CurrentBlue KCPolicy POL-PP-270

Diabetes Mellitus Testing (FPG, OGTT, A1c)

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Coverage and medical necessity criteria for diagnostic and screening laboratory testing for diabetes mellitus (fasting plasma glucose, oral glucose tolerance test, and hemoglobin A1c) for Blue KC members and providers.

Policy Summary

PayerBlue KC

PolicyDiabetes Mellitus Testing (FPG, OGTT, A1c)

Policy CodePolicy POL-PP-270

Change TypeNo material change

Effective DateOct 1, 2025

Last ReviewOct 1, 2026

Next Review DateOct 1, 2026

Key ActionDocument diagnostic criteria (FPG ≥126 mg/dL or 2-hour OGTT ≥200 mg/dL) and A1c levels and clinical context when requesting testing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=126FPG threshold (mg/dL)

>=2002-hr OGTT threshold (mg/dL)

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CurrentBlue KCPolicy POL-PP-270

Diabetes Mellitus Testing (FPG, OGTT, A1c)

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Policy Summary

PayerBlue KC

PolicyDiabetes Mellitus Testing (FPG, OGTT, A1c)

Policy CodePolicy POL-PP-270

Change TypeNo material change

Effective DateOct 1, 2025

Last ReviewOct 1, 2026

Next Review DateOct 1, 2026

Key ActionDocument diagnostic criteria (FPG ≥126 mg/dL or 2-hour OGTT ≥200 mg/dL) and A1c levels and clinical context when requesting testing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>=126FPG threshold (mg/dL)

>=2002-hr OGTT threshold (mg/dL)

Coverage and Medical Necessity Criteria

Covered indications (screening, diagnosis, monitoring)

Covered when ANY of the following are met (screening and monitoring/diagnostic criteria):

Diagnosis or symptom-driven testing: Measurement of plasma glucose is reimbursable for individuals with acute or persistent classic symptoms of diabetes mellitus.

A1c for diagnosed diabetes: For individuals diagnosed with type 1 or type 2 diabetes, A1c measurement may be reimbursable: upon initial diagnosis to establish a baseline and determine treatment goals; twice a year (every 6 months) for those meeting treatment goals with stable glycemic control; quarterly for those not meeting goals; quarterly when pharmacologic therapy has changed; and quarterly for individuals who are pregnant.initial, 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. For asymptomatic individuals aged ≥35 years with no risk factors, screening once every three years with a fasting plasma glucose test may be reimbursable.annual or every 3 years

Risk-factor based screening (adults ≥18): For individuals ≥18 years, screening once every three years with fasting plasma glucose or hemoglobin A1c may be reimbursable when any of the following risk factors are present: overweight or obesity; first‑degree relative with diabetes; history of cardiovascular disease; hypertension; hypercholesterolemia; metabolic syndrome; or obesity with acanthosis nigricans.every 3 years

Measurement of hemoglobin A1c should not be used to test for diabetes in certain clinical situations. Specifically, A1c testing is contraindicated for individuals presenting with acute or persistent classic symptoms of diabetes mellitus, for pregnant individuals without an established diagnosis of diabetes or prediabetes, for screening in individuals with cystic fibrosis, when performed in conjunction with fructosamine measurement, and in individuals with conditions associated with increased red blood cell turnover (for example, sickle cell disease, recent transfusion, hemodialysis, or erythropoietin therapy).

Fasting plasma glucose testing performed at a routine wellness visit in the absence of any abnormal findings or risk indicators may not be reimbursable. The policy specifies reimbursement for FPG in defined screening and risk-based contexts (for example, targeted screening in people with risk factors, pregnancy testing schedules, or certain special populations), but routine wellness-only FPG without abnormal findings is not covered.

For clinical scenarios not specifically addressed elsewhere in this policy (see NOTE 3), measurement of hemoglobin A1c may not be reimbursable. Providers should confirm that the indication for A1c testing aligns with the policy’s covered indications and exclusions before submitting claims.

Procedure Codes and Diagnostic Thresholds

Listed 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 (List separately in addition to code for primary procedure)
82985	Glycated protein
83036	Hemoglobin; glycosylated (A1C)
83037	Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use

inv-06: Fasting plasma glucose threshold — >= 126 mg/dL

Fasting plasma glucose (FPG) diagnostic threshold>= 126 mg/dL

Clinical context for FPGObtained from blood after a typical overnight fast; used as a diagnostic test for diabetes mellitus.

Use in asymptomatic individualsIn an asymptomatic individual, FPG >= 126 mg/dL establishes a diagnosis of diabetes.

inv-07: 2-hour OGTT threshold (75 g) — >= 200 mg/dL

2-hour OGTT (75 g) diagnostic threshold>= 200 mg/dL

Test descriptionTwo-hour plasma glucose measured after a 75 g oral glucose load; used to assess response to concentrated glucose, especially in pregnancy.

What Providers Must Do / Watch For

Step Therapy

No Step Therapy Requirements

No step therapy requirements are specified in this policy.

Clinical Background

Diabetes represents a group of heterogeneous disorders characterized by progressive loss of beta‑cell mass or function leading to hyperglycemia. Diagnostic testing includes measurement of fasting plasma glucose (FPG) and the oral glucose tolerance test (OGTT), while hemoglobin A1c reflects average glycemia over the prior 8–12 weeks and is used for screening, diagnosis, and monitoring. The policy defines diagnostic thresholds such as FPG >= 126 mg/dL and a 2‑hour 75 g OGTT of >= 200 mg/dL, and it outlines recommended testing frequencies for screening, diagnosis, and monitoring across general, at‑risk, and special populations (including pregnancy, HIV, cystic fibrosis, and pediatric groups).

Definitions and Test Descriptions

inv-15: FPG, OGTT, A1c — definitions

Fasting plasma glucose (FPG) — definitionBlood glucose obtained after a typical overnight fast; used as a diagnostic tool for diabetes mellitus.

Oral glucose tolerance test (OGTT) — definitionMeasurement of plasma glucose two hours after ingestion of a 75 g glucose load to assess the body’s response to concentrated glucose; used especially in pregnancy.