This policy is intended to apply to blood samples used to determine glucose levels.

Blood glucose determination may be done using whole blood, serum or plasma.  It may be sampled by capillary puncture, as in the fingerstick method, or by vein puncture or arterial sampling.  The method for assay may be by color comparison of an indicator stick, by meter assay of whole blood or a filtrate of whole blood, using a device approved for home monitoring, or by using a laboratory assay system using serum or plasma.  The convenience of the meter or stick color method allows a patient to have access to blood glucose values in less than a minute or so and has become a standard of care for control of blood glucose, even in the inpatient setting.

Diabetes Screening

Diabetes screening tests are defined as testing furnished to individuals at risk for diabetes, including: (1) a fasting blood glucose test, and (2) a post-glucose challenge test.

Diabetes mellitus is a condition of abnormal glucose metabolism diagnosed from a fasting blood sugar > 126 mg/dL on 2 different occasions; a 2-hour post-glucose challenge > 200 mg/dL on 2 different occasions; or a random glucose test > 200 mg/dL for an individual with symptoms of uncontrolled diabetes.

Pre-diabetes is abnormal glucose metabolism diagnosed from a previous fasting glucose level of 100 to 125 mg/dL, or a 2-hour post-glucose challenge of 140 to 199 mg/dL. The term “pre-diabetes” includes impaired fasting glucose and impaired glucose tolerance.

A post-glucose challenge test is an oral glucose tolerance test with a glucose challenge of 75 gms. of glucose for non-pregnant adults, or a 2-hour post-glucose challenge test alone.

Indications

Blood glucose values are often necessary for the management of patients with diabetes mellitus, where hyperglycemia and hypoglycemia are often present.  They are also critical in the determination of control of blood glucose levels in the patient with impaired fasting glucose (FPG 110-125 mg/dL), the patient with insulin resistance syndrome and/or carbohydrate intolerance (excessive rise in glucose following ingestion of glucose or glucose sources of food), in the patient with a hypoglycemia disorder such as nesidioblastosis or insulinoma, and in patients with a catabolic or malnutrition state.  In addition to those conditions already listed,  glucose testing may be medically necessary in patients with tuberculosis, unexplained chronic or recurrent infections, alcoholism, coronary artery disease (especially in women), or unexplained skin conditions (including pruritis, local skin infections, ulceration and gangrene without an established cause).  Many medical conditions may be a consequence of a sustained elevated or depressed glucose level.  These include comas, seizures or epilepsy, confusion, abnormal hunger, abnormal weight loss or gain, and loss of sensation.  Evaluation of glucose may also be indicated in patients on medications known to affect carbohydrate metabolism.

Diabetes Screening

Individuals who have any of the following risk factors for diabetes are eligible for diabetes screening tests (82947, 82950, 82951):

• Hypertension;
• Dyslipidemia;
• Obesity (a body mass index equal to or greater than 30 kg/m2), or
• Previous identification of elevated impaired fasting glucose or glucose intolerance.

Or, individuals who have a risk factor consisting of at least two of the following characteristics are eligible for diabetes screening tests (82947, 82950, 82951):

• Overweight (a body mass index > 25, but < 30 kg/m2),
• A family history of diabetes,
• Age 65 years or older,
• A history of gestational diabetes mellitus, or delivering a baby weighing > 9 lbs.
  

Limitations

Frequent home blood glucose testing by diabetic patients should be encouraged.  In stable, non-hospitalized patients who are unable or unwilling to do home monitoring, it may be reasonable and necessary to measure quantitative blood glucose up to four times annually.

Depending upon the age of the patient, type of diabetes, degree of control, complications of diabetes, and other co-morbid conditions, more frequent testing than four times annually may be reasonable and necessary.

In some patients presenting with nonspecific signs, symptoms, or diseases not normally associated with disturbances in glucose metabolism, a single blood glucose test may be medically necessary.  Repeat testing may not be indicated unless abnormal results are found or unless there is a change in clinical condition.  If repeat testing is performed, a specific diagnosis code (e.g., diabetes) should be reported to support medical necessity.  However, repeat testing may be indicated where results are normal in patients with conditions where there is a confirmed continuing risk of glucose metabolism abnormality (e.g., monitoring glucocorticoid therapy).

With the exception of routine or screening, any diagnosis other than those listed under the “Covered Diagnosis Codes” section will be denied as not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost.  The member must agree in writing to assume financial responsibility, in advance of receiving the service.  The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Blood Glucose testing for routine or screening purposes other than diabetes screening is excluded from coverage.  Therefore, any diagnosis code listed under the “Screening Diagnosis Codes” section will deny as not covered.

Diabetes Screening

Two screening tests per year (12 months) are covered for individuals diagnosed with pre-diabetes. 

One screening test per year (12 months) is covered for individuals previously tested who were not diagnosed with pre-diabetes, or who have never been tested. 

No coverage is provided for screening tests for individuals previously diagnosed as diabetic since these individuals do not require screening. 

NOTE:

A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without a diagnosis code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. Also, if a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency.

Documentation Requirements

Failure to provide documentation of the medical necessity of tests may result in denial of claims. Such documentation may include notes documenting relevant signs, symptoms or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial.

The ordering physician must include evidence in the patient’s clinical record that an evaluation of history and physical preceded the ordering of glucose testing and that manifestations of abnormal glucose levels were present to warrant the testing.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Diabetes Screening

Report diagnosis code V77.1 with code 82947, 82950, or 82951 to indicate that the purpose of the test(s) is for diabetes screening for a member who does not meet the definition of pre-diabetes.

Report diagnosis code V77.1 and modifier TS (follow-up service) with code 82947, 82950, or 82951 to indicate the purpose of the test(s) is for diabetes screening of a pre-diabetic member.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section states that no payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e). This section prohibits payment for any claim that lacks the necessary information to process the claim.

Title XVIII of the Social Security Act, Section 1156(a)(1). This section states that the healthcare practitioner must assure services will be provided economically and only when, and to the extent, medically necessary.

Transmittal AB-00-108, Change Request 1362

Transmittal 28, Change Request 3690

Transmittal 651, Change Request 4005

Transmittal 758, CR 4161

Transmittal 864, CR 4328

Transmittal 1050, CR 5293

Transmittal 1606, CR 6213

Transmittal 1645, CR 6304

Transmittal 1684, CR 6383

Transmittal 1766, CR 6548

Transmittal 1963, CR 6964

Transmittal 2001, CR 7057

Covered Diagnosis Codes (Applicable to 82947, 82948, 82962)

(Additional covered diagnosis code V77.1 applicable to 82947, 82950, 82951)

Non-covered Diagnosis Codes

(Noncovered diagnosis code V77.1 not applicable to 82947, 82950, 82951)

Screening Diagnosis Codes (Applicable to 82947, 82948, 82950, 82951, 82962)