mp-378 - Medical Policies - Alabama
Intracellular Micronutrient Analysis
Policy Number: MP-378
Latest Review Date: December 2020
Policy Grade: D
Functional Intracellular Analysis (FIA), intracellular micronutrient panel testing, and all other live blood cell testing of intracellular nutritional status is considered not medically necessary and investigational.
DESCRIPTION OF PROCEDURE OR SERVICE:
Commercial laboratories offer panels of tests evaluating intracellular levels of micronutrients (essential vitamins and minerals). Potential uses of these tests include screening for nutritional deficiencies in healthy people or those with chronic disease and aiding in the diagnosis of disease in patients with nonspecific symptoms.
This evidence review evaluates laboratory tests that measures the intracellular levels of micronutrients. This testing, also known as intracellular micronutrient analysis, micronutrient testing, or functional intracellular analysis, is sometimes claimed to be superior to serum testing because intracellular levels reflect more stable micronutrient levels over longer time periods compared with serum levels, because intracellular levels are not influenced by recent nutrition intake. However, the relationship between serum and intracellular levels of micronutrients is complex. The balance of intracellular and extracellular levels depend on a number of factors, including the physiology of cellular transport mechanisms and the individual cell type.
At least two commercial laboratories offer intracellular testing for micronutrients. Laboratories perform a panel of tests evaluating the intracellular level of a variety of micronutrients (e.g. minerals, vitamins, amino acids, fatty acids). The test offered by IntraCellular Diagnostics evaluates epithelial cells from buccal swabs and assesses levels of intracellular mineral electrolyte (i.e., magnesium, calcium, potassium, phosphorus, sodium, and chloride). SpectraCell Laboratories offers a panel of tests that evaluates the intracellular status of micronutrients within lymphocytes in blood samples. The micronutrients measured by the test are as follows:
- Vitamins: Vitamins A, B1, B2, B3, B6, B12, C, D, K; biotin, folate, pantothenic acid
- Minerals: calcium, magnesium, zinc, copper
- Antioxidants: α-lipoic acid, coenzyme Q10, cysteine, glutathione, selenium, vitamin E
- Amino acids: asparagine, glutamine, serine
- Carbohydrate metabolism: chromium, fructose sensitivity, glucose-insulin metabolism
- Fatty acids: oleic acid
- Metabolites: choline, inositol, carnitine
The SpectraCell micronutrient panel also may include SPECTROX™ for evaluation of the total antioxidant function.
The most recent literature review was updated through October 16, 2020.
Summary of Evidence
For individuals who have chronic diseases or nonspecific generalized symptoms who receive intracellular micronutrient analysis, the evidence includes observational studies. Relevant outcomes are symptoms, and change in disease status. No studies were identified that evaluated the clinical validity or clinical utility of intracellular micronutrient testing compared with standard testing for vitamin or mineral levels. Limited data from observational studies are available on correlations between serum and intracellular micronutrient levels. No randomized controlled trials or comparative studies were identified that evaluated the direct health impact of intracellular micronutrient testing. Moreover, there are not sufficient data to construct a chain of evidence that intracellular micronutrient testing would likely lead to identifying patients whose health outcomes would be improved compared with alternative approaches to patient management. The evidence is insufficient to determine the effects of the technology on health outcomes.
Practice Guidelines and Position Statements
No practice guidelines or position statements were identified.
U.S. Preventive Services Task Force Recommendations
Functional intracellular analysis (FIA), essential metabolic analysis, micronutrient testing, comprehensive nutritional panel, SpectraCell, IntraCellular Diagnostics, SpectraCell’s micronutrient test, IntraCellular Diagnostics ExaTest, intracellular micronutrient analysis, SPECTROX®, bostonheart diagnostic®, Fatty Acid Balance test
APPROVED BY GOVERNING BODIES:
Clinical laboratories may develop and validate tests in-house and market them as a laboratory service; laboratory-developed tests (LDTs) must meet the general regulatory standards of the Clinical Laboratory Improvement Amendments (CLIA). Laboratories that offer LDTs must be licensed by CLIA for high-complexity testing. To date, the U.S. Food and Drug Administration has chosen not to require any regulatory review of this test.
Coverage is subject to member’s specific benefits. Group specific policy will supersede this policy when applicable.
ITS: Home Policy provisions apply
FEP contracts: FEP does not consider investigational if FDA approved and will be reviewed for medical necessity.
There is no specific CPT code for this panel of testing. Some of the elements of this testing might be reported with the codes below:
Fatty acids, nonesterified
Vitamin, not otherwise specified
Unlisted chemistry procedure
Lymphocyte transformation, mitogen (phytomitogen) or antigen induced blastogenesis
Electron microscopy, diagnostic
- Barrett S. Dubious diagnostic tests. Quackwatch: Your guide to Quackery, Health Fraud, and Intelligent Decisions, www.quackwatch.org.
- Department of Health and Human Services – Office of Inspector General. CLIA Regulation of Unestablished Laboratory Tests. July 2001. oig.hhs.gov/oei/reports/oei-05-00-00250.pdf.
- Fairfield KM, et al. Vitamins for chronic disease prevention in adults: Scientific review. JAMA, June 2002; 287(23): 3116-3126.
- Fletcher RH, et al. Vitamins for chronic disease prevention in adults: Clinical applications. JAMA, June 2002; 287(23): 3127-3129.
- Haigney MC, Berger R, Schulman S et al. Tissue magnesium levels and the arrhythmic substrate in humans. J Cardiovasc Electrophysiol 1997; 8(9):980-6.
- Haigney MC, Silver B, Tanglao E et al. Noninvasive measurement of tissue magnesium and correlation with cardiac levels. Circulation 1995; 92(8):2190-7.
- Houston MC. The role of cellular micronutrient analysis, nutraceuticals, vitamins, antioxidants and minerals in the prevention and treatment of hypertension and cardiovascular disease. Ther Adv Cardiovasc Dis 2010; 49(3):165-83.
Medical Policy Group, August 2009 (3)
Medical Policy Administration Committee, August 2009
Available for comment August 21-October 5, 2009
Medical Policy Group, August 2010 (1): New key words added, no coverage change
Medial Policy Panel, July 2011
Medical Policy Group, August 2011 (2): Title change, Description change, Addition to coverage policy statement, Update to Key Points, Key Words, Government Approval, References.
Medical Policy Administration Committee, August 2011
Available for comment August 11 – September 26, 2011
Medical Policy Panel, July 2012
Medical Policy Group, September 2012 (2): Key Points updated.
Medical Policy Group, January 2012 (2): Description, Key Points & References updated; policy statement remains unchanged
Medical Policy Panel, July 2013
Medical Policy Group, September 2013 (1): Policy updated with literature search through July 2013; no change to policy statement
Medical Policy Panel, July 2014
Medical Policy Group, July 2014, (1): Policy updated with literature search through June 2014; no change to policy statement
Medical Policy Panel, July 2015
Medical Policy Group, July 2015 (3): 2015 updates to Key Points and Benefit Application, no change to policy statement.
Medical Policy Group, August 2015 (3): added bostonheart diagnostics® and fatty acid balance test to Key Words
Medical Policy Panel, March 2017
Medical Policy Group, March 2017 (3): 2017 Updates to Key Points, Key Words & Coding Section, no References added; No change to policy statement.
Medical Policy Panel, March 2018
Medical Policy Group, March 2018 (4): Updates to Description and Key Points. No change to policy statement.
Medical Policy Panel, December 2018
Medical Policy Group, January 2019 (9): 2018 Updates to Description & Key Points. No change to policy statement.
Medical Policy Panel, December 2019
Medical Policy Group, December 2019 (9): 2019 Updates to Description, Key Points. No change to policy statement. Placed Current CPT Codes into table for ease of reading, no changes to codes.
Medical Policy Panel, December 2020
Medical Policy Group, December 2020 (9): 2020 Updates to Description, Key Points. No references added. No change to policy statement.
This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.
The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.
As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.
The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:
1. The technology must have final approval from the appropriate government regulatory bodies;
2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3. The technology must improve the net health outcome;
4. The technology must be as beneficial as any established alternatives;
5. The improvement must be attainable outside the investigational setting.
Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:
1. In accordance with generally accepted standards of medical practice; and
2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3. Not primarily for the convenience of the patient, physician or other health care provider; and
4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.