CurrentBlue KCPolicy POL-PP-270

Diabetes mellitus testing (FPG, OGTT, HbA1c)

Defines when fasting plasma glucose (FPG), oral glucose tolerance test (OGTT), and hemoglobin A1c testing are reimbursable for diagnosis, screening, and monitoring of diabetes and prediabetes across Blue KC lines of business.

Policy Summary

PayerBlue KC

PolicyDiabetes mellitus testing (FPG, OGTT, HbA1c)

Policy CodePolicy POL-PP-270

Change TypeVersion update (no material clinical changes indicated)

Effective Date10/01/2025

Next Review Date10/01/2026

Key ActionProviders should document the clinical indication, symptoms, pregnancy status, age, and presence of listed risk factors to support reimbursement and verify member eligibility and benefit limits.

SourceLink

POLICY UPDATE CHANGES

Version 002 (10/01/2025) published as Avalon 4 Quarter update

POL-PP-270policy identifier

10/01/2025version effective date

10/01/2026next review date

>=126Fasting plasma glucose threshold for diabetes diagnosis

>=2002-hour OGTT plasma glucose threshold for diabetes diagnosis

Policy Summary

PayerBlue KC

PolicyDiabetes mellitus testing (FPG, OGTT, HbA1c)

Policy CodePolicy POL-PP-270

Change TypeVersion update (no material clinical changes indicated)

Effective Date10/01/2025

Next Review Date10/01/2026

SourceLink

On This Page

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.

When FPG, OGTT, and Hemoglobin A1c Are Reimbursable

Measurement of plasma glucose (FPG) for symptomatic individuals

Fasting plasma glucose may be reimbursable when ANY of the following apply:

ANY of the following

Individuals with acute or persistent classic symptoms of diabetes mellitus
Measurement of plasma glucose may be reimbursable

Measurement of hemoglobin A1c for individuals with established diabetes

Hemoglobin A1c may be reimbursable for individuals with type 1 or type 2 diabetes when ANY of the following apply:

ANY of the following

Upon initial diagnosis to establish baseline and determine treatment goals
Twice a year (every 6 months) for individuals meeting treatment goals with stable glycemic control based on daily monitoring
Quarterly for individuals not meeting treatment goals
Quarterly when pharmacologic therapy has changed
Quarterly for pregnant individuals with established diabetes

Screening for prediabetes or type 2 diabetes in adults

Screening may be reimbursable according to age and risk factors:

ANY of the following

Asymptomatic individuals ≥35 years old with no risk factors: FPG once every 3 years
Adults ≥18 years with risk factors
- Individuals ≥18 years old
- At least one risk factor present
  - Overweight or obese
  - First-degree relatives with diabetes

Screening for people with HIV

Fasting plasma glucose testing may be reimbursable in these situations for people positive for HIV:

ANY of the following

Before starting antiretroviral therapy (ART)
When switching ART
3-6 months after starting or switching ART
Annually when prior screening results were initially normal

Screening in cystic fibrosis and youth

OGTT and other age-specific recommendations:

ANY of the following

Overweight/obese children/adolescents (<18 years)
- Age <18 and overweight/obese
- ANY of the following
  - Maternal history of diabetes or GDM during gestation
  - Family history of type 2 diabetes in first- or second-degree relatives
  - Signs of insulin resistance or associated conditions (acanthosis nigricans, hypertension, dyslipidemia, PCOS, small for gestational age birth weight)

Pregnancy-specific testing

Testing reimbursable during pregnancy and postpartum for GDM:

ANY of the following

Pregnant individuals: FPG or OGTT up to once per month during pregnancy may be reimbursable
Individuals diagnosed with GDM: OGTT 4-12 weeks postpartum to screen for persistent diabetes or prediabetes
If postpartum screening positive, repeat OGTT to confirm diagnosis

Situations where testing may not be reimbursable

FPG and A1c limitations:

ANY of the following

FPG testing at a wellness visit with no abnormal findings: may not be reimbursable
Measurement of hemoglobin A1c in situations not previously addressed: may not be reimbursable

Situations where A1c should not be used

Measurement of hemoglobin A1c should not be performed for the following:

ANY of the following

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 for diabetes in individuals diagnosed with cystic fibrosis
In conjunction with measurement of fructosamine
In individuals with conditions associated with increased RBC turnover (e.g., sickle cell disease, patients on hemodialysis, receiving erythropoietin therapy, recent blood loss or transfusion, HIV positive receiving hemodialysis noted)

Diagnostic and Risk Thresholds

Diagnostic and risk thresholds

Fasting plasma glucose diagnostic threshold>= 126 mg/dL

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

A1c prediabetes risk range5.7% to <6.5%

Relevant CPT / HCPCS Codes

CPT/HCPCS codes referencedCPT|HCPCS

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
82985	Glycated protein
83036	Hemoglobin; glycosylated (A1C)
83037	Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use

Documentation, Eligibility, and Administrative Actions

Documentation Required

Document clinical indication and risk factors

Document the clinical indication for testing and any relevant patient factors in the medical record. Include presenting symptoms, pregnancy status, patient age, and the presence of listed risk factors (for example: overweight/obese, family history of diabetes, hypertension, cardiovascular disease, hypercholesterolemia, metabolic syndrome, acanthosis nigricans, polycystic ovary syndrome, MASLD, prior gestational diabetes, HIV status, or cystic fibrosis) to support reimbursement for FPG, OGTT, or A1c testing.

Affected codes: 82947, 82951, 82952, 82985, 83036, 83037

Prior Authorization

Coverage determined by member benefits

Coverage is determined by the member's benefits at the date of service; providers should verify the member's eligibility and any benefit limits prior to requesting testing to ensure services are covered.

Clinical Background and Test Roles

Diabetes encompasses heterogeneous disorders in which genetic and environmental factors lead to loss of pancreatic β‑cell mass and/or function, producing chronic hyperglycemia that requires laboratory evaluation for diagnosis and management. Fasting plasma glucose (FPG) is measured after an overnight fast and, together with the oral glucose tolerance test (OGTT), is used to establish a diagnosis of diabetes when values meet diagnostic thresholds (FPG ≥ 126 mg/dL or a 2‑hour plasma glucose ≥ 200 mg/dL during a 75 g OGTT).

Hemoglobin A1c (A1c) reflects the post‑translational attachment of glucose to hemoglobin in red blood cells and correlates with average glycemia over the prior 8–12 weeks. Measurement of A1c is recommended when appropriate for screening, diagnosis, and ongoing monitoring of diabetes and prediabetes, with an A1c range of 5.7% to <6.5% identifying individuals at increased risk. Certain clinical conditions that alter red blood cell turnover (for example, sickle cell disease, recent transfusion, erythropoietin therapy, or persons on hemodialysis) can affect A1c accuracy and should be considered when selecting tests.

Defined Terms

Definitions — family history

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

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

Policy Updates

2025-10-01Version publishedLatest

Version 002 (10/01/2025) published as Avalon 4 Quarter update; policy updated with effective date 10/01/2025 (no clinical coverage changes noted).

2025-07-01Version created

Version 001 created 07/01/2025 (initial version).

Diabetes mellitus testing (FPG, OGTT, HbA1c)

When FPG, OGTT, and Hemoglobin A1c Are Reimbursable

Diagnostic and Risk Thresholds

Relevant CPT / HCPCS Codes

Documentation, Eligibility, and Administrative Actions

Clinical Background and Test Roles

Defined Terms

Policy Updates

Referenced Policies