Purpose
Retroactively
effective to January 1, 2024, the purpose of this document is to communicate
the addition of hemoglobin A1c blood test to the preventive coverage of
diabetes screening test and to update the frequency of the diabetes screening tests for Medicare Advantage members.
Background
Screening asymptomatic adults for prediabetes and type 2 diabetes may allow earlier detection, diagnosis, and treatment, with the ultimate goal of improving health outcomes. Prediabetes and type 2 diabetes can be detected by measuring fasting plasma glucose or HbA1c level, or with an oral glucose tolerance test.
Coverage Statement
COVERAGE
Diabetes screening tests are covered as a
preventive service for individuals who meet either of the following
criteria:
- The individual has any of the following risk factors:
- Hypertension
- Dyslipidemia
- Obesity (a body mass index greater than or equal to 30
kg/m2 )
- Previous identification of an elevated impaired fasting
glucose or glucose tolerance (pre-diabetes*)
- The individual has at least two of the following
characteristics:
- Overweight (a body mass index greater than 25 but less
than 30 kg/m2 )
- Family history of diabetes
- Aged 65 years or older
- A history of gestational diabetes mellitus or delivery
of a baby weighing greater than 9 pounds
Diabetes screening tests for
individuals previously diagnosed with diabetes are not considered a preventive
service and, therefore, are not eligible for coverage under the preventive
services benefit. * Pre-diabetes is a condition of abnormal glucose
metabolism diagnosed from a previous fasting glucose level of 100-125 mg/dL or
a 2-hour post-glucose challenge of 140-199 mg/dL. FREQUENCY
Diabetes screening tests are covered as preventive twice within a 12-month period.
Coding
CPT CODES
ICD-10 DIAGNOSIS CODES
Z13.1 Encounter for screening for diabetes mellitus