Thyroid and serum iron testing

Clinical Utilization Management (UM) Guidelines below were developed and/or revised in February 2022, to support clinical coding edits. The updated guidelines state that only medically necessary lab testing for thyroid and serum iron will be covered. Effective September 1, 2023, coverage for labs for CG-LAB-20 — Thyroid Testing and CG-LAB-21 — Serum Iron Testing will be denied unless medically necessary.

Clinical Indications for thyroid testing

Medically necessary

Thyroid function testing is considered medically necessary for individuals who meet any of the following indications:

• For evaluation of signs or symptoms consistent with thyroid disease
• To evaluate, assess, or monitor confirmed or suspected thyroid disease
• To evaluate thyroid function when there are risk factors for thyroid disease

Not medically necessary

The use of thyroid function tests is considered not medically necessary when the criteria listed above are not met, including as a screening test in the absence of risk factors.

Specific clinical UM guidelines are located at CG-LAB-20—ThyroidTesting.

Clinical Indications for serum iron testing

Medically necessary

Serum iron testing is considered medically necessary for any of the following indications:

• Evaluation of suspected iron deficiency in individuals who meet any of the following criteria:
  • Abnormal blood counts consistent with iron deficiency including, but not limited to, the following:
    • Decreased mean corpuscular volume (MCV)
    • Decreased hemoglobin/hematocrit when the MCV is low or normal
    • Increased red cell distribution width (RDW) and low or normal MCV
  • Evidence of acute or chronic blood loss including, but not limited to, the following:
    • Gastrointestinal blood loss
    • Hematuria
    • Menorrhagia
  • Anemia associated with abnormal appetite, malnutrition, or malabsorption
  • Malignancy, chronic inflammation, or infection associated with iron deficiency
  • A lack of response to iron replacement therapy
  • Symptoms or clinical findings associated with iron deficiency
• Evaluation of suspected iron overload in individuals who meet any of the following criteria:
  • Diagnosis of a condition associated with iron overload
  • Symptoms or clinical findings associated with iron overload
• Evaluation of toxic effects of iron and other metals after exposure or for metabolic causes
• Evaluation of iron status following treatment for other nutritional deficiency anemias such as vitamin B12 or folate deficiency.
• Monitoring treatment response following iron replacement therapy or treatment with erythropoiesis-stimulating agents.

Not medically necessary

Serum iron testing is considered not medically necessary when the above criteria are not met, and for all other indications, including but not limited to the following:

• Screening of individuals in the absence of signs, symptoms, or medical history suggestive of iron dysregulation.
• During acute inflammation or infection where the results will not impact or direct treatment or disease management.
• After a normal serum ferritin level has been documented, monitoring iron status in the absence of signs or symptoms of iron imbalance.

Concurrent assessment of transferrin and TIBC is considered not medically necessary for any indication.

Specific Clinical UM Guidelines are located at CG-LAB-21—Serum Iron Testing.

What if I have questions?

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