LCD L35074: Heavy Metal Testing

The term heavy metal testing is historically used to describe elements such as lead, arsenic, mercury, cadmium, and chromium. In general, all of the heavy metals in inorganic form cause GI irritation, resulting in nausea, vomiting, abdominal pain and diarrhea. The next most consistent toxicity for the heavy metals as a group, but not for every heavy metal, is renal toxicity. A further generalization is that each member of the heavy metal group tends to cause multi-organ toxicity. Many metals cause cutaneous abnormalities, such as irritant and allergic contact dermatitis, urticaria, keratoses, and premalignant and malignant lesions. Several of the heavy metals produce central and peripheral nervous system toxicity. Other metals cause pulmonary illness.

However, before any testing for heavy metal is ordered, a detailed medical history of the patient must be obtained, including a careful documentation of occupational and avocational exposure to these toxins. A complete physical examination must be done. While classified as heavy metals, this policy does not include iron or lithium since the former is typically tested for anemia issues, discussed in National Coverage Determination 110.10 (Intravenous Iron Therapy), and the latter is typically tested for monitoring of medications. In addition, iron testing is covered under the National Coverage Determination 190.18 (Serum Iron Studies).

1. Aluminum. Serum aluminum testing is payable for beneficiaries who have been on dialysis with evidence suggesting aluminum toxicity, or for beneficiaries with chronic industrial exposure history

2. Antimony. Serum and/or urine antimony testing is payable for beneficiaries with documented treatment in the past with antileishmaniasis agents or with documented chronic antimony industrial exposure history.

3. Arsenic. Serum and whole blood and/or urine arsenic testing is payable for beneficiaries with unexplained peripheral neuropathies, industrial exposure to arsenic, histories of arsenic pesticide exposure, unexplained encephalopathies, unexplained weight loss, chronic glomerulonephritis, bone marrow hypoplasia, or melanosis of skin, unexplained chronic diarrhea, persistent abdominal pain, or nausea and vomiting.

4. Barium. Serum and or/urine barium testing is payable for beneficiaries with pulmonary disease with industrial exposure to barium or unexplained flaccid paralysis.

5. Beryllium. Serum and/or urine beryllium testing is payable for beneficiaries with pulmonary disease with industrial exposure to beryllium.

6. Bismuth. Serum and/or urine bismuth testing is payable for beneficiaries with bismuth lines on their gums, methemoglobinemia, unexplained pathological fractures, or a history of bismuth medicine abuse.

7. Cadmium. Serum and whole blood and/or urine cadmium testing is payable for beneficiaries with an exposure to cadmium with evidence of pulmonary disease or unexplained renal failure.

8. Chromium. Serum chromium testing is payable for beneficiaries with an industrial exposure to chromium with evidence of pulmonary disease.

9. Cobalt. Serum cobalt testing is payable for beneficiaries with an industrial exposure to cobalt with evidence of pulmonary disease

10. Copper. Serum copper testing is payable for beneficiaries with an industrial exposure to copper with evidence of pulmonary disease, for beneficiaries with Wilson’s Disease, unexplained cardiomyopathy, unexplained renal failure, polycythemia. unexplained myelodysplastic syndrome or known ingestion of zinc.

11. Lead. Blood (serum and whole) and/or urine lead testing is covered if there is documented industrial exposure to lead, documented avocation exposure to lead, retained bullet fragments at or near joints, a blue gum line, a history of moonshine abuse, unexplained peripheral neuropathies, evidence of lead contaminated drinking water, paint stripping, lead lines on bones on radiographs, or basophilic stippling of red blood cells.

12. Manganese. Serum manganese testing is covered for beneficiaries with documented industrial exposure to manganese.

13. Mercury. Serum, whole blood, and/or urine mercury testing is covered for beneficiaries with documented industrial exposure to mercury, with a blue line in their mouth, those with a history of laxative abuse, with a history of pesticide exposure, mercury spillage with vacuuming of the liquid metal, unexplained renal failure, or a history of skin lightening treatments.

14. Molybdenum. Serum molybdenum testing is covered for beneficiaries with documented industrial exposure to molybdenum.

15. Nickel. Serum and/or urine nickel testing is covered for beneficiaries with documented industrial exposure to nickel, unexplained renal failure, unexplained pulmonary disease.

16. Selenium. Serum and/or urine selenium testing is covered for beneficiaries with documented industrial exposure to selenium or on chronic renal dialysis.

17. Thallium. Serum thallium testing is covered for beneficiaries with documented industrial exposure to thallium and unexplained ataxia.

18. Tin. Serum tin testing is covered for beneficiaries with documented industrial exposure to tin.

19. Titanium. Serum titanium testing is covered for beneficiaries with documented industrial exposure to titanium.

20. Zinc. Serum zinc and/or urine testing is covered for beneficiaries with documented industrial exposure to zinc, on chronic renal dialysis, with malabsorption syndromes, Crohn’s disease, unexplained myelodysplastic syndrome or known ingestion of zinc. Zinc testing is not covered for the assessment and supplementation for the treatment of depression.

21. Testings for the following metals are non-covered: Boron, Phosphorous, Silica, Strontium, Sulfur, Uranium, Vanadium

Documented recent, long-term total parenteral nutrition (TPN) with clinical trace element deficiency evidence is an acceptable medical indication for testing for copper, manganese, and zinc.

Zinc deficiency is characterized by growth retardation, loss of appetite, and impaired immune function as well as hair loss, diarrhea, impotence, hypogonadism in males, eye and skin lesions, weight loss, delayed healing of wounds, and taste abnormalities in more severe cases. 1 Zinc nutritional status is difficult to measure adequately using laboratory tests. Plasma or serum zinc levels are the most commonly used indices for evaluating zinc deficiency, but these levels do not necessarily reflect cellular zinc status. 1 It has been suggested that zinc and other micronutrients might influence depression. 2 A recent meta-analysis assessing the relationship between zinc deficiency and depression concluded that there is insufficient evidence demonstrating a causal effect. Furthermore, the authors noted that "the relationship between serum zinc levels and depression could be partially explained by reverse causation, whereby depression influences the intake, bioavailability or biological regulation of zinc". Therefore, zinc assessment and supplementation for the treatment of depression is considered not medically necessary.