ModifiedBlue Cross Blue Shield - TexasPolicy CPCPLAB004

Diabetes Mellitus Testing

Defines Blue Cross Blue Shield of Texas reimbursement criteria for laboratory testing related to diabetes mellitus (screening, diagnosis, and monitoring) and indicates applicability varies by product and plan documents. Affects providers submitting claims for diabetes-related lab tests.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyDiabetes Mellitus Testing

Policy CodePolicy CPCPLAB004

Change TypeCoverage additions and documentation updates (pregnancy testing frequency, MASLD, removal of Note 1)

Effective DateSep 26, 2025

Next Review DateN/A

Key ActionProviders must submit accurate documentation and consult the updated Reimbursement Information section for billing guidance, including quarterly pregnancy testing and MASLD considerations.

SourceLink

POLICY UPDATE CHANGES

Removed Note 1 from Reimbursement Information.

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

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

References were revised during multiple updates.

12number of reimbursement rules

6example procedure codes

Quarterlypregnancy testing added

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Reimbursement and Coverage Criteria

Diabetes testing reimbursement criteria (selected provisions from Part 1)

Covered when the following conditions apply for fasting plasma glucose (FPG), oral glucose tolerance testing (OGTT), or hemoglobin A1c (A1c):

Fasting plasma glucose reimbursable for individuals with acute or persistent classic symptoms of diabetes mellitus.

ALL of the following

ONE of
- 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.

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

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.

ALL of the following

ONE of
- Overweight or obese.
- First-degree relatives of individuals with diabetes.
- History of cardiovascular disease.
- Hypertension.
- Hypercholesterolemia.
- Metabolic syndrome.

ALL of the following

ONE of
- When starting antiretroviral therapy (ART).
- When switching ART.
- 3–6 months after starting or switching ART.
- Annually when initial screening results were normal.

Individuals 10 years of age and older with cystic fibrosis (without CF-related diabetes): annual OGTT screening may be reimbursable.

ALL of the following

ONE of
- Maternal history of diabetes or gestational diabetes during the child's gestation.
- Family history of type 2 diabetes in first- or second-degree relatives.
- Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or small for gestational age birth weight).

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

Individuals diagnosed with gestational diabetes mellitus (GDM): OGTT reimbursable to screen 4–12 weeks postpartum and to repeat confirmatory testing for positive initial postpartum screens.

Not reimbursable: fasting plasma glucose testing at a wellness visit with no abnormal findings, except as addressed by the policy.

Not reimbursable: measurement of hemoglobin A1c in the situations listed (see Note 2) including to test for diabetes in individuals presenting with acute or persistent classic symptoms, in pregnant individuals without an established diagnosis, to screen individuals with cystic fibrosis, in conjunction with fructosamine, or in persons with increased red blood cell turnover (e.g., sickle cell disease, recent transfusion, dialysis, or erythropoietin therapy).

Reimbursement Information changes

Policy changes affecting the Reimbursement Information section — providers should consult the updated Reimbursement Information for billing guidance.

Quarterly testing coverage was added for individuals who are pregnant (A1c quarterly provision).

Coverage considerations were added to include individuals with metabolic dysfunction-associated steatotic liver disease (MASLD).

Note 1 was removed from Reimbursement Information (operational change to notes/definitions).

Procedure Codes, Frequency, and Coding References

Example procedure codesCPT

82947	Glucose; quantitative, blood (except reagent strip)
82951	Glucose tolerance test, 3 specimens (includes glucose)
82952	Glucose tolerance test, each additional specimen
82985	Glucose; blood, reagent strip
83036	Hemoglobin; glycosylated (A1C)
83037	Hemoglobin; glycosylated (A1C), single test

References supporting coding and testing standardsmixed

No codes listed

Pregnancy testing frequency (Hemoglobin A1c) — quarterly during pregnancy

Testing intervalQuarterly hemoglobin A1c testing is specified for individuals who are pregnant (added as #2e in Reimbursement Information).

Policy change dateQuarterly testing for pregnancy was added in the 02/05/2025 update to Reimbursement Information (effective 05/15/2025 summary).

Applicability noteApplies to pregnant individuals as an explicit reimbursable interval in the policy Reimbursement Information section.

Documentation, Claims, and Provider Responsibilities

Documentation Required

Documentation and claim review

Providers are responsible for submission of accurate documentation of services performed and must code claims using valid HIPAA-approved code sets and industry-standard coding guidelines. Claims are subject to code edit protocols and claim review; upon request, providers should submit additional documentation to support services billed.

Submit claims using valid code combinations from HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC as applicable).
Code appropriately per industry standards (Uniform Billing, AMA CPT, CMS NCCI policies, CCI table edits).
Be prepared to provide additional documentation upon request during claim review.

Billing Rule

Reimbursement Information updates

Key Definitions

Definitions — First- and second-degree relatives

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

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

Use in criteriaFamily-history definitions inform risk-based screening eligibility (e.g., adults with first-degree relatives with diabetes).

Definition & scope — Metabolic dysfunction-associated steatotic liver disease (MASLD)

TermMetabolic dysfunction-associated steatotic liver disease (MASLD).

Policy inclusionCoverage considerations for individuals with MASLD were added to Reimbursement Information (listed as #5i in the 02/05/2025 update).