Description: This policy is intended to apply to blood samples used to determine glucose levels. Blood glucose determination may be done using whole blood, serum or plasma. It may be sampled by capillary puncture, as in the fingerstick method, or by vein puncture or arterial sampling. The method for assay may be by color comparison of an indicator stick, by meter assay of whole blood or a filtrate of whole blood, using a device approved for home monitoring, or by using a laboratory assay system using serum or plasma. The convenience of the meter or stick color method allows a patient to have access to blood glucose values in less than a minute or so and has become a standard of care for control of blood glucose, even in the inpatient setting.

Indications:
Blood glucose values are often necessary for the management of patients with diabetes mellitus, where hyperglycemia and hypoglycemia are often present. They are also critical in the determination of control of blood glucose levels in patient with impaired fasting glucose (FPG 110-125 mg/dL), patient with insulin resistance syndrome and/or carbohydrate intolerance (excessive rise in glucose following ingestion of glucose/glucose sources of food), in patient with a hypoglycemia disorder such as nesidioblastosis or insulinoma, and in patients with a catabolic or malnutrition state. In addition to conditions listed, glucose testing may be medically necessary in patients with tuberculosis, unexplained chronic or recurrent infections, alcoholism, coronary artery disease (especially in women), or unexplained skin conditions (i.e.: pruritis, skin infections, ulceration and gangrene without cause). Many medical conditions may be a consequence of a sustained elevated or depressed glucose level, including comas, seizures or epilepsy, confusion, abnormal hunger, abnormal weight loss or gain, and loss of sensation. Evaluation of glucose may be indicated in patients on medications known to affect carbohydrate metabolism.

Effective January 1, 2005, the Medicare law expanded coverage to diabetic screening services. Some forms of blood glucose testing covered under this NCD may be covered for screening purposes subject to specified frequencies. See 42 CFR410.18, sec. 90 ch.18 Claims Processing Manual for screening benefit description.

Limitations:
Frequent home blood glucose testing by diabetic patients should be encouraged. In stable, non- hospitalized patients unable or unwilling to do home monitoring, it may necessary to measure quantitative blood glucose up to 4 times a year. Depending upon patient’s age, type of diabetes, complications, degree of control, and other co-morbid conditions, more frequent testing than 4 times a year may be reasonable and necessary. In patients presenting nonspecific signs, symptoms, or diseases not normally associated with disturbances in glucose metabolism, a single blood glucose test may be medically necessary. Repeat testing may not be indicated unless abnormal results are found or there is a change in clinical condition. If repeat testing is performed, a diagnosis code (e.g., diabetes) should be reported to support medical necessity. However, repeat testing may be indicated where results are normal in patients with conditions of a continuing risk of glucose metabolism abnormality (e.g., monitoring glucocorticoid therapy).

Other:
Documentation Requirements

The ordering physician must include evidence in the patient’s clinical record that an evaluation of history and physical preceded the ordering of glucose testing and that manifestations of abnormal glucose levels were present to warrant the testing.

Frequency Limitations: In stable, non-hospitalized patients who are unable or unwilling to do home glucose monitoring, it may be reasonable and necessary to measure quantitative blood glucose up to 4 times annually.

Depending on the age and condition of the patient, the type of diabetes, degree of control, and other co-morbid conditions, more frequent testing may be reasonable and necessary.