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Low serum B12 can mean that tissues are competing for limited holoTC in the bloodstream, and areas with high B12 turnover (including the bone marrow) may get priority, while the brain, liver and peripheral nerves do not receive enough

Other than patients who have had their stomachs bypassed, there is also an autoimmune condition known as pernicious anemia that leads to a deficiency of intrinsic factor, lack of ability to absorb vitamin B12 and therefore poor availability of cobalamin (vitamin B12)

This came just days after CMS issued the 2026 Final Rule