Nutrient/Nutritional Panel Testing Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 01|01|2024 POLICY LAST REVIEWED: 02|04|2026 OVERVIEW This policy is for nutritional panel testing when used to identify nutritional deficiencies that will lead to personalized nutritional supplement recommendations. Testing is proposed both for healthy individuals to optimize health and for individuals with chronic conditions (eg, mood disorders, fibromyalgia, chronic fatigue) to specify supplements that will ameliorate symptoms.
MEDICAL CRITERIA Not applicable
PRIOR AUTHORIZATION Medicare Advantage Plans and Commercial Products There is no specific CPT coding for the services referenced in this policy. Therefore, an Unlisted CPT code should be used (see Coding Section for details). All Unlisted genetic testing CPT codes require prior authorization to determine what service is being rendered and if the service is covered or not medically necessary. See the Related Policies section.
Note: Laboratories are not allowed to obtain clinical authorization or participate in the authorization process on behalf of the ordering physician. Only the ordering physician shall be involved in the authorization, appeal or other administrative processes related to prior authorization/medical necessity.
In no circumstance shall a laboratory or a physician/provider use a representative of a laboratory or anyone with a relationship to a laboratory and/or a third party to obtain authorization on behalf of the ordering physician, to facilitate any portion of the authorization process or any subsequent appeal of a claim where the authorization process was not followed and/or a denial for clinical appropriateness was issued, including any element of the preparation of necessary documentation of clinical appropriateness. If a laboratory or a third party is found to be supporting any portion of the authorization process, BCBSRI will deem the action a violation of this policy and severe action will be taken up to and including termination from the BCBSRI provider network. If a laboratory provides a laboratory service that has not been authorized, the service will be denied as the financial liability of the participating laboratory and may not be billed to the member. POLICY STATEMENT Medicare Advantage Plans and Commercial Products Nutrient/nutritional panel testing is considered not covered for Medicare Advantage Plans and not medically necessary for Commercial Products for all indications including but not limited to testing for nutritional deficiencies in patients with mood disorders, fibromyalgia, unexplained fatigue, and healthy individuals. Commercial Products Some genetic testing services are not covered and a contract exclusion for any self-funded group that has excluded the expanded coverage of biomarker testing related to the state mandate, R.I.G.L. §27-19-81 described in the Biomarker Testing Mandate policy. For these groups, a list of which genetic testing services are covered with prior authorization, are not medically necessary or are not covered because they are a contract exclusion can be found in the Coding section of the Genetic Testing Services or Proprietary Laboratory Analyses policies. Please refer to the appropriate Benefit Booklet to determine whether the member’s plan has customized benefit coverage. Please refer to the list of Related Policies for more information. Medical Coverage Policy | Nutrient/Nutritional Panel Testing

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

COVERAGE Medicare Advantage Plans and Commercial Products Benefits may vary between groups/contracts. Please refer to the Evidence of Coverage or Subscriber Agreement for applicable not medically necessary/not covered laboratory testing benefits/coverage.

BACKGROUND Nutritional panel testing aims to identify nutritional deficiencies that will lead to personalized nutritional supplement recommendations. Testing is proposed both for healthy individuals to optimize health and for individuals with chronic conditions (eg, mood disorders, fibromyalgia, chronic fatigue) to specify supplements that will ameliorate symptoms.

Genova Diagnostics offers nutritional/nutrient panel testing. Among the tests this company offers is NutrEval FMV, which involves analysis of urine and blood samples and provides information on more than 100 markers including organic acids, amino acids, fatty acids, markers of oxidative stress (direct measurement of glutathione and CoQ10, and markers of oxidative injury and DNA damage) and nutrient elements. Genova Diagnostics produces a report that includes test results categorized as minimal, moderate, or high need for support, along with recommendations for supplements and dosages for items categorized as high need. NutrEval FMV patient reports can recommend supplementation or any of the nutrients if they are found to be areas of high need.

NutrEval Plasma, also by Genova Diagnostics, is a similar test. The only difference between NutrEval FMV and NutrEval Plasma is that the former uses urine (first morning void) whereas the latter uses plasma (fasting sample) to measure amino acids.

SpectraCell Laboratories offers a micronutrient test that measures functional deficiencies at the cellular level. The test assesses how well the body uses 31 vitamins, minerals, amino and fatty acids, antioxidants, and metabolites. SpectraCell categorizes test results into adequate, borderline, and deficient, and offers supplementation suggestions based on each patient’s deficiencies.

Direct evidence of clinical utility is provided by studies that have compared health outcomes for patients managed with and without the test. Because these are intervention studies, the preferred evidence would be from randomized controlled trials (RCTs).

No RCTs were identified that assessed the clinical utility of nutrient/nutritional panel testing for mood disorders, fibromyalgia, unexplained fatigue, or optimization of health and fitness.

Several systematic reviews and meta-analyses evaluating associations between the indications of interest and specific nutrient deficiencies were identified. No systematic reviews or meta-analyses were identified in the association between nutritional deficiencies and unexplained fatigue. A limitation of all reviews is that, although they compared low and high levels of nutrient levels, none addressed whether these low levels constituted actual deficiencies in a particular nutrient.

For individuals who have mood disorders, fibromyalgia, or unexplained fatigue, or healthy individuals who seek to optimize health and fitness who receive nutritional panel testing, the evidence includes several systematic reviews and randomized controlled trials (RCTs) on the association between a single condition and a single nutrient and on the treatment of specific conditions with nutritional supplements. Relevant outcomes are symptoms, change in disease status, and functional outcomes. Systematic reviews have found statistically significant associations between depression or fibromyalgia and levels of several nutrients; however, there is little evidence that nutrient supplementation for patients with depression improves health outcomes. An RCT has also found statistically significant associations between fatigue and levels of vitamin D. However, there is no direct evidence on the health benefits of nutritional panel testing for any condition, including testing healthy individuals, and no evidence that nutritional panel testing is superior to testing for individual nutrients

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

for any condition. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

CODING There is not a specific CPT code for this panel testing. While there may be specific CPT codes for some of the components* of the panel testing, claims for the entire panel MUST be filed only with the Unlisted CPT code noted below.

84999 Unlisted chemistry procedure

*Examples of components of Nutrient/Nutrition panels may include the following codes. This is not an all- inclusive list: 82746 Folic acid; serum 83735 Magnesium 83785 Manganese 84590 Vitamin A 84630 Zinc 82128 Amino acids; multiple, qualitative, each specimen 82136 Amino acids, 2 to 5 amino acids, quantitative, each specimen

RELATED POLICIES Biomarker Testing Mandate Genetic Testing Services
Unlisted Procedures

PUBLISHED Provider Update, April 2026 Provider Update, March 2025 Provider Update, April 2024 Provider Update, March 2023, November 2023 Provider Update, February 2022

REFERENCES

1. Genova Diagnostics. NutrEval FMV; https://www.gdx.net/product/nutreval-fmv-nutritional-test- blood-urine. Accessed November 7, 2025.
2. Genova Diagnostics. NutrEval Plasma; https://www.gdx.net/product/nutreval-nutritional-test-plasma. Accessed November 7, 2025.
3. SpectraCell Laboratories Micronutrient Test Panel. https://www.spectracell.com/micronutrient-test- panel. Accessed November 7, 2025.
4. Petridou ET, Kousoulis AA, Michelakos T, et al. Folate and B12 serum levels in association with depression in the aged: a systematic review and meta-analysis. Aging Ment Health. Sep 2016; 20(9): 965-
5. PMID 26055921
6. Cheungpasitporn W, Thongprayoon C, Mao MA, et al. Hypomagnesaemia linked to depression: a systematic review and meta-analysis. Intern Med J. Apr 2015; 45(4): 436-40. PMID 25827510
7. Swardfager W, Herrmann N, Mazereeuw G, et al. Zinc in depression: a meta-analysis. Biol Psychiatry. Dec 15 2013; 74(12): 872-8. PMID 23806573
8. Anglin RE, Samaan Z, Walter SD, et al. Vitamin D deficiency and depression in adults: systematic review and meta-analysis. Br J Psychiatry. Feb 2013; 202: 100-7. PMID 23377209
9. Hsiao MY, Hung CY, Chang KV, et al. Is Serum Hypovitaminosis D Associated with Chronic Widespread Pain Including Fibromyalgia? A Meta-analysis of Observational Studies. Pain Physician. 2015; 18(5): E877-87. PMID 26431141
10. Daniel D, Pirotta MV. Fibromyalgia--should we be testing and treating for vitamin D deficiency?. Aust Fam Physician. Sep 2011; 40(9): 712-6. PMID 21894281

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

10. Gowda U, Mutowo MP, Smith BJ, et al. Vitamin D supplementation to reduce depression in adults: meta-analysis of randomized controlled trials. Nutrition. Mar 2015; 31(3): 421-9. PMID 25701329
11. Taylor MJ, Carney S, Geddes J, et al. Folate for depressive disorders. Cochrane Database Syst Rev. 2003; 2003(2): CD003390. PMID 12804463
12. Nowak A, Boesch L, Andres E, et al. Effect of vitamin D3 on self-perceived fatigue: A double-blind randomized placebo-controlled trial. Medicine (Baltimore). Dec 2016; 95(52): e5353. PMID 28033244
13. U.S. Preventive Services Task Force (USPSTF). Iron Deficiency Anemia: Screening. 2015; https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/iron-deficiency-anemia-in- young-children-screening#fullrecommendationstart. Accessed November 7, 2025.
14. U.S. Preventive Services Task Force (USPSTF). Iron Deficiency Anemia in Pregnant Women: Screening and Supplementation, 2024. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/iron-deficiency-anemia-in- pregnant-women-screening-and-supplementation. Accessed November 7, 2025.

15. U.S. Preventive Services Task Force (USPSTF). Vitamin D Deficiency: Screening. 2021; https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/vitamin-d-deficiency-screening. Accessed November 7, 2025.

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    This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

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