CurrentHumanaPolicy LAB2023019

Laboratory - Hemoglobin A1c

Humana's billing and reimbursement requirements for hemoglobin A1c laboratory services for Medicare Advantage and Commercial products, including frequency limits and situations where the test is not reimbursable.

Policy Summary

PayerHumana

PolicyLaboratory - Hemoglobin A1c

Policy CodePolicy LAB2023019

Change TypeNo material change

Effective DateMay 1, 2023

Next Review DateJul 1, 2023

Key ActionFollow plan requirements including medical necessity, reasonableness, and any referral or authorization rules; do not bill A1c with fructosamine.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

every 3 monthsA1c frequency (diagnosed diabetes)

once/365 daysA1c frequency (adult detection)

once/3 yearsA1c frequency (pediatric screening 10-17)

up to monthlyA1c frequency (pregnancy)

CPT 83036/83037Applicable CPT codes listed

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Reimbursement criteria

Humana reimburses hemoglobin A1c testing under the following conditions and frequencies.

Individuals with a diagnosis of Type 1 or Type 2 diabetes: A1c (CPT 83036 or 83037) reimbursable once every 3 months.

Adults (≥18) for detection/diagnosis of Type 2 diabetes with at least one listed risk factor (e.g., overweight/obese, pre‑diabetes, history of gestational diabetes, family history of diabetes, cardiovascular disease, hypertension, hypercholesterolemia, metabolic syndrome, polycystic ovary syndrome, high‑risk race/ethnicity, physical inactivity, other conditions associated with insulin resistance): A1c (CPT 83036 or 83037) reimbursable once every 365 days.

Children aged 10–17 with at least one of the following characteristics: overweight or obese, family history of type 2 diabetes, hypertension, dyslipidemia, or polycystic ovary syndrome — A1c (CPT 83036 or 83037) reimbursable once every 3 years for diabetes screening.

Pregnant individuals: A1c (CPT 83036 or 83037) reimbursable up to once per month during pregnancy.

A1c measurement is NOT reimbursable when billed in conjunction with fructosamine (CPT 82985).

Operational guidance

General Humana resources and operational notes relevant to coverage and claims processing:

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

Providers can register for Availity to access eligibility, benefits, referrals, authorizations, claims and electronic remittances.

Claims processing edit notifications and alerts of upcoming claims payment changes are posted on the first Friday of each month; providers should check Humana claims resources for information on referrals, authorizations, and electronic claim submissions.

Do not bill A1c (CPT 83036 or 83037) in conjunction with fructosamine (CPT 82985); follow plan billing and authorization rules when submitting claims.

Evidence citations

Evidence base referenced in policy (informing clinical and analytical considerations):

Guidelines and evidence cited include NICE guidance on Type 2 diabetes management and WHO reports on diabetes.

Peer‑reviewed studies on HbA1c measurement variability, biological variation, and implications for diagnosis and prognosis (e.g., Rohlfing et al., Selvin et al., Weykamp et al.) are referenced to support policy decisions regarding testing frequency and interpretation.

Research on associations between HbA1c variability and clinical outcomes (e.g., cancer development, hypoglycemia‑related hospitalizations) and methodological references (IFCC reference system for HbA1c) are included in the cited literature list.

Coding and Frequency Limits

Applicable CPT codesCPTCovered

83037	Hemoglobin; glycosylated (A1c) by device cleared by FDA for home use
83036	Hemoglobin; glycosylated (A1c)
82985	Fructosamine

Diabetes monitoring frequency (diagnosed)

FrequencyOnce every 3 months for individuals with a diagnosis of Type 1 or Type 2 diabetes (CPT 83036 or 83037).

Applies toMedicare Advantage and Commercial members as specified in policy sections for each product type.

Related codesCPT 83036, CPT 83037

Billing noteClaims are subject to medical necessity and other plan requirements (e.g., referrals/authorizations).

Diabetes detection/diagnosis screening frequency (adults ≥18)

FrequencyOnce every 365 days for adults aged 18 and over at risk for Type 2 diabetes.

Eligible populationAdults (≥18) with risk factors such as overweight/obesity, pre-diabetes, history of gestational diabetes, family history, cardiovascular disease, hypertension, hypercholesterolemia, metabolic syndrome, polycystic ovary syndrome, high-risk race/ethnicity, physical inactivity, or other insulin resistance conditions.

PurposeDetection and diagnosis of Type 2 diabetes.

Pediatric screening frequency (age 10-17)

FrequencyOnce every 3 years for children aged 10–17 when at least one risk characteristic is present.

Risk characteristicsOverweight/obese, family history of type 2 diabetes, hypertension, dyslipidemia, or polycystic ovary syndrome.

Applicable CPT codesCPT 83036 or 83037

Pregnancy monitoring frequency

FrequencyUp to once per month during pregnancy.

PopulationPregnant individuals for monitoring during pregnancy.

Applicable CPT codesCPT 83036 or 83037

Provider Actions and Billing Notes

Billing Rule

Authorization and billing requirements; do not bill A1c with fructosamine

Follow all plan requirements for medical necessity, reasonableness, and any applicable referral or authorization rules when submitting claims for hemoglobin A1c testing. Do not bill hemoglobin A1c (CPT 83036 or 83037) in conjunction with fructosamine (CPT 82985); such combined billing is not reimbursable.

Claims are subject to medical necessity and reasonableness and any applicable referral or authorization requirements.
A1c (CPT 83036 or 83037) is not reimbursable when billed with fructosamine (CPT 82985).

Note

Register with Availity to access member eligibility, benefits, referrals, authorizations, claims and electronic remittance information. Review Humana's claims processing edit notifications and claims resources for up-to-date guidance on referrals, authorizations and electronic claim submissions.

Availity provides access to eligibility, benefits, referrals, authorizations, claims and electronic remittances.
Claims processing edit notifications are posted on the first Friday of each month.
Claims resources include information on referrals, authorizations and electronic claim submissions.

Definitions

Hemoglobin A1c measurement

DefinitionLaboratory test to measure glycosylated hemoglobin used for monitoring and screening diabetes.

Common CPT codesCPT 83036, CPT 83037

Use casesUsed for glycemic control monitoring in diagnosed diabetes and for screening/diagnosis of Type 2 diabetes per policy criteria.

Policy scopeHumana's billing and reimbursement requirements for Medicare Advantage and Commercial products; claims subject to medical necessity and plan rules.

CPT 83037

Code83037

DescriptionHemoglobin; glycosylated (A1c) by device cleared by FDA for home use.

Applicable plansListed for Medicare Advantage and Commercial plan coding sections.

Hemoglobin A1c (HbA1c) — Measurement considerations

Analytical considerationsHbA1c measurements have biological and analytical variability that can affect diagnosis and prognosis decisions.

Reference systemsIFCC Reference Measurement System for HbA1c is cited as part of measurement standardization considerations.

Clinical implicationsShort-term and visit-to-visit variability in HbA1c can impact classification, monitoring, and association with outcomes such as hypoglycemia and other complications.

OpenPayer

Laboratory - Hemoglobin A1c

Coverage Criteria

Coding and Frequency Limits

Provider Actions and Billing Notes

Definitions