CurrentBlue Cross Blue Shield - IllinoisPolicy CPCPLABOO4

Diabetes Mellitus Testing

This policy defines Blue Cross Blue Shield Illinois reimbursement criteria for laboratory testing related to diabetes mellitus (screening, diagnosis, and monitoring) and specifies when tests such as fasting plasma glucose, oral glucose tolerance test (OGTT), and hemoglobin A1c are reimbursable for members and providers.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyDiabetes Mellitus Testing

Policy CodePolicy CPCPLABOO4

Change TypeNew policy

Effective DateJan 1, 2026

Next Review Date

Key ActionSubmit accurate documentation and use valid HIPAA-approved code sets; review plan documents for product-specific coverage before billing.

SourceLink

POLICY UPDATE CHANGES

New policy created and made effective 01/01/2026.

multiplereimbursable testing frequencies described

3 testsprincipal laboratory tests referenced

listedexplicit non-reimbursable situations

yesage-specific recommendations included

Reimbursable and Non-reimbursable Diabetes Testing

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Reimbursable and non-reimbursable diabetes testing criteria

Covered when the following conditions or indications are met:

Measurement of plasma glucose for individuals with acute or persistent classic symptoms of diabetes mellitus.

ALL of the following

Upon initial diagnosis to establish a baseline value and to determine treatment goals.
Twice a year (every 6 months) in individuals who are meeting treatment goals and who, based on daily glucose monitoring, appear to have stable glycemic control.
Quarterly in individuals who are not meeting treatment goals for glycemic control.
Quarterly for individuals who are pregnant.
Quarterly in individuals whose pharmacologic therapy has changed.

For prediabetic individuals: annual screening for type 2 diabetes with a fasting plasma glucose test or measurement of hemoglobin A1c.

Asymptomatic individuals age ≥35 with no risk factors: screening for prediabetes or type 2 diabetes once every 3 years with a fasting plasma glucose test.

Individuals ≥18 years with risk factors (screen once every 3 years with fasting plasma glucose test or hemoglobin A1c). Examples of risk factors include: first-degree relatives of persons with diabetes; overweight or obesity; history of cardiovascular disease; hypercholesterolemia; hypertension; metabolic syndrome; acanthosis nigricans; metabolic dysfunction‑associated steatotic liver disease (MASLD); polycystic ovary syndrome; prior gestational diabetes.

ALL of the following

Persons positive for HIV: fasting plasma glucose screening reimbursable when starting or switching antiretroviral therapy (ART); 3–6 months after starting or switching ART; and annually if initial screening was normal.
Individuals ≥10 years with cystic fibrosis (without CF‑related diabetes): annual OGTT screening reimbursable.
Overweight or obese individuals <18 years: diabetes screening once every 3 years with fasting plasma glucose; OGTT; or hemoglobin A1c reimbursable when additional risk factors are present (family history in first‑ or second‑degree relatives; maternal history of diabetes or GDM during gestation; signs of insulin resistance or associated conditions).
Pregnant individuals: fasting plasma glucose test or OGTT up to once per month during pregnancy reimbursable.
Individuals diagnosed with gestational diabetes mellitus (GDM): OGTT reimbursable to screen for persistent diabetes or prediabetes 4–12 weeks postpartum and to confirm positive initial postpartum screening.

ALL of the following

Fasting plasma glucose testing at a wellness visit with no abnormal findings for situations not addressed above is not reimbursable.
Measurement of hemoglobin A1c is not reimbursable in situations not previously addressed. Specific non‑reimbursable situations include: to test for diabetes in individuals presenting with acute or persistent classic symptoms of diabetes mellitus; in pregnant individuals without an established diagnosis of diabetes or prediabetes; to screen for diabetes in individuals diagnosed with cystic fibrosis; in conjunction with measurement of fructosamine; and in individuals with conditions associated with increased red blood cell turnover (e.g., sickle cell disease, recent blood loss or transfusion, hemodialysis, erythropoietin therapy).

Procedure Codes and Testing Frequency

Procedure codes notemixed

The procedure code list is not exhaustive; inclusion does not guarantee coverage.

Hemoglobin A1c frequency thresholds

Twice-yearly (every 6 months)Hemoglobin A1c testing reimbursable twice a year for individuals meeting treatment goals and who, based on daily glucose monitoring, appear to have stable glycemic control.

Quarterly — not meeting goalsHemoglobin A1c testing reimbursable quarterly for individuals who are not meeting treatment goals for glycemic control.

Quarterly — pregnancyHemoglobin A1c testing reimbursable quarterly for individuals who are pregnant.

Quarterly — therapy changeHemoglobin A1c testing reimbursable quarterly when an individual’s pharmacologic therapy has changed.

Initial diagnosisHemoglobin A1c testing reimbursable upon initial diagnosis to establish a baseline value and to determine treatment goals.

Documentation, Coding, and Claims Review Requirements

Documentation Required

Documentation, coding, and product‑specific applicability

Providers must submit accurate documentation of services performed and code claims using valid HIPAA-approved code sets. Claims may be reviewed against benefit coverage, provider contract language, medical and coding policies, and coding software logic; upon request, providers should submit any additional documentation. Not all lab management reimbursement criteria apply to every product — providers should review applicable plan documents for eligible coverage.

Submit accurate documentation and supporting records when requested.
Use valid code combinations from HIPAA‑approved code sets (eg, CPT, HCPCS, ICD‑10).
Claims may be subject to review against plan documents, provider contracts, medical policies, and coding software logic.
Review product-specific plan documents to confirm whether reimbursement criteria apply.

Terminology and Specific Situations

Family member categories for risk assessment

First-degree relativesParents, full siblings, and children of the individual.

Second-degree relativesGrandparents, aunts, uncles, nieces, nephews, grandchildren, and half-siblings of the individual.

Use in risk assessmentThese family-member categories are used to identify individuals eligible for risk‑based diabetes screening (e.g., screening every 3 years for those ≥18 with risk factors).

Hemoglobin A1c non-reimbursable situations

Symptomatic individualsHemoglobin A1c should not be performed to test for diabetes in individuals presenting with acute or persistent classic symptoms of diabetes mellitus.

Pregnant without established diabetes/prediabetesHemoglobin A1c should not be performed in pregnant individuals without an established diagnosis of diabetes or prediabetes.

Cystic fibrosis screeningHemoglobin A1c should not be used to screen for diabetes in individuals diagnosed with cystic fibrosis.

Concurrent fructosamine measurementHemoglobin A1c should not be performed in conjunction with measurement of fructosamine.

Conditions with increased RBC turnoverHemoglobin A1c should not be performed in individuals with conditions associated with increased red blood cell turnover (e.g., sickle cell disease, recent blood loss or transfusion, hemodialysis, erythropoietin therapy, or HIV-positive individuals receiving hemodialysis/erythropoietin).

OpenPayer

Diabetes Mellitus Testing

Reimbursable and Non-reimbursable Diabetes Testing

Procedure Codes and Testing Frequency

Documentation, Coding, and Claims Review Requirements

Terminology and Specific Situations

Document History and Material Changes