Intracellular Micronutrient Testing Panel

Policy ID: L-191-008

Section: Laboratory

Effective Date: September 01, 2019

Revised Date: December 20, 2023

Revision Effective Date: March 03, 2025

Last Reviewed: January 14, 2025

Applies To: Commercial and Medicaid Expansion

Description

Intracellular micronutrient testing (also known as: micronutrient testing, essential metabolic analysis, leukocyte nutrient analysis, functional micronutrient analysis) is a novel lab panel that measures the intracellular level of multiple nutrients. Micronutrients measured by this test include but are not limited to the following:

Vitamins- A, B1, B2, B3, B6, B12, C, D, K, E
Biotin, Folate, Pantothenate,
Minerals- Calcium, Magnesium, Manganese, Zinc, Copper
Amino Acids, Asparagine, Glutamine, Serine
Fatty acids, Oleic Acid
Antioxidants -Alpha Lipoic Acid, Coenzyme Q10, Cysteine, Glutathione, Selenium
Carbohydrate Metabolism- Chromium, Fructose Sensitivity, Glucose-Insulin Metabolism
Metabolites- Choline, Inositol. Carnitine
Total antioxidant function and immune Response Score (offered by SpectraCell Laboratories)

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Intracellular micronutrient testing panel is considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

82136

82180

82306

82310

82379

82495

82525

82607

82652

82725

82746

82978

83735

83785

84207

84252

84255

84425

84446

84590

84591

84597

84630

84999

86353

88348

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-16-2019 New Policy

Internal Medical Policy Committee 5-19-2020 Annual Review

Internal Medical Policy Committee 5-20-2021 Annual Review-no changes in criteria

Internal Medical Policy Committee 11-23-2021 Revision-

Updated language

Internal Medical Policy Committee 9-28-2022 Annual Review - no changes in criteria

Internal Medical Policy Committee 9-12-2023 Annual Review - no changes in criteria

Internal Medical Policy Committee 1-16-2024 Revision - Effective March 04, 2024

Updated references

Internal Medical Policy Committee 1-14-2025 Annual Review - no changes in criteria

Added Policy Application

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: L-191-007

Section: Laboratory

Effective Date: September 01, 2019

Revised Date: December 02, 2021

Revision Effective Date: January 03, 2022

Last Reviewed: September 12, 2023

Archived Date: March 03, 2024

Applies To: Commercial and Medicaid Expansion

Description

Vitamins- A, B1, B2, B3, B6, B12, C, D, K, E
Biotin, Folate, Pantothenate,
Minerals- Calcium, Magnesium, Manganese, Zinc, Copper
Amino Acids, Asparagine, Glutamine, Serine
Fatty acids, Oleic Acid
Antioxidants -Alpha Lipoic Acid, Coenzyme Q10, Cysteine, Glutathione, Selenium
Carbohydrate Metabolism- Chromium, Fructose Sensitivity, Glucose-Insulin Metabolism
Metabolites- Choline, Inositol. Carnitine
Total antioxidant function and immune Response Score (offered by SpectrCell Laboratories)

Criteria

Procedure Codes

82136

82180

82306

82310

82379

82495

82525

82607

82652

82725

82746

82978

83735

83785

84207

84252

84255

84425

84446

84590

84591

84597

84630

84999

86353

88348

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-16-2019 New Policy

Internal Medical Policy Committee 5-19-2020 Annual Review

Internal Medical Policy Committee 5-20-2021 Annual Review-no changes in criteria

Internal Medical Policy Committee 11-23-2021 Revision-

Updated language

Internal Medical Policy Committee 9-28-2022 Annual Review - no changes in criteria

Internal Medical Policy Committee 9-12-2023 Annual Review - no changes in criteria

Links

References (PDF)

Disclaimer

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