Overutilization

Please keep in mind of certain Medicare limitations regarding reimbursement for laboratory testing.   Restrictions include but are not limited to the following tests:

  1. Glycohemoglobin (may be ordered once every 90 days)
  2. Ferritin (may be ordered once every 60 days)
  3. Lipid Profile (may be ordered annually but more frequently with the appropriate diagnosis such as hypercholesterolemia, hyperlipidemia, ETC).

Restrictions for Medicare coverage of thyroid function testing have resulted in the following protocol to be put in place.  Medicare coverage includes the following three ordering patterns:

  1. TSH, Thyroxin (T4 Total) and T3 Uptake;
  2. TSH and Free T4; or
  3. Any thyroid test ordered single-handedly.

Medicare coverage considers C. Reactive Protein High Sensitivity medically necessary only if the one of the following diagnoses applies:

  • E78.00 Pure hypercholesterolemia, unspecified
  • E78.01 Familial hypercholesterolemia
  • E78.1 Pure hyperglyceridemia
  • E78.2 Mixed hyperlipidemia
  • E78.3 Hyperchylomicronemia
  • E78.4 Other hyperlipidemia
  • I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris
  • Z74.09* Other reduced mobility
  • Z78.9* Other specified health status

Please be aware that, as of April 2020, Medicare is rejecting payment for #507 C. Reactive Protein – Inflammation and #509 C. Relative Protein – High Sensitivity when both tests are ordered: “during the same session/date as a previously processed service for the patient”.


In regards to Vitamin D testing (CPT Code 82306), once a beneficiary has been shown to be vitamin D deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors.

Ordering outside the guidelines/protocols as mentioned above will result in denial by Medicare for some or all of the testing. Coverage is not provided for TESTS PERFORMED AS PART OF A ROUTINE MEDICAL EXAMINATION OR FOR SCREENING PURPOSES. These tests are “Medicare Limited Coverage Tests” and can only be covered with specified diagnoses approved by Medicare.  Aculabs has previously provided copies of this documentation to you as a reference.

READ MORE ABOUT MEDICAL NECESSITY AND OVERUTILIZATION