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Clinical Policy Bulletin:
Lead Testing
Number: 0553


Policy

Aetna considers lead testing medically necessary for diagnosis of persons with signs and symptoms of lead poisoning (e.g., lowered IQ scores, decreased attention span, impaired hearing, speech and other developmental delays, abdominal pain, headaches, vomiting, and constipation).

Aetna considers lead screening medically necessary for persons with occupational lead exposures.*  The United States Occupational Safety and Health Administration (OSHA) mandates lead testing for individuals who have workplace lead exposures.

* Note: Some plans exclude coverage of medical services required for work.  Please check benefit plan descriptions for details.

In addition, Aetna considers lead screening a medically necessary preventive health care service for children according to guidelines from the Centers for Disease Control and Prevention (CDC), the U.S. Preventive Services Task Force (USPSTF), the American Academy of Pediatrics (AAP), and the American Academy of Neurology (AAN).  Note: Some Aetna plans exclude coverage of preventive services.  Please check benefit plan descriptions.

The CDC, the USPSTF, the AAP, and the AAN recommend lead screening of preschool-age children in the following high-risk groups:

  • Are developmentally delayed; or
  • Are exposed to contaminated dust or soil; or
  • Are victims of abuse or neglect; or
  • Have abnormal oral behaviors (e.g., pica) which place them at risk; or
  • Have close contact with a person who has or had an elevated lead level; or
  • Have emigrated (or have been adopted) from countries where lead poisoning is prevalent; or
  • Have iron deficiency; or
  • Have unexplained illness (e.g., abdominal pain, lethargy, seizures and severe anemia); or
  • Live in communities in which the prevalence of lead levels requiring individual intervention, including residential lead hazard control or chelation, is high or undefined; or
  • Live in or frequently visit a home or child care facility built before 1950; or
  • Live in or regularly visit a home or child care facility built before 1978 that is being or has recently been renovated or remodeled; or
  • Live near lead industry or heavy traffic; or
  • Live with someone whose job or hobby involves lead exposures; or
  • Take traditional ethnic remedies that contain lead; or
  • Use lead-based pottery.

Note: No major organizations currently recommend routine screening of asymptomatic pregnant women for elevated lead levels.



Background

Lead poisoning is a potentially devastating condition that threatens about 5 % of American pre-schoolers.  When lead-based paint peels and chips off of older walls, it can be inhaled and cause permanent damage to a young child's nervous system.  Recurrent exposure to even small amounts of lead may result in lead poisoning since lead can accumulate in the body.  Neurobehavioral abnormalities of mild lead poisoning may manifest as lowered IQ scores, decreased attention span, impaired hearing, speech and other developmental delays; however, most children of pre-school age with mild lead poisoning are asymptomatic.  The probability of developing encephalopathy, the most serious complication of lead poisoning, increases as the exposure to lead and blood level of lead rises.  Encephalopathy may be preceded by abdominal pain, headaches, vomiting, and constipation.  The Centers for Disease Control and Prevention defines lead poisoning as a blood lead level of 10 mg/dL.  As sustained blood levels rise above 10 to 15 mg/dL, young children under age 6 years are at progressively increasing risk not only for future neurobehavioral and cognitive problems, but also for development of recurrent symptomatic episodes of physical manifestations of lead poisoning.

Screening for elevated lead levels in asymptomatic children at increased risk for lead exposure has been demonstrated to improve clinical outcomes.  If capillary blood is used as a screening test, elevated lead levels should be confirmed by measurement of venous blood lead.

The optimal frequency of screening for lead exposure in children, or for repeated testing of children previously found to have elevated blood lead levels, is unknown and is left to clinical discretion.

Kosnett et al (2007) summarized a body of published literature that establishes the potential for hypertension, effects on renal function, cognitive dysfunction, and adverse female reproductive outcome in adults with whole-blood lead concentrations less than 40 microg/dL.  Based on this literature, and these researchers' collective experience in evaluating lead-exposed adults, they recommended that individuals be removed from occupational lead exposure if a single blood lead concentration exceeds 30 microg/dL or if 2 successive blood lead concentrations measured over a 4-week interval are greatet than or equal to 20 microg/dL.  Removal of individuals from lead exposure should be considered to avoid long-term risk to health if exposure control measures over an extended period do not decrease blood lead concentrations to less than 10 microg/dL or if selected medical conditions exist that would increase the risk of continued exposure.  Recommended medical surveillance for all lead-exposed workers should include quarterly blood lead measurements for individuals with blood lead concentrations between 10 and 19 microg/dL, and sem-iannual blood lead measurements when sustained blood lead concentrations are les than 10 microg/dL.  It is advisable for pregnant women to avoid occupational or avocational lead exposure that would result in blood lead concentrations greater than 5 microg/dL.  Chelation may have an adjunctive role in the medical management of highly exposed adults with symptomatic lead intoxication but is not recommended for asymptomatic individuals with low blood lead concentrations.

The United States Occupational Safety and Health Administration (OSHA) mandates lead testing for individuals who have workplace lead exposures.  According to OSHA (1995), the blood lead level of all employees who are exposed to inorganic lead above 30 ug/m(3) for more than 30 days per year is to be determined at least every 6 months.  The frequency is increased to every 2 months for employees whose last blood lead level was between 40 ug/100 g whole blood.  For employees who are removed from exposure to lead due to an elevated blood lead, a new blood lead level must be measured monthly.

There is insufficient evidence to recommend for or against routine screening for lead exposure in asymptomatic pregnant women.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT Codes covered if selection criteria are met:
83655
ICD-9 codes covered if selection criteria are met (not all-inclusive):
280.0 - 280.9 Iron deficiency anemia
307.52 Pica
315.00 - 315.9 Specific delays in development
389.00 - 389.9 Hearing loss
564.00 - 564.09 Constipation
780.01 Coma
780.02 Transient alteration of awareness
780.39 Other convulsions
780.79 Other malaise and fatigue [lethargy]
781.3 Lack of coordination [ataxia]
783.0 Anorexia
783.40 - 784.43 Lack of expected normal physiological development in childhood
784.0 Headache
787.01 - 787.03 Nausea and vomiting
789.00 - 789.09 Abdominal pain
984.0 - 984.9 Toxic effect of lead and its compounds (including fumes)
995.52 Child neglect (nutritional)
995.59 Other child abuse and neglect
E861.5 Accidental poisoning by lead paints
E866.0 Accidental poisoning by lead and its compounds and fumes
E904.0 Abandonment or neglect of infants and helpless persons
V15.86 Exposure to lead


The above policy is based on the following references:
  1. U.S. Preventive Services Task Force. Screening for elevated lead levels in childhood and pregnancy. In: Guide to Clinical Preventive Services. 2nd ed. C DiGuiseppi, ed. Baltimore, MD: Williams & Wilkins; 1996:247-267.
  2. American Academy of Pediatrics Committee on Environmental Health. Screening for elevated blood lead levels. Pediatrics. 1998;101(6):1072-1078.
  3. Behrman RE, ed. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, PA: WB Saunders Co.; 2000:2156-2160.
  4. Benjamin JT, Platt C. Is universal screening for lead in children indicated: An analysis of lead results in Augusta, Georgia in 1997. J Med Assoc Ga. 1999;88(4):24-26.
  5. Berlin CM Jr. Lead poisoning in children. Curr Opin Pediatr. 1997;9(2):173-177.
  6. Silbergeld EK. Preventing lead poisoning in children. Annu Rev Public Health. 1997;18:187-210.
  7. Needleman HL. Childhood lead poisoning: The promise and abandonment of primary prevention. Am J Public Health. 1998;88(12):1871-1877.
  8. Filipek PA, Accardo PJ, Ashwal S, et al. Practice parameter: Screening and diagnosis of autism. Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society. Neurology. 2000;55(4):468-479.
  9. Sanborn MD, Abelsohn A, Campbell M, et al. Identifying and managing adverse environmental health effects: 3. Lead exposure. CMAJ. 2002;166(10):1287-1292.
  10. Shevell M, Ashwal S, Donley D, et al. Practice parameter: Evaluation of the child with global developmental delay: Report of the Quality Standards Subcommittee of the American Academy of Neurology and The Practice Committee of the Child Neurology Society. Neurology. 2003;60(3):367-380.
  11. American Academy of Pediatrics Committee on Environmental Health. Lead exposure in children: Prevention, detection, and management. Pediatrics. 2005;116(4):1036-1046.
  12. U.S. Preventive Services Task Force. Screening for elevated blood lead levels in children and pregnant women. Pediatrics. 2006;118(6):2514-2518.
  13. Rischitelli G, Nygren P, Bougatsos C, et al. Screening for elevated blood lead levels in childhood and pregnancy: Update of a 1996 U.S. preventive services task force review. Evidence Synthesis No. 44. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); December 2006.
  14. Centers for Disease Control and Prevention (CDC), Advisory Committee on Childhood. Interpreting and managing blood lead levels < 10 microg/dL in children and reducing childhood exposures to lead: Recommendations of CDC's Advisory Committee on Childhood Lead Poisoning Prevention. MMWR Recomm Rep. 2007;56(RR-8):1-16.
  15. Kosnett MJ, Wedeen RP, Rothenberg SJ, et al. Recommendations for medical management of adult lead exposure. Environ Health Perspect. 2007;115(3):463-471.
  16. U.S. Department of Labor, Occupational Safety and Health Services Administration (OSHA). Medical surveillance guidelines -- 1910.1025. App C. Regulations (Standards 29 CFR). Washington, DC: U.S. Department of Labor; October 11, 1995. Available at: http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10033. Accessed July 10, 2009.
  17. Warniment C, Tsang K, Galazka SS. Lead poisoning in children. Am Fam Physician. 2010;81(6):751-757.
  18. McLaine P, Navas-Acien A, Lee R, et al. Elevated blood lead levels and reading readiness at the start of kindergarten. Pediatrics. 2013;131(6):1081-1089.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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