ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPLAB004

Diabetes Mellitus Testing

This clinical payment and coding policy governs reimbursement criteria for laboratory testing related to diabetes mellitus (eg, fasting plasma glucose, hemoglobin A1c, OGTT) for Blue Cross Blue Shield of New Mexico members; providers should verify specific plan documents and product applicability.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyDiabetes Mellitus Testing

Policy CodePolicy CPCPLAB004

Change TypeMaterial additions and clarifications (new screening criteria, pediatric guidance, exclusions)

Effective DateApr 15, 2024

Next Review Date

Key ActionSubmit accurate documentation for diabetes-related laboratory testing; verify eligibility and apply the updated reimbursement criteria (including new 3-year asymptomatic screening and pediatric guidance).

SourceLink

POLICY UPDATE CHANGES

For asymptomatic individuals who are 35 years of age or older and who have no risk factors for diabetes, screening for prediabetes or type 2 diabetes once every three years with a fasting plasma glucose test may be reimbursable.

Revised #8 to specify screening frequency and acceptable tests for overweight or obese individuals less than 18 years of age with risk factors (FPG, OGTT, or HbA1c once every three years).

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

Revised reimbursement statements and added Notes in prior updates (examples include addition of statements #1, #5, #6, #9 and revisions to guidance on A1c reimbursement).

Document updated with literature review; references revised, some added and others removed.

11numbered reimbursement rules listed

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Reimbursement and Coverage Criteria

Reimbursement criteria for diabetes testing

Conditions, indications, and frequency for which testing may be reimbursable.

ALL of the following

ANY of the following
- Fasting plasma glucose may be reimbursable for individuals with acute or persistent classic symptoms of diabetes mellitus (eg, polyuria, polyphagia, polydipsia).
ANY of the following
- ALL of the following
  - Upon initial diagnosis to establish a baseline value and to determine treatment goals.
  - Twice yearly (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.
ALL of the following
- Annual screening for type 2 diabetes in prediabetic individuals may be reimbursable with a fasting plasma glucose test or measurement of hemoglobin A1c.
ALL of the following
- For asymptomatic individuals 35 years of age or older with no risk factors for diabetes, screening for prediabetes or type 2 diabetes once every three years with a fasting plasma glucose test may be reimbursable.
ALL of the following
- For asymptomatic individuals 18 years of age or older with risk factors, screening once every three years with a fasting plasma glucose test or measurement of hemoglobin A1c may be reimbursable. Risk factors include: overweight or obese; first-degree relatives with diabetes; history of cardiovascular disease; hypertension; hypercholesterolemia; metabolic syndrome; obesity with acanthosis nigricans; polycystic ovary syndrome; prior gestational diabetes mellitus.
ALL of the following
- For individuals who are positive for HIV, fasting plasma glucose screening may be reimbursable when starting antiretroviral therapy (ART), when switching ART, 3–6 months after starting or switching ART, and annually when initial screening results were normal.
ALL of the following
- For individuals aged 10 years and older with cystic fibrosis (without CF-related diabetes), annual screening for CF-related diabetes with an OGTT may be reimbursable.
ALL of the following
- For 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 such as acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or small for gestational age birth weight), diabetes screening once every three years with a fasting plasma glucose test, an OGTT, or measurement of hemoglobin A1c may be reimbursable.
ALL of the following
- For pregnant individuals, a fasting plasma glucose test or an OGTT up to once per month during pregnancy may be reimbursable.
ALL of the following
- For individuals diagnosed with gestational diabetes mellitus, an OGTT may be reimbursable to screen for persistent diabetes or prediabetes 4–12 weeks postpartum, and to repeat screening to confirm a diagnosis if the initial postpartum screen is positive.
ALL of the following
- Fasting plasma glucose testing at a wellness visit with no abnormal findings is not reimbursable for situations not otherwise addressed above.
- Measurement of hemoglobin A1c is not reimbursable in situations not previously addressed; specifically, A1c should not be used to test symptomatic individuals with classic diabetes symptoms, to screen pregnant individuals without an established diagnosis of diabetes or prediabetes, to screen individuals with cystic fibrosis, in conjunction with fructosamine, or in individuals with conditions associated with increased red blood cell turnover (eg, sickle cell disease, recent transfusion, hemodialysis, or erythropoietin therapy).

References for definitions and notes

Reimbursement criteria

Reimbursement rules (numbered statements) describe when FPG, OGTT, or HbA1c may be reimbursable or not:

ALL of the following

#1: For individuals with acute or persistent classic symptoms of diabetes mellitus, measurement of fasting plasma glucose may be reimbursable.
#2: For individuals with diagnosed type 1 or type 2 diabetes, hemoglobin A1c reimbursable for baseline at diagnosis, twice yearly if stable and meeting goals, quarterly if not meeting goals, and quarterly when pharmacologic therapy changes.
#3: For prediabetic individuals, annual screening with fasting plasma glucose or hemoglobin A1c may be reimbursable.
#4 (added): For asymptomatic individuals 35 years or older with no risk factors, screening once every three years with fasting plasma glucose may be reimbursable.

Example Procedure Codes and Test References

Example procedure codesCPT

82947	Glucose; quantitative, blood (except reagent strip)
82951	Glucose; tolerance test (GTT), 3 specimens (includes glucose)
82952	Glucose; tolerance test, each additional beyond 3 specimens
82985	Glucose, blood, reagent strip (eg, home blood glucose monitor)
83036	Hemoglobin; glycosylated (A1C) by device cleared by the FDA for home use
83037	Hemoglobin; glycosylated (A1C), non-POCT

Tests referencedmixed

No codes listed

inv-05: Screening interval — once every three years for certain populations

Screening intervalScreening for prediabetes or type 2 diabetes once every three years with a fasting plasma glucose test for certain asymptomatic and pediatric populations (see policy statements #4 and #8).

Pediatric intervalOverweight or obese individuals under 18 with qualifying risk factors: diabetes screening once every three years with FPG, OGTT, or HbA1c may be reimbursable (policy statement #8).

Post-ART HIV screening intervalFor HIV‑positive individuals starting or switching antiretroviral therapy: FPG screening at initiation, 3–6 months after start/switch, and annually if initial results were normal.

Gestational screening frequencyPregnant individuals: FPG or OGTT up to once per month during pregnancy may be reimbursable (policy statement #9).

inv-06: Age threshold for asymptomatic screening — 35 years

Documentation, Claims, and Provider Restrictions

Documentation Required

Documentation and Claim Review

Providers are responsible for submission of accurate documentation of services performed and for coding claims using valid HIPAA-approved code sets (e.g., CPT, HCPCS, ICD-10, NDC, DRG) and industry-standard coding guidelines. Claims are subject to code edit protocols and claim review against benefit terms, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers must submit additional documentation to support medical necessity, coding, or coverage determinations.

Submit claims using valid HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, DRG) and follow industry coding guidelines.
Be prepared to provide additional documentation upon request to support claims and medical necessity.
Claims are subject to code edit protocols and review against plan documents, provider contracts, and applicable policies.

Definitions and Related Terms

inv-09: Plan documents that govern (Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions) — override this policy when in conflict.

Governing documentsPlan documents (e.g., Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions) govern and will prevail over this CPCP if a conflict arises.

Provider contractsIf conflict exists between this CPCP and a provider contract, the provider contract will govern.

BCBSNM discretionBCBSNM may use reasonable discretion in interpreting and applying this policy to services delivered in a particular case; BCBSNM has final discretionary authority as provided under applicable plan documents.

inv-10: Definition of first-degree and second-degree relatives.

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

Second‑degree relatives

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyDiabetes Mellitus Testing

Policy CodePolicy CPCPLAB004

Change TypeMaterial additions and clarifications (new screening criteria, pediatric guidance, exclusions)

Effective DateApr 15, 2024

Next Review Date

SourceLink

On This Page

Billing Rule

Reimbursement Provider Actions and Restrictions

Reimbursement is limited to specified screening scenarios and is not blanket coverage. Do not bill for screening tests outside the reimbursable indications below; such claims may be denied. For wellness visits with no abnormal findings, fasting plasma glucose testing is not reimbursable except as noted in the specified reimbursable situations.

For asymptomatic individuals age 35 and older with no diabetes risk factors: screening for prediabetes or type 2 diabetes once every three years with a fasting plasma glucose test may be reimbursable.
For overweight or obese individuals <18 years old: diabetes screening once every three years with fasting plasma glucose, OGTT, or hemoglobin A1c may be reimbursable when any listed risk factors are present.
For situations not specifically addressed in the reimbursement statements: fasting plasma glucose testing at a wellness visit with no abnormal findings is not reimbursable.

inv-11: FPG / OGTT / HbA1c — definitions and role as screening/diagnostic tests.

FPG (Fasting Plasma Glucose)A blood test used for screening and diagnosis of prediabetes and type 2 diabetes; policy permits FPG for multiple indications (e.g., symptomatic individuals, asymptomatic ≥35 every 3 years, pediatric screening, HIV‑related screening, pregnancy/gestational testing).

OGTT (Oral Glucose Tolerance Test)An oral glucose tolerance test may be reimbursable for specific populations including annual OGTT for cystic fibrosis patients ≥10 years, gestational testing during pregnancy, and pediatric screening in overweight/obese youth with risk factors (every 3 years).

HbA1c (Hemoglobin A1c)Measurement of hemoglobin A1c is an accepted screening/monitoring test for diagnosed diabetes and for screening in certain populations (e.g., overweight/obese <18 with risk factors); however, A1c should not be used in specified situations per Note 3 (see exclusions).

Exclusions and limitationsA1c should not be used to test individuals with acute classic symptoms, to screen pregnant individuals without diagnosis, to screen cystic fibrosis patients, in conjunction with fructosamine, or in persons with increased RBC turnover (e.g., sickle cell disease, recent transfusion, hemodialysis, erythropoietin therapy).