Anthem Blue Cross Connecticut CG-LAB-30 Outpatient Laboratory-based Blood Glucose Testing Form

This document addresses laboratory testing to determine blood glucose concentration. Blood glucose determination may be done using whole blood, serum, or plasma. This document does not address blood glucose testing in the hospital or emergency department settings. This document also does not address self-testing of blood glucose monitoring (BGM) using test strips.

For information regarding other methods to assess glycemic control for individuals with diabetes mellitus (DM), see:

• CG-DME-42 Continuous Glucose Monitoring Devices
• CG-DME-50 Automated Insulin Delivery Systems
• CG-DME-51 External Insulin Pumps
• CG-LAB-25 Outpatient Glycated Hemoglobin and Protein Testing

Clinical Indications

Medically Necessary:

Blood glucose testing is considered medically necessary for individuals who meet any of the following criteria (A through Q):

1. Signs or symptoms of either of the following:
   1. Hypoglycemia; or
   2. Hyperglycemia; or
2. Overweight or obesity* of any age; or
3. From a population with a high prevalence of diabetes mellitus**; or
4. Impaired fasting glucose has been found on other testing; or
5. Pregnant and considered to be at high risk for type 2 diabetes mellitus; or
6. Prior testing at least 3 months previously showed abnormal blood glucose results; or
7. Insulin resistance syndrome; or
8. Carbohydrate intolerance; or
9. Hypoglycemia disorders, such as nesidioblastosis or insulinoma; or
10. Catabolic or malnutrition states; or
11. Tuberculosis; or
12. Unexplained chronic or recurrent infection; or
13. Alcohol use disorder; or
14. Coronary artery disease; or
15. Unexplained skin conditions (including pruritis, local skin infections, ulceration and gangrene without an established cause); or
16. Chronic glucocorticoid therapy; or
17. To evaluate glycemic status for individuals with established diabetes mellitus, prediabetes, or a history of gestational diabetes when done no more often than the following test frequencies:
    1. Up to once yearly for individuals with prediabetes; or
    2. Up to two times per year for individuals with diabetes mellitus who are meeting treatment goals; or
    3. Within the first year postpartum and then up to once yearly for individuals who have had gestational diabetes.

Notes:
See the Discussion section below for more information about:
*ADA, ACOG, and USPSTF recommendations about individuals who have overweight or obesity; and
** See discussion section for information regarding populations with high prevalence of diabetes mellitus.

Not Medically Necessary:

Blood glucose testing is considered not medically necessary when the criteria above are not met and for all other indications.