ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPLAB004

Diabetes Mellitus Testing

Defines Blue Cross Blue Shield of New Mexico reimbursement criteria for laboratory testing related to diagnosis and monitoring of diabetes mellitus and prediabetes, and indicates which patient populations and frequencies are eligible for reimbursement.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyDiabetes Mellitus Testing

Policy CodePolicy CPCPLAB004

Change TypeMaterial coverage updates (pregnancy, MASLD, age-based screening) and editorial removals

Effective DateSep 26, 2025

Next Review DateN/A

Key ActionSubmit accurate documentation supporting reimbursable diabetes-related laboratory tests and provide additional records upon request.

SourceLink

POLICY UPDATE CHANGES

Added quarterly testing for individuals who are pregnant to reimbursement information (#2e).

Added reimbursement criterion for individuals with metabolic dysfunction-associated steatotic liver disease (MASLD) (#5i).

Added new reimbursement statement allowing screening for asymptomatic individuals age 35+ once every three years with fasting plasma glucose.

Added new statement that for all other situations not addressed, fasting plasma glucose testing at a wellness visit with no abnormal findings is not reimbursable (#11).

Removed Note 1 from Reimbursement Information.

11enumerated reimbursement rules/conditions

6procedure codes listed

3yr

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Coverage and Reimbursement Criteria

Main coverage criteria

Reimbursable testing and frequency criteria

ALL of the following

ANY of the following
- Individuals with acute or persistent classic symptoms of diabetes mellitus; measurement of fasting plasma glucose may be reimbursable.
ANY of the following
- Individuals with a diagnosis of type 1 or type 2 diabetes; hemoglobin A1c may be reimbursable in any of the following situations:
- 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 in individuals whose pharmacologic therapy has changed.
  - Quarterly for individuals who are pregnant.
ANY of the following
- For prediabetic individuals, annual screening for type 2 diabetes with a fasting plasma glucose test or measurement of hemoglobin A1c may be reimbursable.
ANY of the following
- Asymptomatic individuals 35 years of age or older with no risk factors: screening for prediabetes or type 2 diabetes once every three years with a fasting plasma glucose test may be reimbursable.
ANY of the following
- Individuals 18 years of age or older with any of the following risk factors: overweight or obese; first-degree relatives of individuals with diabetes; history of cardiovascular disease; hypertension; hypercholesterolemia; metabolic syndrome; obesity with acanthosis nigricans; polycystic ovary syndrome; metabolic dysfunction-associated steatotic liver disease (MASLD). Screening once every three years with a fasting plasma glucose test or measurement of hemoglobin A1c may be reimbursable.
ANY of the following
- Individuals positive for HIV: screening with a fasting plasma glucose test may be reimbursable at ART initiation, at ART switch, 3–6 months after starting or switching ART, and annually when initial screening results were normal.
ANY of the following
- Individuals 10 years of age and older diagnosed with cystic fibrosis but not CF-related diabetes: annual screening for CF-related diabetes with an OGTT may be reimbursable.
ANY of the following
- Overweight or obese individuals less than 18 years of age with risk factors (maternal history of diabetes/GDM during gestation; family history of type 2 diabetes in first- or second-degree relatives; signs of insulin resistance or conditions associated with insulin resistance): diabetes screening once every three years with a fasting plasma glucose test, an OGTT, or measurement of hemoglobin A1c may be reimbursable.
ANY of the following
- Pregnant individuals: a fasting plasma glucose test or an OGTT up to once per month during pregnancy may be reimbursable.
ANY of the following
- Individuals diagnosed with gestational diabetes mellitus (GDM): an OGTT may be reimbursable to screen 4–12 weeks postpartum; if initial postpartum screening is positive, repeat screening to confirm diagnosis of persistent diabetes or prediabetes may be reimbursable.
ALL of the following
- For all other situations not addressed above, fasting plasma glucose testing at a wellness visit with no abnormal findings is not reimbursable.
- Measurement of hemoglobin A1c should not be performed in the following situations: 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; in individuals with a condition associated with increased red blood cell turnover (e.g., sickle cell disease, HIV positive individuals receiving hemodialysis or erythropoietin therapy, recent blood loss or transfusion).

ALL of the following

See Notes for definitions of first- and second-degree relatives and Note 2 for hemoglobin A1c exceptions.

Reimbursement criteria excerpts

Recent and prior reimbursement statements (numbered) specify covered testing intervals and populations.

ANY of the following

Quarterly diabetes testing was added as reimbursable for individuals who are pregnant (policy update added #2e).

ANY of the following

Reimbursement information was updated to add screening/reimbursement for individuals with metabolic dysfunction-associated steatotic liver disease (MASLD) (policy update added #5i).

ANY of the following

Screening for asymptomatic individuals 35 years or older with no risk factors may be reimbursable once every three years with a fasting plasma glucose test (added as new #4).

ANY of the following

Procedure Codes and Testing Frequencies

Listed procedure codesCPT

82947	Glucose; quantitative, blood (except reagent strip)
82951	Glucose; tolerance test (GTT), 3 specimens (incl. glucose) (deprecated/legacy mapping)
82952	Glucose; tolerance test, each additional beyond 3 (legacy)
82985	Glucose, blood, other (may represent point-of-care)
83036	Hemoglobin; glycosylated (A1C)
83037	Hemoglobin; glycosylated (A1C) by device cleared for home use

Reference guidance coded entrymixed

References and guideline sources cited for diagnostic and management guidance (USPSTF, WHO, AAFP, Endocrine Society, NICE, AACE, ADA-related laboratory guidance, KDIGO, MASLD overview).

Hemoglobin A1c — Stable control

A1c frequency when meeting goalsTwice a year (every 6 months)

Applies toIndividuals with a diagnosis of type 1 or type 2 diabetes mellitus meeting treatment goals

PurposeSurveillance of stable glycemic control based on daily glucose monitoring

Hemoglobin A1c — Unstable control or therapy change

A1c frequency when not meeting goals or therapy changedQuarterly

Applies toIndividuals with diagnosed diabetes who are not meeting glycemic goals or whose pharmacologic therapy has changed

Documentation, Billing, and Provider Responsibilities

Documentation Required

Documentation and claims review — Providers responsible for submission of accurate documentation and urged to submit additional documentation

Providers are responsible for submission of accurate documentation of services performed. Providers are expected to submit claims for services rendered using valid code combinations from HIPAA-approved code sets and to code claims appropriately according to industry standard coding guidelines (including but not limited to: Uniform Billing Editor, American Medical Association Current Procedural Terminology and CPT® Assistant, HCPCS, ICD-10-CM/PCS, National Drug Codes, DRG guidelines, CMS National Correct Coding Initiative Policy Manual, CCI table edits, and other CMS guidelines). Claims are subject to code edit protocols and claim review, including review against benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, the provider is urged to submit any additional documentation to support the claim.

Submit claims using valid HIPAA-approved code sets and industry-standard coding guidelines
Claims may be reviewed against plan documents, provider contracts, medical and coding policies, and software edits
Providers may be asked to submit additional documentation upon request

Definitions and Glossary

First‑degree relatives

DefinitionParents, full siblings, and children

ContextUsed to identify first-degree family history risk for diabetes screening reimbursement

Policy sourceNote 1 in Reimbursement Information

Second‑degree relatives

DefinitionGrandparents, aunts, uncles, nieces, nephews, grandchildren, and half-siblings

ContextUsed to describe second‑degree family history in screening criteria

Policy source

Billing Rule

Reimbursement updates and edits — Reimbursement Information updated with specific numbered statements including testing intervals and populations (e.g., pregnancy quarterly)

Reimbursement Information has been updated over multiple revisions. Significant reimbursement updates and edits include: additions and clarifications of reimbursable testing intervals and specific populations (for example, quarterly testing for individuals who are pregnant; screening intervals for asymptomatic individuals age 35+; screening frequency for overweight/obese individuals <18 years with risk factors), addition of new statements specific to populations such as individuals with metabolic dysfunction‑associated steatotic liver disease (MASLD), removal or revision of certain numbered notes, and general clarifications to when fasting plasma glucose, oral glucose tolerance testing (OGTT), and hemoglobin A1c measurements are reimbursable or not reimbursable. Providers should refer to the Reimbursement Information section of this policy for the current numbered statements, notes, and effective dates.

01/23/2025: Added #2e — Quarterly testing for individuals who are pregnant; added #5i for individuals with MASLD
04/15/2024: Added new #4 — Asymptomatic individuals age 35+ without risk factors: screening once every three years with fasting plasma glucose may be reimbursable; clarified screening intervals for overweight/obese individuals <18 with risk factors; added new #11 stating fasting plasma glucose at a wellness visit with no abnormal findings is not reimbursable for other situations
11/01/2023: Reimbursement information revised with new statements #1, #5, #6, #9; revised #3 to include fasting plasma glucose; added Notes 1–3; clarified that measurement of hemoglobin A1c is not reimbursable for situations not previously described
09/26/2025: Removed Note 1; references revised; literature review updates