Intracellular Micronutrient Testing Panel

Section: Laboratory
Effective Date: September 01, 2019
Revised Date: July 16, 2019
Last Reviewed: May 19, 2020

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 SpectrCell Laboratories)

Criteria

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

Links

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.