Subject:
Intravenous/Intramuscular Vitamin and/or Mineral Therapy
Description:
_______________________________________________________________________________________
IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
__________________________________________________________________________________________________________________________
Intravenous (IV) and intramuscular (IM) vitamin and/or mineral therapy involve the administration of a solution of vitamin(s) and/or mineral(s) through a vein or into a muscle. It is employed when a patient requires urgent vitamin supplementation or when a patient is unable to assimilate vitamins via the usual route. Total parenteral nutrition (TPN) is the intravenous administration (usually through a central line that goes directly to the heart) of a complete form of nutrition containing protein, sugar, fat and added vitamins and minerals as needed by a patient. [For the medical appropriateness of TPN, please refer to a separate policy on Nutritional Support (Policy #066) under the Treatment Section of this database.]
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
1. The intravenous (IV) or intramuscular (IM) administration of vitamin(s) and/or mineral(s) must be ordered by the treating physician.
2. The IV or IM administration of vitamin(s) and/or mineral(s) is considered medically necessary when all of the following lettered criteria are met:
a. member’s signs and/or symptoms documented in the member’s medical records support a diagnosis of vitamin and/or mineral deficiency ; and
b. member has vitamin and/or mineral deficiency established by an appropriate serum analysis and documented in the member’s medical records; and
[INFORMATIONAL NOTE: There are several techniques used to test vitamin and/or mineral levels. The use of hair or nail analysis to establish a diagnosis of vitamin and/or mineral deficiency is not acceptable since these tests are unreliable and have not been proven to be effective in ascertaining vitamin and/or mineral deficiencies. A diagnosis of vitamin and/or mineral deficiency must be established with the appropriate serum analysis. Laboratory test results (prior to initiating therapy) should be documented in the patient’s medical record to support the medical necessity of the treatment.]
c. other routes of vitamin administration (e.g., oral) are less effective, not feasible, or not appropriate.
[INFORMATIONAL NOTE: Most vitamin and/or mineral deficiency problems can be determined from a comprehensive history and physical examination. The medical literature suggests that any diagnostic evaluation would be targeted for the specific vitamin and/or mineral deficiency suspected, and not a general screen. Laboratory findings should be considered together with the patient’s comprehensive history and physical examination before considering IV or IM vitamin and/or mineral therapy.]
3. Other uses of IV or IM vitamin and/or mineral therapy are not considered medically necessary (e.g., IV/IM vitamins and/or minerals that are prescribed solely as a nutritional supplement).
Medicare Coverage:
There is no National Coverage Determination (NCD) for Intravenous/Intramuscular Vitamin and/or Mineral Therapy.
Per National Coverage Determination (NCD) for Intravenous Iron Therapy (110.10), sodium ferric gluconate complex in sucrose injection is covered as a first line treatment of iron deficiency anemia when furnished intravenously to individuals undergoing chronic hemodialysis who are receiving supplemental erythropoeitin therapy.
Per National Coverage Determination (NCD) for Vitamin B12 Injections to Strengthen Tendons, Ligaments, etc., of the Foot (150.6), Vitamin B12 injections to strengthen tendons, ligaments, etc., of the foot are not covered under Medicare because there is no evidence that vitamin B12 injections are effective for the purpose of strengthening weakened tendons and ligaments.
Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has not issued a determination for Intravenous/Intramuscular Vitamin and/or Mineral Therapy. Therefore, Medicare Advantage Products will follow the Horizon BCBSNJ Medical Policy for Intravenous/Intramuscular Vitamin and/or Mineral Therapy other than Intravenous Iron Therapy and vitamin B12 injections which have National Coverage Determinations.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE-SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
________________________________________________________________________________________
Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
___________________________________________________________________________________________________________________________
Index:
Intravenous/Intramuscular Vitamin and/or Mineral Therapy
Intravenous Vitamin Therapy
Intravenous Mineral Therapy
Intramuscular Vitamin Therapy
Intramuscular Mineral Therapy
Mineral Therapy
Vitamin Therapy
References:
1. Trailblazer Health Enterprises, LLC. Part B Texas Local Medicare Review Policy (LMRP): Assays for Vitamins and Metabolic Function. - L-95B-R5. Revision effective: 02/01/06. http://www.trailblazerhealth.com/lmrp.asp?ID=532&Imrptype=tx
2. Centers for Medicare and Medicaid Services (CMS). Coverage Issues Manual - Supplies and Drug Section #45-29: Intravenous iron therapy. http://cms.hhs.gov/manuals/06_cim/ci45.asp
3. Centers for Medicare and Medicaid Services (CMS). Coverage Issues Manual - Diagnostic Services Section #50-24: Hair Analysis - Not Covered. http://cms.hhs.gov/manuals/06_cim/ci50.asp
4. American Medical Association. Policy # H-175.995: Hair Analysis - A Potential for Medical Abuse. http://www.ama-assn.org
5. Seidel S, Kreutzer R, Smith D et al. Assessment of commercial laboratories performing hair mineral analysis. JAMA. 2001 Jan 3;285(1):67-72.
6. Steindel SJ, Howanitz PJ. The uncertainty of hair analysis for trace metals. JAMA. 2001 Jan 3;285(1):83-5.
7. Barrett S. Commercial Hair Analysis: A Cardinal Sign of Quackery. Quackwatch. Revised on august 10, 2010. http://www.quackwatch.com/01QuackeryRelatedTopics/hair.html (last accessed July 1, 2015)
8. Zeegers MP, Goldbohm RA, Bode P et al. Prediagnostic toenail selenium and risk of bladder cancer. Cancer Epidemiol Biomarkers Prev 2002 Nov;11(11):1292-7.
9. Kardinaal AF, Kok FJ, Kohlmeier L et al. Association between toenail selenium and risk of acute myocardial infarction in European men. The EURAMIC Study. European Antioxidant Myocardial Infarction and Breast Cancer. Am J Epidemiol 1997 Feb 15;145(4):373-9.
10. Vecht-Hart CM, Bode P et al. Calcium and magnesium in human toenails do not reflect bone and mineral density. Clin Chim Acta 1995 Apr 30;236(1):1-6.
11. Fairfield KM, Fletcher RH. Vitamins for chronic disease prevention in adults: scietific review. JAMA. 2002 Jun 19;287(23):3116-26.
12. Fletcher RH, Fairfield KM. Vitamins for chronic disease prevention in adults: clinical applications. JAMA. 2002 Jun 19;287(23):3127-9.
13. Making Treatment Decisions: Greek Cancer Cure. American Cancer Society. http://www.cancer.org/docroot/ETO/content/ETO_5_3X_Greek_Cancer_Cure.asp?sitearea=ETO
14. American Heart Association. AHA Scietific Position: Vitamin and Mineral Supplements. http://www.americanheart.org/presenter.jhtml?identifier=4788
15. New York Online Access to Health (NOAH): Complementary and Alternative Medicine. http://www.noah-health.org/english/alternative/alternative.html#Doctor
16. Harvard School of Public Health. Vitamins. http://www.hsph.harvard.edu/nutriotionsource/vitamins.html
17. Food & Nutrition Center: Using vitamin and mineral supplements wisely. MayoClinic.com. May 10, 2002. http://www.mayoclinic.com/invoke.cfm?objectid=3549DCAA-3380-4B0B-86EB23C76CA5FAE3
18. Alternative approaches to diet and nutrition that may prevent or control chronic illness as well as promote health: The use of vitamins and other nutritional supplements in the prevention of chronic disease. Colorardo HealthSite ~ Alternative/Complementary Medicine. http://www.coloradohealthsite.org/holistic/nutrition/diet_1.htm
19. National Institutes of Health (NIH). National Center for Complementary and Alternative Medicine (NCCM). http://www.nih.gov
20. Palmetto GBA. Assays for Vitamins and Metabolic Function (LCD ID L31775). 01/23/2015. Available at:http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=31775&ContrId=229&ver=44&ContrVer=1&Date=03%2f04%2f2013&DocID=L31775&bc=AAAAAAgAAAAAAA%3d%3d& (accessed 07/01/2015)
21. Wolowiec P, Michalak I et al. Hair analysis in health assessment. Clin Chim Acta. 2013 Apr18;419:139-71.
22. UpToDate. Overview of dietary trace elements. Literature review current through March 2016.
23. UpToDate. Nutrition support in critically ill patients: An overview. Literature review current through March 2016.
24. Pazirandeh S, Burns DL, Griffin IJ. Overview of dietary trace elements. In: UpToDate, Lipman TO, Hoppin AG (Eds), UpToDate, Waltham, MA. (Accessed on March 3, 2017.)
25. Seres D. Nutrition support in critically ill patients: An overview. In: UpToDate, Parsons PE, Lipman TO, Finlay G (Eds), UpToDate, Waltham, MA (Accessed March 3, 2017.)
26. Fairfield KM. Vitamin supplementation in disease prevention. In: UpToDate, Seres D, Kunins L (Eds), UpToDate, Waltham, MA (Accessed March 11, 2019).
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
_________________________________________________________________________________________
Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
____________________________________________________________________________________________________________________________ |