CurrentHumanaPolicy LAB2024001

Laboratory - Diabetes Mellitus Testing

Humana Medicare Advantage payment policy describing reimbursement rules for diabetes-related laboratory testing (HbA1c and oral glucose tolerance tests) and who is eligible for testing frequency; intended for providers submitting claims for Humana Medicare Advantage members.

Policy Summary

PayerHumana

PolicyLaboratory - Diabetes Mellitus Testing

Policy CodePolicy LAB2024001

Change TypeRevised reimbursement frequency guidance

Effective Date11/2024

Next Review Date

Key ActionSubmit claims with appropriate diagnosis and frequency documentation to support medical necessity for HbA1c or OGTT per the policy frequencies.

SourceLink

POLICY UPDATE CHANGES

Policy lists reimbursement frequencies for hemoglobin A1c and oral glucose tolerance testing across multiple clinical scenarios (diabetes, prediabetes, high-risk adults, children, cystic fibrosis, pregnancy).

3 monthsA1c reimbursable frequency for individuals with diagnosed type 1 or type 2 diabetes

annualA1c reimbursable frequency for individuals with prediabetes

3 yrsA1c reimbursable frequency for screening adults ≥18 at risk

3 yrsDiabetes screening frequency for children 10-17 with risk factors

365 daysOGTT reimbursable frequency for individuals ≥10 years with cystic fibrosis

monthlyOGTT reimbursable frequency during pregnancy

Coverage Criteria for HbA1c and OGTT

Coverage criteria — Hemoglobin A1c (A1c) and OGTT

Reimbursement criteria for hemoglobin A1c (A1c) and oral glucose tolerance testing (OGTT) by clinical indication and patient population. Covered when the following criteria are met:

Diabetes diagnosis

Individuals with a diagnosis of type 1 or type 2 diabetes: Hemoglobin A1c (CPT 83037) reimbursable once every 3 months.

Prediabetes

Individuals with a diagnosis of prediabetes: Hemoglobin A1c (CPT 83037) reimbursable annually.

Adults at increased risk (age ≥18)

Adults 18 years and older without diagnosed diabetes but with one or more of the listed risk factors: Hemoglobin A1c (CPT 83037) reimbursable once every 3 years.

Policy Summary

PayerHumana

PolicyLaboratory - Diabetes Mellitus Testing

Policy CodePolicy LAB2024001

Change TypeRevised reimbursement frequency guidance

Effective Date11/2024

Next Review Date

Key ActionSubmit claims with appropriate diagnosis and frequency documentation to support medical necessity for HbA1c or OGTT per the policy frequencies.

SourceLink

On This Page

Listed risk factors include: cardiovascular disease; family history of diabetes; high-risk race/ethnicity (e.g., African American, Latino or Hispanic, Native American, Asian American or Pacific Islander) at risk for type 2 diabetes (e.g., obesity); 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.

Children (screening, ages 10–17)

Children ages 10–17 with at least one risk factor (acanthosis nigricans; dyslipidemia; family history of type 2 diabetes; hypertension; overweight or obese): Screening with OGTT (CPT 82951/82952) or Hemoglobin A1c (CPT 83037) reimbursable once every 3 years.

Cystic fibrosis

Individuals age ≥10 years diagnosed with cystic fibrosis: OGTT (CPT 82951, CPT 82952) reimbursable once every 365 days.

Pregnancy

Pregnant individuals: OGTT (CPT 82951, CPT 82952) reimbursable up to once per month during pregnancy.

Applicable Codes and Reimbursement Frequencies

Applicable CPT CodesCPTCovered

83037	Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use
82951	Glucose; tolerance test (GTT), 3 specimens (includes glucose)
82952	Glucose; tolerance test, each additional beyond 3 specimens

Covered CPT Codes - Additional NoteCPT

82952

List separately in addition to code for primary procedure

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 with a diagnosis of prediabetes.

A1c for at‑risk adults (screening)Hemoglobin A1c (CPT 83037) reimbursable once every 3 years for adults ≥18 with listed risk factors (cardiovascular disease; family history of diabetes; 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 Hemoglobin A1c (CPT 83037) reimbursable once every 3 years for children ages 10–17 with at least one risk factor (acanthosis nigricans; dyslipidemia; family history of type 2 diabetes; hypertension; overweight/obese).

OGTT for cystic fibrosisOGTT (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 Authorization

Documentation Required

Claims subject to plan requirements and authorizations

Claims payments are subject to plan requirements including medical necessity, reasonableness, and applicable referral or authorization requirements.

Definitions: HbA1c and OGTT

A1c and OGTT — CPT codes and descriptions

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

CPT 82951Glucose; tolerance test (GTT), 3 specimens (includes glucose).

CPT 82952Glucose; tolerance test, each additional beyond 3 specimens (listed separately in addition to primary procedure).