CurrentHumanaPolicy LAB2O24O01

Laboratory Diabetes Mellitus Testing

Defines Humana Medicare Advantage payment/reimbursement rules for laboratory testing used to screen for, diagnose, or monitor diabetes mellitus (including HbA1c and oral glucose tolerance testing) and specifies frequency and billing interactions for Medicare Advantage members.

Policy Summary

PayerHumana

PolicyLaboratory Diabetes Mellitus Testing

Policy CodePolicy LAB2O24O01

Change TypeNo material changes

Effective DateNov 1, 2024

Next Review Date

Key ActionMeasure hemoglobin A1c per the listed frequencies; do not bill A1c (83037) with fructosamine (82985).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Q3MHbA1c (diag diabetes)

annualHbA1c (prediabetes)

Q3YHbA1c (at-risk adults)

Q3YPediatric screening (10–17)

365dOGTT (CF)

monthlyOGTT (pregnancy)

Coverage Criteria for Diabetes-Related Laboratory Testing

Coverage criteria

Coverage rules and frequencies for hemoglobin A1c (CPT 83037) and oral glucose tolerance testing (CPT 82951, 82952) under specified clinical scenarios.

Individuals with diagnosed diabetes (type 1 or type 2): Measurement of hemoglobin A1c (CPT 83037) reimbursable once every 3 months.

Individuals with prediabetes: Annual screening for type 2 diabetes with hemoglobin A1c (CPT 83037) reimbursable.

Adults age 18 and over at increased risk for type 2 diabetes: Screening with hemoglobin A1c (CPT 83037) reimbursable once every 3 years when any of the following risk factors are present: overweight or obese; history of gestational diabetes; family history of diabetes; cardiovascular disease; hypertension; metabolic syndrome; hypercholesterolemia; metabolic dysfunction-associated steatotic liver disease (MASLD); high-risk race/ethnicity (e.g., African American, Latino or Hispanic, Native American, Asian American, Pacific Islander); polycystic ovary syndrome; physical inactivity; other clinical conditions associated with insulin resistance (e.g., acanthosis nigricans).

Policy Summary

PayerHumana

PolicyLaboratory Diabetes Mellitus Testing

Policy CodePolicy LAB2O24O01

Change TypeNo material changes

Effective DateNov 1, 2024

Next Review Date

Key ActionMeasure hemoglobin A1c per the listed frequencies; do not bill A1c (83037) with fructosamine (82985).

SourceLink

On This Page

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Relevant Codes and Frequency Limits

Relevant CPT codesCPTCovered

82951	Glucose tolerance test (GTT) 3 specimens (includes glucose)
82952	Glucose tolerance test, each additional beyond 3 specimens
83037	Hemoglobin A1c

Frequency limits

Diagnosed diabetes (type 1 or type 2)Hemoglobin A1c (CPT 83037) reimbursable once every 3 months.

Prediabetes screeningHemoglobin A1c (CPT 83037) reimbursable annually for individuals with diagnosed prediabetes.

Adults ≥18 at riskHemoglobin A1c (CPT 83037) reimbursable once every 3 years for adults 18+ with risk factors (e.g., overweight/obesity, history of gestational diabetes, family history, cardiovascular disease, hypertension, metabolic syndrome, hypercholesterolemia, MASLD, high‑risk race/ethnicity, PCOS, physical inactivity, other insulin resistance conditions).

Children 10–17 with risk factorsScreening with OGTT (CPT 82951/82952) or Hemoglobin A1c (CPT 83037) reimbursable once every 3 years for youth with overweight/obesity, family history of type 2 diabetes, or hypertension.

Cystic fibrosis (≥10 years)OGTT (CPT 82951/82952) reimbursable once every 365 days for individuals aged 10 or older with cystic fibrosis.

PregnancyOGTT (CPT 82951/82952) reimbursable up to once per month during pregnancy.

Provider Billing and Reimbursement Rules

Billing Rule

Hemoglobin A1c (CPT 83037) reimbursement rules

Measure hemoglobin A1c (CPT 83037) is reimbursable per the frequencies and indications below. For individuals with a diagnosis of type 1 or type 2 diabetes, hemoglobin A1c testing is reimbursable once every 3 months. For individuals with a diagnosis of prediabetes, annual hemoglobin A1c screening is reimbursable. For adults age 18 and over at increased risk for type 2 diabetes, hemoglobin A1c screening is reimbursable once every 3 years; risk factors include overweight/obesity, history of gestational diabetes, family history of diabetes, cardiovascular disease, hypertension, metabolic syndrome, hypercholesterolemia, metabolic dysfunction-associated steatotic liver disease (MASLD), high-risk race/ethnicity (e.g., African American, Latino/Hispanic, Native American, Asian American, Pacific Islander) with obesity, polycystic ovary syndrome, physical inactivity, and other conditions associated with insulin resistance (e.g., acanthosis nigricans). Hemoglobin A1c is also reimbursable once every 3 years for pediatric screening (ages 10–17) when at least one risk factor is present (overweight/obese, family history of type 2 diabetes, hypertension, dyslipidemia, acanthosis nigricans, polycystic ovary syndrome).

Individuals with diagnosed type 1 or type 2 diabetes: reimbursable once every 3 months
Prediabetes diagnosis: reimbursable annually
Adults ≥18 at increased risk: reimbursable once every 3 years (see risk factors)
Pediatric screening (ages 10–17) with ≥1 risk factor: reimbursable once every 3 years

Billing Rule

OGTT (CPT 82951, 82952) reimbursement rules

Oral glucose tolerance test (OGTT) (CPT 82951, 82952) is reimbursable per the frequencies and indications below: for pediatric screening (ages 10–17) with at least one risk factor (overweight/obese, family history of type 2 diabetes, hypertension, dyslipidemia, acanthosis nigricans, polycystic ovary syndrome) once every 3 years; for individuals with cystic fibrosis aged ≥10 years, once every 365 days; and for pregnant individuals, up to once per month during pregnancy.

Pediatric screening (ages 10–17) with ≥1 risk factor: reimbursable once every 3 years
Cystic fibrosis (age ≥10): OGTT reimbursable once every 365 days
Pregnancy: OGTT reimbursable up to once per month during pregnancy

Denial Risk

Prohibited concomitant billing

Hemoglobin A1c (CPT 83037) is not reimbursable when billed in conjunction with measurement of fructosamine (CPT 82985).

Do not bill CPT 83037 with CPT 82985 on the same claim for reimbursement

Definitions

Prediabetes

DefinitionPrediabetes — a clinical state identified in this policy as 'prediabetes' for which annual screening for type 2 diabetes with hemoglobin A1c (CPT 83037) is reimbursable; individuals with prediabetes are eligible for the annual HbA1c screening stated in the policy.

Screening implicationPrediabetes status triggers coverage for annual HbA1c (CPT 83037) to screen for progression to type 2 diabetes.

Related populationsIndividuals labeled as having prediabetes are distinguished from those with diagnosed diabetes (who receive HbA1c every 3 months) and from at‑risk adults (who may be screened every 3 years).

Oral glucose tolerance test (OGTT)

CPT codes82951 — Glucose tolerance test (GTT) 3 specimens (includes glucose); 82952 — Glucose tolerance test, each additional specimen beyond 3 (listed separately).

PurposeOGTT is used for screening and diagnosis of diabetes, including pediatric screening and cystic fibrosis‑related diabetes as specified in coverage criteria.

Frequency rulesOGTT (CPT 82951/82952) reimbursable once every 3 years for children aged 10–17 with risk factors; once every 365 days for individuals ≥10 with cystic fibrosis; up to once per month during pregnancy.

Hemoglobin A1c (HbA1c)

CPT code83037 — Hemoglobin A1c (HbA1c)

Clinical useMeasurement of HbA1c is used for monitoring and screening for diabetes and prediabetes as described in the policy's frequency limits.

Billing interactionMeasurement of HbA1c (CPT 83037) is NOT reimbursable when billed in conjunction with measurement of fructosamine (CPT 82985).