CMS HbA1c Form

Summary Of Evidence

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Analysis of Evidence

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Hemoglobin A1c (HbA1c) refers to the major component of hemoglobin A1.

Performance of the HbA1c test at least 2 times a year in patients who are meeting treatment goals and who have stable glycemic control is supported by the American Diabetes Association Standards of Medical Care in Diabetes - 2016 (ADA Standards).¹ For beneficiaries with stable glycemic control (defined as 2 consecutive HbA1c results meeting the treatment goals) performing the HbA1c test at least 2 times a year may be considered reasonable and necessary. The ADA framework for considering treatment goals recognizes that “patient characteristics/health status” are important factors when considering glycemic goals.² Beneficiaries eligible for the Medicare home health benefit, for example, often have multiple coexisting chronic illnesses that would support a higher target goal for the HbA1c (e.g., < 8.5%), in order to avoid adverse events (e.g., hypoglycemia-related emergency department visits and acute inpatient hospitalization). 

Palmetto GBA will allow 1 additional HbA1c test every 3 months for a total of 8 tests per year in patients with uncontrolled blood glucose levels. Additional tests beyond that frequency may be reimbursed on appeal with appropriate documentation of medical necessity.

HbA1c may be inaccurate in certain situations including anemia, transfusions, hemoglobinopathies and conditions of rapid red cell turnover. Other tests to assess diabetes, including glucose, glycated protein, or fructosamine levels, may be used and are described in the Lab National Coverage Determination 190.21 (NCD for Glycated Hemoglobin / Glycated Protein). This NCD lists the ICD-10 codes for HbA1c for frequencies up to once every 3 months.