level of both 25OHD and calcitriol are not 
needed as a panel for determining a patient's vitamin D status or to monitor routine vitamin D replacement 
therapy for most diseases. It is expected that the medical record will justify the tests chosen for a particular 
disease entity, that all available components of 25 OH vitamin D and other metabolite levels will not be 
performed routinely on every patient, and that supportive documentation for test choices will be available to the 
Contractor upon request. 
 
This Contractor does not expect to receive billing for the various component sources of 25 OH vitamin D 
separately (such as stored D or diet derived D). Only one total 25 OH vitamin D assay (comprising the sum of 
both 25OHD2 and 25OHD3) will be considered for reimbursement on any particular day, if medically 
necessary, for the patient's condition. Once a beneficiary has been shown to be vitamin D deficient, further testing may be medically necessary only 
to ensure adequate replacement has been accomplished for this vitamin deficiency, although, generally, other 
parameters are measured. Annual testing of the vitamin D status may be appropriate depending upon the 
indication and other mitigating factors. Because there can be variability in individual 25OHD responses to 
supplemental vitamin D in high-risk individuals, the serum 25OHD levels could be retested after about 3 
months of supplementation to confirm that the target 25OHD level has been reached. If the follow up test 
shows they have not yet reached the target level, the test can be repeated in another 3 months until the target 
level is achieved. 
 
You can find this rule at the Medicare Local Coverage Determination (LCD) L34658: Vitamin D Assay 
Testing. 
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.