CurrentHumanaPolicy LAB2024001

Laboratory - Diabetes Mellitus Testing

Medicare Advantage payment policy describing Humana's reimbursement rules for laboratory testing related to diabetes mellitus (A1c and oral glucose tolerance tests) for Medicare Advantage members and related screening intervals and clinical risk groups.

Policy Summary

PayerHumana

PolicyLaboratory - Diabetes Mellitus Testing

Policy CodePolicy LAB2024001

Change TypeNo material changes

Effective DateNov 1, 2024

Next Review Date

Key ActionSubmit claims supported by medical necessity and applicable referrals or authorizations for Medicare Advantage members.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Every 3 monthsA1c frequency for diagnosed diabetes

Every 3 yearsRoutine screening interval (adults ≥18 w/ risk)

AnnualCF-related diabetes screening

Up to monthlyOGTT frequency during pregnancy

Every 3 yearsPediatric screening (10–17) with risk

Coverage Criteria for Diabetes Testing

Coverage criteria for diabetes testing

Covered when ALL of the following criteria are met:

ALL of the following

Adults and general rules
- Individuals with a diagnosis of type 1 or type 2 diabetes; hemoglobin A1c (CPT 83037) reimbursable once every 3 months
  Frequency limit applies to Medicare Advantage members
- Individuals with a diagnosis of prediabetes; hemoglobin A1c (CPT 83037) reimbursable annually
- Adults age ≥18 at risk for type 2 diabetes: screening hemoglobin A1c (CPT 83037) reimbursable once every 3 years if ANY of the listed risk factors present
  See risk-factor list in child node

Policy Summary

PayerHumana

PolicyLaboratory - Diabetes Mellitus Testing

Policy CodePolicy LAB2024001

Change TypeNo material changes

Effective DateNov 1, 2024

Next Review Date

Key ActionSubmit claims supported by medical necessity and applicable referrals or authorizations for Medicare Advantage members.

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.

Risk factors for adults (use to determine 3-year screening eligibility)

Cardiovascular disease
Family history of diabetes
High-risk race/ethnicity at risk for type 2 diabetes (e.g., African American, Latino or Hispanic, Native American, Asian American or Pacific Islander)
History of gestational diabetes
Hypercholesterolemia
Hypertension
Metabolic dysfunction-associated steatotic liver disease (MASLD)
Metabolic syndrome
Other clinical conditions associated with insulin resistance (e.g., acanthosis nigricans)
Overweight or obese
Physical inactivity
Polycystic ovary syndrome

Pediatric rules (age 10–17)

Children ages 10–17 with at least one risk factor: OGTT (CPT 82951, 82952) or hemoglobin A1c (CPT 83037) reimbursable once every 3 years
Pediatric risk factors include: acanthosis nigricans, dyslipidemia, family history of type 2 diabetes, hypertension, overweight or obese, polycystic ovary syndrome

Special populations and pregnancy

Individuals ≥10 years with cystic fibrosis: screening for CF-related diabetes with OGTT (CPT 82951, 82952) reimbursable once every 365 days
Pregnant individuals: OGTT (CPT 82951, 82952) reimbursable up to once per month during pregnancy

Applicable Procedure Codes and Frequency Thresholds

Applicable procedure codesCPT

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).
83037	Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use

Reimbursement frequency thresholds — A1c and OGTT

A1c for diagnosed diabetesHemoglobin A1c (CPT 83037) reimbursable once every 3 months for individuals with type 1 or type 2 diabetes.

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

Adult screening interval with risk factorsA1c (CPT 83037) reimbursable once every 3 years for adults ≥18 with specified risk factors (cardiovascular disease; family history; high‑risk race/ethnicity; history of gestational diabetes; hypercholesterolemia; hypertension; MASLD; metabolic syndrome; other insulin resistance conditions; overweight/obesity; physical inactivity; PCOS).

Pediatric screening (ages 10–17)Screening with OGTT (CPT 82951/82952) or A1c (CPT 83037) reimbursable once every 3 years for children 10–17 with at least one risk factor (acanthosis nigricans; dyslipidemia; family history; hypertension; overweight/obese).

CF-related diabetes screeningOGTT (CPT 82951/82952) reimbursable once every 365 days for individuals ≥10 years diagnosed with cystic fibrosis.

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

Claims Processing and Provider Actions

Note

Medicare Advantage claims — processing note

As a Medicare Advantage plan, claims are processed in accordance with Medicare Advantage payment policies. All payments remain subject to plan requirements including medical necessity and reasonableness. Additionally, providers must comply with any applicable referral or prior authorization requirements before services are rendered. Failure to obtain required authorizations or to document medical necessity may result in claim denial or recovery of payments.

Applies to Medicare Advantage claims unless superseded by an applicable National Coverage Determination (NCD) or Local Coverage Determination (LCD).
Ensure documentation on the medical record supports the medical necessity and reasonableness of the service billed.
Verify and obtain any required referrals or prior authorizations per plan procedures prior to claim submission.

Test Definitions

Test definitions — CPT mappings

OGTT primary code (3‑specimen)CPT 82951 — Glucose; tolerance test (GTT), 3 specimens (includes glucose).

OGTT additional specimen codeCPT 82952 — Glucose; tolerance test, each additional beyond 3 specimens (list separately in addition to primary procedure).

Hemoglobin A1c codeCPT 83037 — Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use.