Local Medical Review Policy (LMRP) and National Coverage
Determinations (NCD) for Glycated Hemoglobin (A1c)
Local Medical Review Policy(LMRPs) or National Coverage Determinations (NCDs) dictate
the coverage for clinical laboratory tests in regard to medical necessity issues. LMRPs and
NCDs typically include: (1) Indications and Limitations of Coverage, (2) Covered ICD-9
Codes, (3) Reasons for Non-coverage, (4) Non-covered ICD-9 Codes, and (5)
Documentation Requirements. Policy may be published for a single assay, disease or
group of tests. Most policies connect with a single CPT code, however some apply to a
group of related codes. Only a limited number of LMRPs are published by each Medicare
carrier. LMRPs differ from state to state, NCDs apply uniformly to all providers throughout
the country.
A new NCD for A1c will become effective November 25, 2002. Until then, existing LMRPs
will apply. After November 25th the following ICD-9 codes and frequency limits will apply in
all states.
ICD-9 Codes Covered by Medicare
211.7 Benign neoplasm of islets of Langerhans
250.00-250.93 Diabetes mellitus and related codes
251.0 Hypoglycemic coma
251.1 Other specified hypoglycemia
251.2 Hypoglycemia, unspecified
251.3 Post-surgical hypoinsulinemia
251.4 Abnormal secretion of glucagon
251.8 Other specified disorders of pancreatic internal secretion
251.9 Unspecified disorder of pancreatic internal secretion
258.0-258.9 Polyglandular dysfunction and related disorders
271.4 Renal glycosuria
275.0 Disorders of iron metabolism (hemachromatosis)
577.1 Chronic pancreatitis
579.3 Other and unspecified post-surgical nonabsorption
648.00 Diabetes mellitus complicating pregnancy, unspecified episode
648.03 Diabetes mellitus complicating pregnancy, antipartum complication
648.04 Diabetes mellitus complicating pregnancy, postpartum complication
648.80 Abnormal glucose tolerance complicating pregnancy, unspecified episode
648.83 Abnormal glucose tolerance complicating pregnancy, antipartum complication
648.84 Abnormal glucose tolerance complicating pregnancy, postpartum complication
790.2 Abnormal glucose tolerance test
790.6 Other abnormal blood chemistry (hyperglycemia)
962.3 Poisoning by insulin and antidiabetic agents
V12.2 Personal history of endocrine, metabolic, and immunity disorders
V58.69 Long term current use of other medication
Frequency of testing considered medically necessary
Every 3 months to monitor a diabetic patient’s metabolic control
Every 1-2 months when treatment regimen is altered to improve control
Every month for diabetic pregnant women
Patients with uncontrolled type I or II diabetes may be tested more frequently, however, the
medical record must support such increased testing.
