Multiregional Medicare Contractor Proposes Restrictions on Vitamin D Testing

The Academy recently called on a Medicare contractor with operations in 16 states to be more inclusive in its list of acceptable medical conditions for coverage of vitamin D assay testing.

In a Feb. 16 letter, AAFP Board Chair Jim King, M.D., of Selmer, Tenn., blasted National Government Services Inc. for providing a list of covered diagnosis codes "that is flawed and incomplete." The contractor's policy "would undeniably shortchange current medical practice," he said, resulting in inadequate care for patients who need the test.

"Indeed, it appears that the draft LCD (local coverage determination) is based upon sound medical practice from the 1980s, not the 21st century," added King.

According to the draft LCD, measurement of vitamin D levels is only indicated for patients with

However, said King, there are other circumstances where vitamin D measurement is helpful. "Family physicians see many patients with osteoporosis and osteopenia," and measurement of the 25-OH vitamin D level, is the best way to assess and treat some of those patients.

King asked the contractor to further review and revise the draft Medicare LCD, "so the list of acceptable medical conditions is complete and includes historically accepted conditions, including, but not limited to, osteoporosis, osteopenia and malabsorption syndromes."

David Mehr, M.D., is a professor and director of research in the department of family and community medicine at the University of Missouri-Columbia School of Medicine. He called the draft LCD "an extraordinarily short-sighted policy" that seems to have been created with little, if any, geriatric input.

Mehr, who also serves as director of the Fellowship in Geriatric Medicine at the same university, said he relies on vitamin D testing to help him make the best possible health decisions for his older patients.

"Vitamin D deficiency is common, particularly in frail older adults, but the symptoms are often subtle -- bone pain, weakness," said Mehr, adding that he routinely orders the testing in his patients who have had a hip fracture.

Mehr said vitamin D levels are assessed in patients with osteoporosis because "vitamin D deficiency is common and may adversely affect treatment with bisphosphonates."

He also pointed out that there is substantial research that suggests vitamin D deficiency can be related to falls, fractures and lower extremity weakness. "The diagnosis of osteomalacia can't be made until after doing a vitamin D level," Mehr said.

In his letter, King noted that the draft LCD also overlooked the measurement of vitamin D in patients who have undergone bariatric surgery for weight loss.

He argued that measurement of vitamin D "is a very important test that appears to be having expanded applications and has a relationship to many disease states with readily identifiable treatment and improved prognosis."