Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
| Contract | Contractor | Type | States |
|---|---|---|---|
| 09102 | First Coast Service Options, Inc. | A and B MAC | FL |
| 09202 | First Coast Service Options, Inc. | A and B MAC | PR |
| 09302 | First Coast Service Options, Inc. | A and B MAC | VI |
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A57755 (Billing and Coding: Vitamin B<sub>12</sub> Injections) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A57755: Billing and Coding: Vitamin B<sub>12</sub> Injections (Billing and Coding, effective 2024-04-01)
- Covered ICD-10-CM codes
- 44
- 1 group
- Non-covered ICD-10-CM codes
- 1
- Procedure codes listed
- 2
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| D51.0 | — |
| D51.1 | — |
| D51.2 | — |
| D51.3 | — |
| D51.8 | — |
| D51.9 | — |
| D52.0 | — |
| D52.1 | — |
| D52.8 | — |
| D52.9 | — |
| D53.1 | — |
| D53.9 | — |
| D81.818 | — |
| D81.819 | — |
| E40 | Kwashiorkor |
| E41 | Nutritional marasmus |
| E42 | Marasmic kwashiorkor |
| E44.1 | — |
| E45 | Retarded development following protein-calorie malnutrition |
| E46 | Unspecified protein-calorie malnutrition |
| E53.8 | — |
| E64.0 | — |
| G32.0 | — |
| K29.30 | — |
Procedure codes: J3420 (Injection, Vitamin B-12 Cyanocobalamin, Up To 1000 Mcg), J3425 (Injection, Hydroxocobalamin, Intramuscular, 10 Mcg).
Coverage indications, limitations and medical necessity
Compliance with the provisions in this LCD may be monitored and addressed through post payment data analysis and subsequent medical review audits.
History/Background and/or General Information
Vitamin B 12 is essential for the formation of red blood cells and is used in the treatment of diseases in which there is defective red cell formation.
Covered Indications
Vitamin B 12 injection will be considered medically reasonable and necessary under the following circumstances:
• Vitamin B 12 administration by injection is a covered benefit accepted as medically necessary when the beneficiary has a history of a low serum B 12 or conditions causing or caused by a low serum B 12 .
In addition, vitamin B 12 will be considered medically reasonable and necessary when administered as an adjunct to pemetrexed or pralatrexate treatment as follows:
• For pemetrexed patients, patients must receive one intramuscular injection of vitamin B 12 during the week preceding the first dose of pemetrexed and every three cycles thereafter
• For pralatrexate patients, supplement patients with vitamin B 12 1 mg intramuscularly no more than 10 weeks prior to the first dose of pralatrexate, and every 8-10 weeks thereafter
Subsequent vitamin B 12 injections may be given the same day as either pemetrexed or pralatrexate.
Limitations
Please refer to CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual , Chapter 1, Part 2, Section 150.6 Vitamin B 12 Injections to Strengthen Tendons, Ligaments, etc., of the Foot regarding non coverage.
Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
Summary of evidence (opening)
N/A
the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2015-10-01
- Current revision effective
- 2021-01-01
- Last reviewed by the contractor
- 2018-04-25
- MCD version
- 25
- Derived from
- L29309
The contractor lists one National Coverage Determination as related: NCD 150.6 Vitamin B12 Injections to Strengthen Tendons, Ligaments, etc., of the Foot. Where an NCD speaks, it controls; the LCD can only address what the NCD leaves open.
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the First Coast Service Options, Inc. hub lists every other active policy from the same contractor.
Frequently asked questions
What does LCD L33967 cover?
Vitamin B 12 is essential for the formation of red blood cells and is used in the treatment of diseases in which there is defective red cell formation. The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L33967 apply to?
First Coast Service Options, Inc. applies it to Medicare claims in FL, PR, VI. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L33967?
The companion billing and coding article A57755 lists 44 ICD-10-CM codes in 1 group that support medical necessity and 1 that do not; the first 24 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L33967?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.