ModifiedBlue Cross Blue Shield - TexasPolicy CPCPLAB004

Diabetes Mellitus Testing

Reimbursement and coding criteria for laboratory testing related to diabetes mellitus screening, diagnosis, and monitoring; applies to providers submitting claims to Blue Cross and Blue Shield of Texas and members covered under plan documents.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyDiabetes Mellitus Testing

Policy CodePolicy CPCPLAB004

Change TypeCoverage criteria updated — pregnant testing frequency addedMASLD named

Effective DateMay 15, 2025

Next Review Date

Key ActionSubmit accurate documentation with claims and be prepared to provide additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

Added #2e: Quarterly testing for individuals who are pregnant.

Added #5i: Coverage consideration for individuals with metabolic dysfunction-associated steatotic liver disease (MASLD).

References revised following literature review.

1policy update recorded on 02/05/2025

Quarterlytesting frequency added for pregnant individuals

MASLDnewly mentioned clinical subgroup

quarterlyHbA1c frequency for uncontrolled or therapy change

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

Reimbursable testing scenarios and restrictions

ALL of the following

ANY of the following
- Individuals with acute or persistent classic symptoms of diabetes mellitus (See NOTE 1)
- Asymptomatic individuals ≥35 years with no risk factors — screening once every 3 years
- Individuals ≥18 years with risk factors — screening once every 3 years (risk factors include overweight/obesity; first-degree relatives of individuals with diabetes; history of cardiovascular disease; hypertension; hypercholesterolemia; metabolic syndrome; obesity with acanthosis nigricans; polycystic ovary syndrome)
- Prediabetic individuals — annual screening
- Pregnant individuals — fasting plasma test or OGTT up to once per month during pregnancy
- People with HIV — at ART initiation, when switching ART, 3–6 months after starting or switching ART, and annually if initial screening normal
- Individuals 10 years and older with cystic fibrosis (without CF-related diabetes) — annual OGTT
- Overweight or obese individuals <18 years with risk factors (maternal history of diabetes/GDM; family history in first- or second-degree relatives; signs of insulin resistance) — screening once every 3 years

ALL of the following

ANY of the following
- Upon initial diagnosis to establish a baseline value and determine treatment goals
- Twice yearly (every 6 months) in individuals meeting treatment goals with stable glycemic control
- Quarterly in individuals 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

ALL of the following

ANY of the following
- Individuals 10 years and older with cystic fibrosis (annual)
- Pregnant individuals — OGTT up to once per month during pregnancy
- Individuals diagnosed with GDM — OGTT 4–12 weeks postpartum to screen for persistent diabetes or prediabetes; repeat if initial postpartum screening is positive to confirm diagnosis

ALL of the following

Measurement of hemoglobin A1c is not reimbursable for situations noted in Note 3 (e.g., testing for diabetes in individuals with acute classic symptoms; pregnant individuals without an established diagnosis; individuals with cystic fibrosis; concomitant fructosamine measurement; conditions with increased RBC turnover)
Fasting plasma glucose testing at a wellness visit with no abnormal findings is not reimbursable

Updated coverage criteria highlights

Policy update summary affecting coverage details:

ALL of the following

Quarterly testing for individuals who are pregnant was added to reimbursement information (listed as #2e)

ALL of the following

Metabolic dysfunction-associated steatotic liver disease (MASLD) was specifically added to the list of conditions referenced in reimbursement information (listed as #5i)

ALL of the following

References were revised following a literature review; consult the full policy for the updated reference list and details

Procedure Codes and Monitoring Frequency

Procedure codes (not exhaustive)mixed

Policy includes a procedure code section but does not list codes in this window.

inv-05: HbA1c monitoring frequency thresholds — baseline, twice yearly if meeting goals, quarterly if not meeting goals/therapy changed/pregnant

Baseline at diagnosisHbA1c: upon initial diagnosis to establish a baseline value and to determine treatment goals.

Twice yearly if meeting goalsHbA1c: twice a year (every 6 months) in individuals who are meeting treatment goals and who have stable glycemic control based on daily glucose monitoring.

Quarterly if not meeting goals or therapy changedHbA1c: quarterly in individuals who are not meeting treatment goals or whose pharmacologic therapy has changed.

Quarterly in pregnancyHbA1c: quarterly for individuals who are pregnant (operationally added 02/05/2025).

inv-06: Testing frequency for pregnant individuals — Quarterly

Documentation, Claims, and Provider Responsibilities

Documentation Required

Documentation and claim review

Providers must submit accurate documentation of services performed, code claims using valid HIPAA-approved code sets, and code appropriately per industry standard coding guidelines. Claims are subject to code edit protocols and review against benefit coverage, provider contracts, medical policies, clinical payment and coding policies, and coding software logic; upon request, providers should submit additional documentation.

Submit accurate documentation of services performed and use valid HIPAA-approved code combinations.
Code claims according to industry-standard guidelines (e.g., UB Editor, AMA CPT, HCPCS, ICD-10-CM/PCS).
Claims are subject to code edit protocols, benefit and contract review, clinical policies, and coding software logic.
Provide additional documentation upon request.

Definitions and Testing Limitations

inv-09: First-degree and second-degree relatives — definition of family-degree relationships

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

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

Usage contextFamily-degree definitions are referenced for screening recommendations (e.g., risk-based screening in children/adolescents and adults).

inv-10: Situations where HbA1c should not be used — clinical scenarios and exceptions

Acute classic symptomsDo not use HbA1c to test for diabetes in individuals presenting with acute or persistent classic symptoms of diabetes mellitus.

Pregnancy without established diagnosis

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyDiabetes Mellitus Testing

Policy CodePolicy CPCPLAB004

Change TypeCoverage criteria updated — pregnant testing frequency addedMASLD named

Effective DateMay 15, 2025

Next Review Date

Key ActionSubmit accurate documentation with claims and be prepared to provide additional documentation upon request.

SourceLink

On This Page

Prediabetic individuals — annual screening may be reimbursable

Individuals ≥18 years with risk factors — screening every 3 years may be reimbursable

ALL of the following

Measurement of hemoglobin A1c is not reimbursable in situations listed under Note 3

Pregnancy testing frequencyHemoglobin A1c: quarterly for individuals who are pregnant (added to Reimbursement Information #2e).

Billing Rule

Reimbursement updates (summary)

The policy was updated 02/05/2025 (effective 05/15/2025) to add quarterly testing for individuals who are pregnant and to add metabolic dysfunction-associated steatotic liver disease (MASLD) as a named condition in the reimbursement information; references were also revised following a literature review.

Added #2e: Quarterly testing for individuals who are pregnant.
Added #5i: Inclusion of MASLD in reimbursement information.
References revised following literature review.

Do not use HbA1c in pregnant individuals without an established diagnosis of diabetes or prediabetes.

Cystic fibrosis screeningDo not use HbA1c to screen for diabetes in individuals diagnosed with cystic fibrosis.

Concurrent fructosamine measurementDo not perform HbA1c in conjunction with measurement of fructosamine.

Conditions with increased RBC turnoverDo not use HbA1c in individuals with conditions associated with increased red blood cell turnover (e.g., sickle cell disease, recent transfusion, hemodialysis, erythropoietin therapy).

inv-11: References / Literature review — cited studies and guidelines informing the policy

Guidelines and laboratory standardsSacks DB et al., Guidelines and Recommendations for Laboratory Analysis in the Diagnosis and Management of Diabetes Mellitus (Diabetes Care, 2023) and IFCC/CAP reference materials.

KDIGO diabetes management in CKDKDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease (Rossing et al., 2022).

Foundational HbA1c studiesNathan DM et al., The clinical information value of the glycosylated hemoglobin assay (N Engl J Med, 1984) and Rohlfing C. et al. on biological variation of glycohemoglobin.

Measurement variability and implicationsSelvin E., Short-term variability in measures of glycemia and implications for classification of diabetes (Arch Intern Med, 2007); Miller WG et al., harmonization for clinical chemistry analytes.

Policy update and literature reviewPolicy Update History (02/05/2025): document updated with literature review; references revised and quarterly pregnancy testing added.