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 indicates which patient groups and testing frequencies may be reimbursable.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyDiabetes Mellitus Testing

Policy CodePolicy CPCPLAB004

Change TypeMaterial updates to reimbursement statements (added pregnancy quarterly testing, MASLD guidance, age‑based screening, clarified non‑reimbursable wellness testing)

Effective DateApr 15, 2025

Next Review Date

Key ActionSubmit accurate documentation with claims and be prepared to provide additional documentation upon request; coverage is subject to plan documents and provider contracts.

SourceLink

POLICY UPDATE CHANGES

Quarterly testing reimbursable for individuals who are pregnant.

Testing considerations added for individuals with metabolic dysfunction-associated steatotic liver disease (MASLD).

Screening for asymptomatic individuals age 35+ without risk factors using fasting plasma glucose once every three years may be reimbursable.

Clarified that fasting plasma glucose testing at a wellness visit with no abnormal findings is not reimbursable for situations not otherwise addressed.

4+distinct reimbursement statements added or revised

≥11enumerated reimbursable scenarios

QuarterlyA1c frequency when not meeting goals / therapy changed / pregnancy

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Reimbursable Diabetes Testing Criteria

Procedure Codes and Coding Notes

Procedure codes (non-exhaustive)mixed

Procedure codes list exists but is not exhaustive; inclusion does not guarantee coverage.

No explicit CPT/HCPCS/ICD-10 codes in this document segmentmixed

No codes listed

Screening interval for asymptomatic age 35+ without risk factors

Screening intervalFasting plasma glucose once every three years for asymptomatic individuals age ≥35 with no risk factors

Test type specifiedFasting plasma glucose (not hemoglobin A1c) is the indicated screening test for this interval

Policy source changeNew reimbursement statement added in 04/15/2024 update (Policy Update History)

Documentation, Claims, and Provider Requirements

Documentation Required

Documentation and claims review

Providers are responsible for submitting accurate documentation of services performed and for coding claims using valid code combinations from HIPAA-approved code sets. Claims should be coded in accordance with industry-standard coding guidelines (including, but not limited to, Uniform Billing, AMA CPT and CPT Assistant, HCPCS, ICD-10-CM/PCS, NDCs, DRG guidelines, CMS NCCI Policy Manual, and CCI table edits).

Submit any additional documentation upon request.
Code claims appropriately to reflect services rendered; follow applicable coding guidance and edits.
Claims are subject to plan benefit terms, provider contract language, medical and clinical payment and coding policies, and claims-editing software logic.

Note

Reimbursement Information changes

Reimbursement Information has been updated over multiple revisions. Notable changes include: addition of quarterly testing guidance for individuals who are pregnant; addition of guidance for individuals with metabolic dysfunction‑associated steatotic liver disease (MASLD); inclusion of age‑based screening reimbursements (asymptomatic individuals age 35+ once every three years with fasting plasma glucose); clarification that for overweight/obese individuals <18 years diabetes screening every three years with fasting plasma glucose, OGTT, or HbA1c may be reimbursable when risk factors are present; and a clarification that fasting plasma glucose testing at a wellness visit with no abnormal findings is not reimbursable in other situations. See Policy Update History for full dates and revision details.

Key Definitions

Definition — First- and second-degree relatives

First-degree relativesParents, full siblings, and children

Second-degree relativesGrandparents, aunts, uncles, nieces, nephews, grandchildren, and half-siblings

Use in risk assessmentDefined relationships are used to identify family history as a risk factor for diabetes screening reimbursement

MASLD (policy reference)

Condition identifiedMetabolic dysfunction-associated steatotic liver disease (MASLD)

Policy actionSpecific reimbursement guidance for individuals with MASLD was added to Reimbursement Information (Policy Update History).