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Date Printed: June 23, 2017: 11:32 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

05-86000-31

Original Effective Date: 09/15/11

Reviewed: 04/27/17

Revised: 05/15/17

Subject: Intracellular Micronutrient Analysis

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Intracellular micronutrient analysis, also known as micronutrient testing and functional intracellular analysis (FIA), is a broad panel of laboratory tests said to reveal microdeficiencies at subcellular levels that are not detected using standard testing for vitamin or mineral levels. Examples of micronutrients that may be measured in the panel include vitamins, minerals, amino acids, metabolites, fatty acids, carbohydrates, and antioxidants. The panel may also include an evaluation of total antioxidant function. Proposed uses of the testing include screening for nutritional deficiencies in individuals who do not have signs or symptoms of nutritional deficiency, screening for those with chronic disease, and aiding in the diagnosis of disease in patients with generalized symptoms.

At least 2 commercial laboratories offer intracellular testing for micronutrients. Laboratories perform a panel of tests evaluating the intracellular level of a variety of micronutrients (eg, minerals, vitamins, amino acids, fatty acids). The test offered by IntraCellular Diagnostics evaluates epithelial cells from buccal swabs and assesses levels of intracellular mineral electrolyte ie magnesium, calcium, potassium, phosphorous, sodium, and chloride. SpectraCell Laboratories offers a panel of tests that evaluates the intracellular status of micronutrients (such as vitamins, minerals, metabolites, amino and fatty acids) within lymphocytes in blood samples. The SpectraCell micronutrient panel also includes an evaluation of total antioxidant function.

POSITION STATEMENT:

Intracellular micronutrient panel testing is considered experimental or investigational for all indications. The evidence is insufficient to determine the effects of the technology on health outcomes.

BILLING/CODING INFORMATION:

There is no specific CPT or HCPCS code for intracellular micronutrient panel testing.

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products: No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

None applicable

OTHER:

Other names or key words used to report intracellular micronutrient analysis:

Note: The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

REFERENCES:

  1. Blue Cross and Blue Shield Association, Medical Policy Reference Manual- Intracellular Micronutrient Analysis 2.04.73, 03/17.
  2. ClinicalTrials.gov, Supplemental Adjuvants for Intracellular Nutrition and Treatment (SAINTS), sponsored by Mid-Atlantic Retina Consultations, accessed 08/03/15.
  3. ClinicalTrials.gov, Vitamin C Supplementation as a Preventive Treatment of Diabetic Peripheral Neuropathy, sponsored by Washington State University, accessed 07/11/12.
  4. Filipek PA, et al, Practice Parameter: Screening and Diagnosis of Autism- Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society. Neurology. 2000 Aug 22;55(4):468-79. Accessed at aan.com 07/11/13.
  5. Fletcher RH, et al, Vitamins for Chronic Disease Prevention in Adults: Clinical Applications. JAMA, 2002 Jun 19;287(23):3127-9.
  6. Ostroff C, SPECTROX™ (Total Antioxidant Function), accessed at drcathyostroff.com 07/25/14.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 04/27/17.

GUIDELINE UPDATE INFORMATION:

09/15/11

New Medical Coverage Guideline.

09/15/12

Annual review; position statement maintained and references updated.

09/15/13

Annual review; position statement maintained and references updated.

09/15/14

Annual review; position statement maintained; references updated.

09/15/15

Annual review; position statement maintained and references updated.

05/15/17

Revision; Investigational position statement maintained; description and references updated.

Date Printed: June 23, 2017: 11:32 AM