FINAL

METRAHEALTH PART B MEDICARE JACKSON MS (10250)

LOCAL MEDICAL REVIEW POLICY

SUBJECT:  Glycated Hemoglobin
POLICY NUMBER:  OTH-9515
DESCRIPTION: Glycosylated Hemoglobin (Hb AIC) is a stable product of nonenzymatic glycosylation of the beta-chain of hemoglobin by plasma glucose.  Glycated hemoglobin measurement is a valuable  tool in the management of some patients with diabetes mellitus.  Elevation of glucose in the blood causes the level of glycated hemoglobin in the red blood cells to rise.  Since red blood cells have a life span of approximately 120 days, the level of glycated hemoglobin gives  the clinician a guide as to the control of the blood glucose level over that period of time.  It  is a longitudinal measure of  glucose control, as opposed to individual blood glucose  eterminations.  The test is not useful or  necessary in management of most cases of diabetes ellitus.
POLICY TYPE: Local Medical Necessity Policy
HCPCS SECTION BENEFIT CATEGORY: Pathology and Laboratory
HCPCS CODES: 83036 - Hemoglobin, glycated
HCFA'S NATIONAL POLICY: None
INDICATIONS AND LIMITATIONS OF COVERAGE: Glycated hemoglobin is occasionally indicated in the management of disorders of glucose metabolism, e.g., diabetes mellitus.
COVERED ICD-9 CODES: 250.00 - 250.93 Diabetes Mellitus
648.00 - 648.04 Gestational Diabetes
648.80 - 648.84  Abnormal glucose tolerance test in pregnancy
790.2  Abnormal glucose tolerance test
790.6  Hyperglycemia NOS
Note:    Diagnostic codes are to be used at their highest level of specificity.  Fourth and fifth digits should be utilized when they are available.
EMC and hard copy claims will be monitored for appropriateness and frequency.
REASONS FOR NONCOVERAGE:  Coverage will not be provided for tests obtained for screening purposes or for tests obtained for medically unnecessary indications.  This test will be denied unless a disorder of glucose metabolism is present.
NONCOVERED ICD-9 CODE(S):  Glycosylated hemoglobin determinations obtained for diagnoses other than those listed as covered will be denied as not medically necessary.
SOURCES OF INFORMATION: 1.  Ravel, Richard; Clinical Laboratory Medicine; Clinical Application of Laboratory Data, 5th Edition, pg. 471-473 (1989.
 2. Other Carriers' Policies
CODING GUIDELINES: The ICD-9-CM diagnosis code and CPT code must be linked on the claim form.
Place of Service: Office (11) 
Independent Laboratory (81)
DOCUMENTATION REQUIREMENTS: The medical record must contain appropriate clinical notes and laboratory studies to support the diagnosis and the utilization of this test.
Payments can be made on a REVIEW basis for diagnosis other than those listed above.  The utility and need for these services must be documented to be:
1. Safe and effective.
2. Appropriate for the diagnosis.
3. Not for convenience.
4. A need not met by another service already performed.
Documentation should include but is not limited to:
1. Peer reviewed medical literature.
2. AMA DATTA reports.
3. Policy of specialty groups.
4. Office notes, lab reports.
OTHER COMMENTS: Glycosylated hemoglobin determinations performed at frequencies greater than every three  months should seldom be medically necessary.
Nonphysician Claims (i.e., independent clinical labs) - Documentation supporting the medical  necessity of this item such as ICD-9 codes, must be submitted with each claim.  Claims submitted  without such evidence will be denied as being not medically necessary.
This policy will be utilized in conducting postpayment reviews.
RATIONALE FOR CREATING POLICY: This policy was developed in response to a review of data indicating overutilization of the hemoglobin AIC lab test without medical necessity to support the frequency in which the test was  performed.
CAC NOTES: This policy was discussed at the 9/26/95 CAC meeting.
There were no comments received during comment period (09/26/95 - 11/10/95).
START DATE OF COMMENT PERIOD: 09/26/95
START DATE OF NOTICE PERIOD:  09/26/95
EFFECTIVE DATE:  01/10/96
REVISION DATE:
REVISION NUMBER:

This policy does not reflect the sole opinion of the carrier or Carrier Medical Director.  Although the final decision rests with the carrier, this policy was developed in cooperation with the Carriers Advisory Committee, which includes representatives from:

 Medical Specialty Societies

 Mississippi State Medical Association

 Mississippi Foundation for Medical Care

Additional Distribution: Medical Directors in Region IV
Published in Medicare News