ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLAB004

Diabetes Mellitus Testing

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Defines Blue Cross Blue Shield - Oklahoma reimbursement and coverage criteria for laboratory testing used to screen for, diagnose, and monitor diabetes mellitus and prediabetes; applies to providers submitting claims for members covered under BCBSOK plans.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyDiabetes Mellitus Testing

Policy CodePolicy CPCPLAB004

Change TypeMaterial updates to reimbursement statements (added pregnancy quarterly frequency, MASLD indication, triennial screening for age ≥35clarified non-reimbursable wellness FPG)

Effective DateSep 26, 2025

Last ReviewSep 26, 2025

Next Review Date

Key ActionDocument indication and frequency (e.g., pregnancy quarterly, MASLD, triennial screening) when ordering and submitting claims to support reimbursement.

SourceLink

POLICY UPDATE CHANGES

Added quarterly testing reimbursement for individuals who are pregnant.

Added coverage for individuals with metabolic dysfunction-associated steatotic liver disease (MASLD).

Added reimbursable one-time triennial screening with fasting plasma glucose for asymptomatic individuals age 35+ with no risk factors.

Added statement that fasting plasma glucose testing at a wellness visit with no abnormal findings is not reimbursable for other situations.

Removed Note 1 from Reimbursement Information and revised references after literature review.

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ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLAB004

Diabetes Mellitus Testing

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Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyDiabetes Mellitus Testing

Policy CodePolicy CPCPLAB004

Change TypeMaterial updates to reimbursement statements (added pregnancy quarterly frequency, MASLD indication, triennial screening for age ≥35clarified non-reimbursable wellness FPG)

Effective DateSep 26, 2025

Last ReviewSep 26, 2025

Next Review Date

Key ActionDocument indication and frequency (e.g., pregnancy quarterly, MASLD, triennial screening) when ordering and submitting claims to support reimbursement.

SourceLink

POLICY UPDATE CHANGES

Added quarterly testing reimbursement for individuals who are pregnant.

Added coverage for individuals with metabolic dysfunction-associated steatotic liver disease (MASLD).

Added reimbursable one-time triennial screening with fasting plasma glucose for asymptomatic individuals age 35+ with no risk factors.

Added statement that fasting plasma glucose testing at a wellness visit with no abnormal findings is not reimbursable for other situations.

Removed Note 1 from Reimbursement Information and revised references after literature review.

quarterlytesting frequency added for pregnancy

every 3 yearsscreening allowed for asymptomatic ≥35 y/o

MASLDnew covered indication

6procedure codes listed

1.0policy version

Coverage Criteria and Reimbursable Scenarios

Reimbursable testing indications and frequencies

Covered when the specific testing indication and frequency match the scenarios below.

Fasting plasma glucose for symptomatic individuals: Measurement of fasting plasma glucose may be reimbursable for individuals with acute or persistent classic symptoms of diabetes mellitus.

Hemoglobin A1c monitoring in diagnosed diabetes: Measurement of hemoglobin A1c may be reimbursable for individuals with type 1 or type 2 diabetes in any of the following situations: (a) upon initial diagnosis to establish a baseline and determine treatment goals; (b) twice yearly (every 6 months) for those meeting treatment goals with stable control; (c) quarterly for individuals not meeting treatment goals; (d) quarterly after pharmacologic therapy changes; (e) quarterly during pregnancy.baseline; every 6 months; every 3 months

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

Asymptomatic age-based screening (>=35 years): Asymptomatic individuals 35 years of age or older with no risk factors: screening once every three years with a fasting plasma glucose test may be reimbursable.once every 3 years

Adult risk-factor based screening (>=18 years): Individuals 18 years of age or older with risk factors may be screened once every three years with a fasting plasma glucose test or measurement of hemoglobin A1c. Risk factors include: overweight or obesity; first-degree relatives with diabetes; history of cardiovascular disease; hypertension; hypercholesterolemia; metabolic syndrome; obesity with acanthosis nigricans; polycystic ovary syndrome; metabolic dysfunction-associated steatotic liver disease (MASLD); prior gestational diabetes.once every 3 years

HIV-positive individuals: For individuals positive for HIV, screening with a fasting plasma glucose test is 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.3-6 months after change; then annual

Cystic fibrosis screening: For individuals 10 years of age and older with cystic fibrosis who do not have CF-related diabetes, annual screening with an OGTT may be reimbursable.annual

Pediatric overweight/obese screening (<18 years): Overweight or obese children and adolescents under 18 years with risk factors (maternal GDM, family history in first- or second-degree relatives, signs of insulin resistance or associated conditions) may be screened once every three years with fasting plasma glucose, OGTT, or measurement of hemoglobin A1c.once every 3 years

Pregnancy testing frequency: Pregnant individuals may have a fasting plasma glucose test or an OGTT up to once per month during pregnancy reimbursable.up to once per month

Gestational diabetes postpartum OGTT: For individuals diagnosed with gestational diabetes mellitus, an OGTT may be reimbursable to screen 4–12 weeks postpartum for persistent diabetes or prediabetes; if initial postpartum screening is positive, repeat OGTT is reimbursable to confirm diagnosis.4-12 weeks postpartum

Reimbursement updates and coverage statements

Policy reimbursement information includes the following added or revised statements that affect coverage and frequency.

Quarterly testing for pregnancy (new #2e): Quarterly testing was added for individuals who are pregnant; reimbursement allows measurement of hemoglobin A1c quarterly and unspecified diabetes testing quarterly during pregnancy as specified in Reimbursement Information.quarterly

See policy update entries for #2e.

MASLD added as covered indication (new #5i): Metabolic dysfunction-associated steatotic liver disease (MASLD) was added as an explicit risk factor/indication for screening reimbursement.

See policy update entry for #5i.

Triennial screening for asymptomatic adults >=35 (new #4): For asymptomatic individuals 35 years of age or older with no risk factors, screening once every three years with a fasting plasma glucose test was added as reimbursable.once every 3 years

Measurement of hemoglobin A1c and fasting plasma glucose are reimbursable only when performed for covered clinical indications and frequencies described in this policy. Hemoglobin A1c is not reimbursable in specific situations listed in the policy (see Note 2), including when used 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 individuals diagnosed with cystic fibrosis, in conjunction with fructosamine measurement, or when conditions exist that increase red blood cell turnover (e.g., sickle cell disease, recent transfusion, erythropoietin therapy, or certain hemodialysis contexts).

Fasting plasma glucose (FPG) may be reimbursable when ordered for covered screening, diagnostic, or monitoring indications and per the frequency limits in this policy; however, FPG performed at a routine wellness visit with no abnormal findings is not reimbursable unless the test falls within one of the specific reimbursable scenarios described elsewhere in this policy.

The policy explicitly states that fasting plasma glucose testing performed at a wellness visit with no abnormal findings is not reimbursable for situations not otherwise addressed by the policy. This clarification was added to the reimbursement statements to guide claim adjudication and may result in denial when FPG is ordered during routine well visits without an indicated clinical reason.

Hemoglobin A1c is excluded from reimbursement in the following circumstances per policy Note 2: (1) to test for diabetes in individuals with acute or persistent classic symptoms of diabetes; (2) in pregnant individuals without an established diagnosis of diabetes or prediabetes; (3) to screen for diabetes in individuals diagnosed with cystic fibrosis; (4) when ordered in conjunction with fructosamine; and (5) in individuals with conditions associated with increased red blood cell turnover (for example, sickle cell disease, recent blood loss or transfusion, erythropoietin therapy, or certain hemodialysis situations).

For any clinical situation not specifically addressed by the reimbursable indications and frequency statements, a fasting plasma glucose test ordered at a wellness visit with no abnormal findings is not reimbursable. Providers should confirm that the clinical indication and timing align with the policy's enumerated scenarios before ordering or submitting a claim for FPG in a routine wellness context.

Covered Indications and Populations

Screening, diagnosis, and monitoring — populations

Top-level coverage criteria for screening, diagnosis, and monitoring across populations.

Adults (general): Screening, diagnosis, and monitoring for adults include: symptomatic evaluation with fasting plasma glucose; screening every 3 years for adults >=18 with risk factors using FPG or HbA1c; asymptomatic adults >=35 with no risk factors may be screened once every 3 years with FPG.see individual items

Children and adolescents: Overweight or obese children/adolescents <18 years with risk factors may be screened once every three years with fasting plasma glucose, OGTT, or HbA1c.once every 3 years

Pregnant individuals may receive FPG or OGTT up to once per month during pregnancy; hemoglobin A1c reimbursement includes quarterly frequency during pregnancy.up to monthly; quarterly for HbA1c

Testing Frequency Limits

inv-23: Fasting plasma glucose or hemoglobin A1c — Once every 3 years

TestsFasting plasma glucose or hemoglobin A1c

FrequencyOnce every 3 years

ContextRoutine asymptomatic screening for adults (e.g., age-based or risk-factor based screening per policy statements #4 and #5)

inv-24: Hemoglobin A1c for individuals meeting treatment goals with stable control — Twice per year (every 6 months)

TestHemoglobin A1c

FrequencyTwice per year (every 6 months)

Context

Procedure Codes

Listed procedure codesmixed

82947	Glucose; quantitative, blood (unless otherwise specified)
82951	Glucose; tolerance test (GTT), 3 specimens (includes glucose)
82952	Glucose; tolerance test (GTT), each additional specimen (list separately in addition to code for primary test)
82985	Glycated hemoglobin (A1c) by device cleared for home use or point-of-care
83036	Hemoglobin; glycosylated (A1c) (e.g., HbA1, HbA1c) by HPLC or other method
83037	Hemoglobin; glycosylated (A1c) by device cleared for home use or point-of-care (alternate code listed)

Provider Actions, Documentation, and Claims Guidance

Documentation Required

Provider documentation responsibility and claims review

If a conflict arises between this Clinical Payment and Coding Policy and any plan document under which a member is entitled to Covered Services, the plan document will govern. If a conflict arises between a CPCP and any provider contract pursuant to which a provider participates in and/or provides Covered Services to eligible member(s) and/or plans, the provider contract will govern. 'Plan documents' include, but are not limited to, Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents. Blue Cross and Blue Shield of Oklahoma may use reasonable discretion interpreting and applying this policy to services being delivered in a particular case. BCBSOK has full and final discretionary authority for their interpretation and application to the extent provided under any applicable plan documents. 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 appropriately according to industry standard coding guidelines (including but not limited to: UB, AMA CPT, CPT Assistant, HCPCS, ICD-10-CM/PCS, NDCs, DRG guidelines, CMS NCCI Policy Manual, and CCI table edits). Claims are subject to code edit protocols and review against benefit terms, 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.

Provider documentation responsibility: Providers must submit accurate and complete documentation supporting the medical necessity, indication, and frequency of testing.
Claims review and edits: Claims are subject to code edits, benefit terms, contract language, and medical policy review; appropriate coding guidelines must be followed.

Ordering Requirements

Note

ORDERING REQUIREMENTS — verify plan-specific coverage

Requirements for ordering and coverage may vary by product; review the member’s plan documents to confirm eligible coverage and code claims per standard coding guidelines before ordering tests.

Check Certificates of Health Care Benefits, benefit booklets, and Summary Plan Descriptions for plan-specific coverage.
Code claims according to industry coding standards (CPT, HCPCS, ICD-10, and CMS/NCCI guidance).

Step Therapy

ORDERING REQUIREMENTS — follow reimbursement scenarios

Order tests consistent with the updated reimbursement statements and enumerated scenarios/frequencies to support eligibility for reimbursement.

Align orders with statements such as quarterly pregnancy testing (#2e), MASLD indication (#5i), and once-every-3-years screening for asymptomatic ≥35 (#4).
When ordering, ensure documentation in the record supports the indicated scenario and frequency.

Non-Covered Services

Measurement of hemoglobin A1c is not covered for diagnosing diabetes in individuals who present with acute or persistent classic symptoms of diabetes mellitus. The policy also excludes A1c for screening in pregnant individuals who do not already have an established diagnosis of diabetes or prediabetes, and excludes its use to screen individuals with cystic fibrosis. Additional exclusions include use in conjunction with fructosamine testing and use when conditions that affect red blood cell turnover are present (e.g., sickle cell disease, recent transfusion, erythropoietin therapy).

Fasting plasma glucose testing performed at a wellness visit with no abnormal findings is not covered for situations that are not otherwise addressed by the policy. The policy added a specific reimbursement statement clarifying this non‑reimbursable scenario to assist with claims adjudication and provider ordering decisions.

Background

This policy defines coverage for laboratory testing used to screen for, diagnose, and monitor diabetes mellitus and prediabetes across multiple populations and settings. It addresses fasting plasma glucose (FPG), oral glucose tolerance testing (OGTT), and hemoglobin A1c (HbA1c), specifying reimbursable indications and frequency limits—for example, triennial screening with FPG for asymptomatic adults aged ≥35 with no risk factors, annual or more frequent testing in higher‑risk or special populations, and quarterly testing during pregnancy as noted in the reimbursement updates. The policy also lists explicit exclusions and non‑reimbursable situations (see notes regarding HbA1c and wellness FPG) and instructs providers to document the clinical indication and timing consistent with the policy to support reimbursement.

Definitions and Terms

inv-17: First- and second-degree relatives — relationship definitions

First-degree relativesParents, full siblings, and children

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

UsageFamily history in first- or second-degree relatives is a listed risk factor for screening (see policy statements #5 and #8)

inv-18: MASLD — Metabolic dysfunction-associated steatotic liver disease definition and reference

TermMetabolic dysfunction-associated steatotic liver disease (MASLD)

Policy roleListed as a covered indication for diabetes screening (policy statement 2.5.i / #5i added in updates)

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyDiabetes Mellitus Testing

Policy CodePolicy CPCPLAB004

Change TypeMaterial updates to reimbursement statements (added pregnancy quarterly frequency, MASLD indication, triennial screening for age ≥35clarified non-reimbursable wellness FPG)

Effective DateSep 26, 2025

Last ReviewSep 26, 2025

Next Review Date

Key ActionDocument indication and frequency (e.g., pregnancy quarterly, MASLD, triennial screening) when ordering and submitting claims to support reimbursement.

SourceLink

On This Page

See policy update entry for #4.

Non-reimbursable wellness FPG clarification (new #11): Clarified that fasting plasma glucose testing at a wellness visit with no abnormal findings is not reimbursable for situations not otherwise addressed by the policy.

See policy update entry for #11.

Operational revisions and removed notes: Note 1 was removed and references were revised as part of the update history; providers should consult the current Reimbursement Information text for precise numbered statements and documentation expectations.

See policy update history.

HIV-positive individuals: Individuals positive for HIV: screening with FPG when starting or switching ART, 3–6 months after starting or switching ART, and annually if initial screening was normal.3-6 months then annual

Cystic fibrosis: Individuals >=10 years with cystic fibrosis (without CFRD) may have annual OGTT screening reimbursable.annual

MASLD is listed as a covered indication qualifying individuals for screening once every three years with FPG or HbA1c under adult risk-factor criteria.once every 3 years

Pregnancy

Pregnancy testing frequency (policy addition): Pregnant individuals: testing reimbursable quarterly (new reimbursement statement #2e) and FPG or OGTT up to once per month during pregnancy as clinically indicated.quarterly; up to once per month

Providers should document pregnancy and testing frequency to support reimbursement.

MASLD

MASLD as covered indication: Metabolic dysfunction-associated steatotic liver disease (MASLD) is explicitly included as a risk factor/indication for screening reimbursement under the adult risk-factor criteria (new statement #5i).

Asymptomatic adults age 35+ without risk factors

Asymptomatic adults >=35 with no risk factors — triennial FPG screening: 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 (policy addition #4).once every 3 years

For individuals with diagnosed diabetes who are meeting treatment goals and have stable glycemic control (policy statement 2.b)

inv-25: Hemoglobin A1c — Quarterly frequency where indicated

TestHemoglobin A1c

FrequencyQuarterly (every 3 months)

ContextFor individuals not meeting glycemic goals, after pharmacologic therapy changes, or during pregnancy (policy statements 2.c, 2.d, 2.e)

inv-26: Fasting plasma glucose or hemoglobin A1c — Annual frequency statements

TestsFasting plasma glucose or hemoglobin A1c

FrequencyAnnual

ContextPrediabetic individuals or annual follow-up after normal HIV-related screening (policy statements 3 and 6.d)

inv-27: Fasting plasma glucose or OGTT — Up to once per month where specified

TestsFasting plasma glucose or oral glucose tolerance test (OGTT)

FrequencyUp to once per month

ContextDuring pregnancy (policy statement 9: up to once per month during pregnancy)

inv-28: OGTT — Annual frequency to be rendered as specified

TestOral glucose tolerance test (OGTT)

FrequencyAnnual

ContextAnnual screening for cystic fibrosis-related diabetes in individuals ≥10 years without CF-related diabetes (policy statement 7)

inv-29: Unspecified diabetes tests (per reimbursement statement #2e) — Quarterly

TestsUnspecified diabetes tests (per reimbursement statement #2e)

FrequencyQuarterly

ContextQuarterly testing specified for pregnant individuals in the reimbursement updates (statement #2e); providers should document indication and frequency to support reimbursement.

inv-30: Fasting plasma glucose for asymptomatic individuals >=35 y/o without risk factors — Once every 3 years

TestFasting plasma glucose

FrequencyOnce every 3 years

ContextAsymptomatic individuals 35 years of age or older with no risk factors: screening for prediabetes or type 2 diabetes (policy statement 4)

Billing Rule

Procedure codes and reimbursement applicability

1. FPG, OGTT, and A1c are reimbursable only per the specific clinical indications and frequencies described below; routine wellness FPG without abnormal findings is not reimbursable. 2. Providers should document the clinical indication (e.g., symptoms, risk factors, pregnancy, ART initiation, cystic fibrosis screening, GDM follow-up) and the date/interval of prior testing to support the frequency billed.

Affected tests: Fasting plasma glucose (FPG), oral glucose tolerance test (OGTT), hemoglobin A1c (A1c).
Non-reimbursable scenario: FPG at a wellness visit with no abnormal findings (see Reimbursement Information #11).

Note

Reimbursement scenario requirements and frequency guidance

Reimbursement scenario requirements — document indication and frequency at time of service. Key frequency rules to support reimbursement: • Acute or persistent classic diabetic symptoms: FPG may be reimbursable. • Diagnosed diabetes (type 1 or 2): A1c reimbursable at initial diagnosis; twice yearly if meeting goals and stable; quarterly if not meeting goals, if therapy changed, or if pregnant. • Prediabetes: annual FPG or A1c. • Asymptomatic age ≥35 with no risk factors: FPG once every 3 years. • Age ≥18 with risk factors: FPG or A1c once every 3 years. • HIV on ART: baseline, change, 3–6 months after start/change, then annually if initial screening normal. • Cystic fibrosis (≥10 years): annual OGTT. • Overweight/obese <18 years with risk factors: screening every 3 years with FPG, OGTT, or A1c. • Pregnancy: FPG or OGTT up to once per month; GDM: OGTT for 4–12 weeks postpartum and repeat if initial postpartum positive.

Quarterly pregnancy screening: A1c may be reimbursable quarterly for individuals who are pregnant.
Triennial screening: Asymptomatic individuals ≥35 with no risk factors — FPG once every 3 years; adults ≥18 with risk factors — FPG or A1c once every 3 years.

Documentation Required

Provider documentation action

Provider-action: Preserve and submit documentation showing the specific clinical indication, relevant risk factors, pregnancy status, ART timing, CF status, prior test dates, and any therapy changes to support the test billed.

Documentation Required

Pregnancy and postpartum documentation action

Provider-action: When billing for pregnancy-related or postpartum testing, document gestational status, pregnancy trimester when relevant, and dates of postpartum screening; indicate prior positive screens when ordering follow-up OGTTs.

Documentation Required

Supportive documentation required for reimbursement

Supportive documentation for reimbursement — providers should document the indication and the frequency rationale on the medical record and supply it upon request to substantiate reimbursement under the numbered reimbursement statements in this policy.

Document: indication (symptoms, diagnosis, risk factors, pregnancy, ART initiation/change, CF), last test date and result, and reason for increased frequency (e.g., therapy change, unstable control).

Denial Risk

Claims review and potential denial

Claims are subject to review and may be denied or reprocessed based on code edits, member benefit coverage, provider contract terms, clinical payment and coding policies, and medical policy findings. Providers may be asked to provide additional documentation to support reimbursement; failure to supply requested documentation may result in claim denial or recoupment.

Billing Rule

Non-reimbursable wellness FPG

Fasting plasma glucose testing performed solely as part of a routine wellness visit with no abnormal findings and no documented indication (risk factors, symptoms, pregnancy, ART/CF/GDM history) is not reimbursable. Ensure the medical record clearly supports the medical necessity when billing FPG in preventive or wellness contexts.

ReferenceSee clinical/literature references supporting MASLD as indication (policy references include MASLD overview sources)