Lead Testing

Number: 0553

Policy

Aetna considers blood lead testing (measurement of blood lead level) 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. Footnotes 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.

Footnotes persons with occupational 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.

Aetna considers blood lead testing medically necessary for pregnant or lactating women who have any of the risk factors for lead exposure listed in Table 1 of the Appendix. Note: Routine blood lead testing for average-risk pregnant women without risk factors is not considered medically necessary.

Aetna considers measurement of lead in bone, hair, teeth, or urine experimental and investigational because the effectiveness of these approaches has not been established.

Note on Retesting Persons Previously Tested with Magellan Diagnostics LeadCare Analyzer:

The U.S. Food and Drug Administration (FDA) has recalled the Magellan Diagostics LeadCare Lead Test Analyzer. The Centers for Disease Control and Prevension (CDC) recommends that healthcare providers re-test persons who:

  1. are younger than 6 years (72 months) of age at the time of the alert (May 17, 2017); and
  2. had a venous blood lead test result of less than 10 micrograms per deciliter (μg/dL) analyzed using a Magellan Diagnostics LeadCare analyzer at an onsite (e.g., healthcare facility) or at an offsite laboratory.

The CDC also recommends that healthcare providers re-test currently pregnant or lactating women whose previous test was with the Magellan Diagnostics LeadCare Analyzer.

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.

An UpToDate review on “Adult lead poisoning” (Goldman and Hu, 2015) states that “Laboratory testing -- The key clinical monitoring test for diagnosing lead toxicity is the blood lead level [BLL].  Measuring lead in urine, hair, or other media is not as accurate or reliable.  The blood lead level is a good indicator of exposure that has occurred within the previous few weeks.  In interpreting the results, it is important to use levels appropriate to adult toxicity, rather than children's (which sometimes are the ranges of concern reported by the testing laboratories)”.

An UpToDate review on “Childhood lead poisoning: Clinical manifestations and diagnosis” (Hurwitz and Lee, 2015) states that “Bone and dentine lead levels, measured by K x-ray fluorescence spectroscopy or atomic absorption spectroscopy, respectively, are better indicators of the child's total lead burden than BLLs.  However, these tests are not routinely available, and are not recommended by the Centers for Disease Control and Prevention (CDC).  BLLs remain the gold standard for the diagnosis of lead poisoning in children”.

Per the American College of Obstetricians and Gynecologists (ACOG, 2012), routine blood lead testing of all pregnant women is not recommended; however, risk assessment of lead exposure should take place at the earliest contact with pregnant or lactating women. If a single risk factor is identified (see Table 1 in Appendix), blood lead testing should be performed.

Appendix

Table: Risk Factors for Lead Exposure in Pregnant and Lactating Women
Risk Factors for Lead Exposure in Pregnant and Lactating Women
Recent emigration from or residency in areas where ambient lead contamination is high—women from countries where leaded gasoline is still being used (or was recently phased out) or where industrial emissions are not well controlled.
Living near a point source of lead—examples include lead mines, smelters, or battery recycling plants (even if the establishment is closed).
Working with lead or living with someone who does—women who work in or who have family members who work in an industry that uses lead (e.g., lead production, battery manufacturing, paint manufacturing, ship building, ammunition production, or plastic manufacturing).
Using lead-glazed ceramic pottery—women who cook, store, or serve food in lead-glazed ceramic pottery made in a traditional process and usually imported by individuals outside the normal commercial channels.
Eating nonfood substances (pica)—women who eat or mouth nonfood items that may be contaminated with lead, such as soil or lead-glazed ceramic pottery.
Using alternative or complementary substances, herbs, or therapies—women who use imported home remedies or certain therapeutic herbs traditionally used by East Indian, Indian, Middle Eastern, West Asian, and Hispanic cultures that may be contaminated with lead.
Using imported cosmetics or certain food products—women who use imported cosmetics, such as kohl or surma or certain imported foods or spices that may be contaminated with lead.
Engaging in certain high-risk hobbies or recreational activities—women who engage in high-risk activities (e.g., stained glass production or pottery making with certain leaded glazes and paints) or have family members who do.
Renovating or remodeling older homes without lead hazard controls in place—women who have been disturbing lead paint, creating lead dust, or both or have been spending time in such a home environment.
Consumption of lead-contaminated drinking water—women whose homes have leaded pipes or source lines with lead.
Having a history of previous lead exposure or evidence of elevated body burden of lead—women who may have high body burdens of lead from past exposure, particularly those who have deficiencies in certain key nutrients (calcium or iron).
Living with someone identified with an elevated lead level—women who may have exposure in common with a child, close friend, or other relative living in the same environment. 

Source: The American College of Obstetricians and Gynecologists (ACOG, 2012).

Table: CPT Codes / HCPCS Codes / ICD-10 Codes
Code Code Description

Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":

CPT Codes covered if selection criteria are met:
83655 Lead [not covered for measurement of lead in bone, hair, teeth, or urine]

ICD-10 codes covered if selection criteria are met (not all-inclusive):
D50.0 - D50.9 Iron deficiency anemia
F50.81 - F50.89 Other eating disorders [Pica in adults]
F80.0 - F89 Pervasive and specific developmental disorders
F98.3 Pica of infancy and childhood
G40.001 - G40.919 Epilepsy and recurrent seizures
G44.1 Vascular headache, not elsewhere classified
H90.0 - H91.93 Conductive and sensorineural hearing loss
K59.00 - K59.09 Constipation
O26.891 - O26.899 Other specified pregnancy related conditions [lead exposure]
R10.0 - R10.13
R10.30 - R10.829
R10.84 - R10.9		 Abdominal pain
R11.0 - R11.2 Nausea and vomiting
R27.0 Ataxia, unspecified
R40.20 - R40.3 Coma
R40.4 Transient alteration of awareness
R51 Headache
R53.0 - R53.1
R53.81, R53.83		 Other malaise and fatigue [lethargy]
R56.9 Unspecified convulsions
R62.0 - R62.59 Lack of expected normal physiological development in childhood
R63.0 Anorexia
T56.0X1+ - T56.0X4+ Toxic effect of lead and its compounds
T74.02X+ Child neglect or abandonment, confirmed
T74.92X+ Unspecified child maltreatment, confirmed
Z00.121 Encounter for routine child health examination with abnormal findings
Z13 Encounter for screening for other diseases and disorders
Z57.2 Occupational exposure to dust [lead exposure]
Z57.4 Occupational exposure to toxic agents in agriculture [lead exposure]
Z57.8 Occupational exposure to other risk factors [lead exposure]
Z77.011 Contact with and (suspected) exposure to lead

ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):
Z33.1 Pregnant state, incidental
Z34.0 - Z34.93 Encounter for supervision of normal first pregnancy

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.
  19. Goldman RH, Hu H. Adult lead poisoning. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed April 2015.
  20. Hurwitz RL, Lee DA. Childhood lead poisoning: Clinical manifestations and diagnosis. UpToDate [online serial]. Waltham, MA: UpToDate; reviewed April 2015.
  21. Specht AJ, Weisskopf MG, Nie LH. Theoretical modeling of a portable x-ray tube based KXRF system to measure lead in bone. Physiol Meas. 2017;38(3):575-585.
  22. Groskopf C, Bennett SR, Gherase MR, Fleming DE. Detection of lead in bone phantoms and arsenic in soft tissue phantoms using synchrotron radiation and a portable x-ray fluorescence system. Physiol Meas. 2017;38(2):374-386.
  23. Centers for Disease Control and Prevention (CDC). Potential for falsely low blood lead test results from LeadCare® analyzers. CDC Health Advisory. Distributed by CDC Health Alert Network. CDCHAN-00403. Atlanta, GA: CDC; May 17. 2017.
  24. American College of Obstetricians and Gynecologists (ACOG), Committee on Obstetric Practice. Lead screening during pregnancy and lactation. Committee Opinion No. 533. Washington, DC: ACOG; August 2012. Reaffirmed 2018. Available at: https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Lead-Screening-During-Pregnancy-and-Lactation?IsMobileSet=false. Accessed December 4, 2018.