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DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services


Diabetes-Related Services
FACT SHEET The summary of information presented in this fact sheet is intended for Medicare Fee-For-Service physicians, providers, suppliers, and other health care professionals who furnish or provide referrals for and/ or file claims for the Medicare-covered preventive benefitsdiscussed in this fact sheet.

Medicare provides coverage of diabetes screening tests for beneficiaries at risk for diabetes or those diagnosed with pre-diabetes. The diabetes screening blood tests covered by Medicare include:

Diabetes Mellitus Diabetes (diabetes mellitus) is defined as a condition of abnormal glucose metabolism using thefollowing criteria:

❖ A fasting blood glucose test; and ❖ A post-glucose challenge test; not limited to ❖ an oral glucose tolerance test with a glucose

challenge of 75 grams of glucose for non-pregnant adults; or

❖ A fasting blood glucose greater than or equal to
126 mg/dL on two different occasions;

❖ a 2-hour post-glucose challenge test alone.
Coverage Information To be eligible forthe diabetes screening tests, beneficiaries must have any of the following risk factors:

❖ A 2-hour post-glucose challenge greater than or ❖ A random glucose test over 200 mg/dL for a

equal to 200 mg/dL on two different occasions; or person with symptoms of uncontrolled diabetes.

Pre-diabetes Pre-diabetes is a condition of abnormal glucose metabolism diagnosed from a previous fastingglucose level of 100-125 mg/dL or a 2-hour postglucose challenge of 140-199 mg/dL. The term “pre-diabetes” includes impaired fasting glucose and impaired glucose tolerance.

❖ Hypertension; ❖ Dyslipidemia; • Obesity (a body mass index greater than or
equal to 30kg/m2);

• Previous identification of an elevated
impaired fasting glucose or glucose tolerance.

ICN 006840 May 2011

OR At leasttwo of the following characteristics:

❖ Overweight (a body mass index greater than 25
but less than 30 kg/m2);

self-management of diabetes. A qualified DSMT program includes the following services:

❖ A family history of diabetes; ❖ Age 65 or older; or ❖ A history of gestational diabetes mellitus, or

❖ Instruction in self-monitoring of
blood glucose,

delivery of a baby weighinggreater than 9 pounds.

❖ Education about diet and exercise, ❖ An insulin treatment plan developed
specifically for insulin-dependent beneficiaries, and self-management.

Medicare provides coverage for diabetes screening tests with the following frequency: Beneficiaries diagnosed with pre-diabetes Medicare provides coverage for a maximum of two diabetes screening tests within a 12-month period(but not less than 6 months apart) for beneficiaries diagnosed with pre-diabetes. Beneficiaries previously tested but not diagnosed as pre-diabetic or who have never been tested Medicare provides coverage for one diabetes screening test within a 12-month period (i.e., at least 11 months have passed following the month in which the last Medicare-covered diabetes screening test was performed) forbeneficiaries who were previously tested and were not diagnosed with pre-diabetes, or who have never been tested. Medicare provides coverage for the diabetes screening tests as a Part B benefit. The beneficiary will pay nothing (there is no coinsurance or copayment and no Medicare Part B deductible for this benefit). NOTE: The diabetes screening benefit covered by Medicare is a stand-alone billableservice separate from the Initial Preventive Physical Examination and does not have to be obtained within a certain time frame following a beneficiary’s Medicare Part B enrollment.

❖ Motivation for beneficiaries to use the skills for
Medicare provides coverage of DSMT services only if the treating physician or treating qualified nonphysician practitioner managing the beneficiary’s diabetic...
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