Code is covered without prior authorization (high confidence)
Documentation Required
Documentation of the clinical indication or the applicable ICD-10 diagnosis code from the list of covered diagnoses when submitting CPT/diagnosis codes for reimbursement (e.g., listed ICD-10 codes such as D50.*, F98.3, T56.0X*, Z77.011, etc.).
For occupational lead exposure screening, documentation of workplace lead exposure per OSHA requirements or employer/occupational exposure records supporting occupational exposure status.
For pregnant or lactating women, documentation that at least one risk factor for lead exposure (from the Appendix table) was identified on risk assessment (ACOG-recommended risk assessment at earliest contact).
Documentation of signs or symptoms of lead poisoning when testing is performed for diagnostic purposes (examples in policy: lowered IQ, decreased attention span, impaired hearing/speech/developmental delays, abdominal pain, headaches, vomiting, constipation).
Key Coverage Criteria
Screening of preschool-age children in the following high-risk groups: abnormal oral behaviors (e.g., pica) placing them at risk.
Screening of preschool-age children in the following high-risk groups: close contact with a person who has or had an elevated lead level.
Lead screening for persons with occupational lead exposures (OSHA-mandated testing for workplace lead exposures).
Screening of preschool-age children in the following high-risk groups: emigrated (or adopted) from countries where lead poisoning is prevalent.
Screening of preschool-age children in the following high-risk groups: have iron deficiency.
Screening of preschool-age children in the following high-risk groups: have unexplained illness (e.g., abdominal pain, lethargy, seizures, severe anemia).
If capillary blood is used and an elevated lead level is found, documentation of confirmatory venous blood lead measurement is required (capillary screening elevated result should be confirmed by venous measurement).
For patients being retested due to the Magellan LeadCare recall, documentation of the prior test (showing it was analyzed using a Magellan Diagnostics LeadCare analyzer) and the prior venous blood lead result (when applicable) should be available to support CDC-recommended retesting.