Coverage Policy Manual
Policy #: 2011026
Category: PPACA Preventive
Initiated: September 2010
Last Review: June 2022
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: TYPE 2 DIABETES MELLITUS SCREENING FOR ADULTS

Description:
The Federal Patient Protection and Preventive Care Act was passed by Congress and signed into law by the President in March 2010.  The preventive services component of the law became effective 23 September 2010. A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to cover those preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task Force.  
 
Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.
 
Task Force recommendations are graded on a five-point scale (A-E), reflecting the strength of evidence in support of the intervention.  Grade A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination.  Grade B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination.  Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds.  Grade D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.  Grade E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.
 
Those preventive medicine services listed as Grade A & B recommendations are covered without cost sharing (i.e., deductible, co-insurance, or co-pay) by Health Plans for appropriate preventive care services provided by an in-network provider.  If the primary purpose for the office visit is for other than Grade A or B USPSTF preventive care services, deductible, co-insurance, or copay may be applied.
 
 

Policy/
Coverage:
Effective January 2023
 
The USPSTF recommends screening for prediabetes and type 2 diabetes in adults who are overweight or obese. Clinicians should offer or refer patients with prediabetes to effective preventive interventions. Screening will be allowed one time a year and counseling sessions will be limited to 12 sessions a year.
 
The appropriate ICD-10 codes to report these services are Z00.00, Z00.01 and Z13.1.
 
Codes that may be used to report this service include 83036 or 82947 or 82950.
 
When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’. The correct coding as listed for both ICD-10 and CPT or HCPCS codes are also required.
 
Effective Prior to January 2023
 
The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults who are overweight or obese. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity. Screening will be allowed one time a year and counseling sessions will be limited to 12 sessions a year.
 
The appropriate ICD-10 codes to report these services are Z00.00, Z00.01 and Z13.1.  
 
Codes that may be used to report this service include 83036 or 82947 or 82950.
 
When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.  The correct coding as listed for both ICD-10 and CPT or HCPCS codes are also required.
 
Effective Prior to June 2018
 
The USPSTF recommends screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. This screening test is allowed one time a year.
 
The appropriate ICD-9 codes to report these services are V70.0 and V77.1.  
 
The appropriate ICD-10 codes to report these services are Z00.00, Z00.01 and Z13.1.  
 
Codes that may be used to report this service include 83036 or 82947 or 82950.
 
When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.  The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 

Rationale:
Diabetes is a tremendous clinical and public health burden for the U.S. population. Data from the NHANES (National Health and Nutrition Examination Survey) indicated that 19.3 million U.S. adults 20 years of age or older (9.3% of the adult population) had diabetes in 2002. Diabetes was undiagnosed in one third of these individuals.  An additional 26% of the population had IFG. The prevalence of diagnosed diabetes increased from 5.1% from 1988 to 1994 to 6.5% from 1999 to 2002. Prevalence is increasing most rapidly among individuals with a body mass index of 35 kg/m2 or greater.
 
The prevalence of diabetes (diagnosed and undiagnosed) increases with age, reaching 21.6% for those 65 years of age or older. African Americans, Hispanic or Latino Americans, American Indians, and some Asian Americans and Native Hawaiians or other Pacific Islanders are at particularly high risk for type 2 diabetes mellitus. The prevalence of diagnosed diabetes is twice as high in non-Hispanic black and Mexican-American persons as in non-Hispanic white persons.  Modifiable factors, including reductions in physical activity, dietary changes, and increased frequency of testing, may play a role in the increasing prevalence of diabetes.
 
Diabetes was the sixth leading cause of death in 2000. Overall, risk for premature death among individuals with diabetes is about twice that for those without. Adults with diabetes have rates of stroke and death from heart disease that are about 2 to 4 times higher than adults without diabetes. Diabetes is the leading cause of new cases of blindness among adults age 20 to 74 years and the leading cause of end-stage renal disease, accounting for 44% of new cases of end-stage renal disease. More than 60% of lower-limb amputations not due to trauma occur among individuals with diabetes.
 
This recommendation concerns adults without symptoms of diabetes or evidence of possible diabetes complications. Symptoms of diabetes include polyuria, polydipsia, and polyphagia. Possible diabetes complications include nonhealing ulcers or infections and established vascular disease (for example, coronary artery disease, stroke, and peripheral artery disease). Persons with these symptoms or conditions should be tested for diabetes.
 
For adults with blood pressure 135/80 mm Hg or lower, the USPSTF found convincing evidence that intensive glycemic control in persons with clinically detected (as opposed to screening-detected) diabetes can reduce progression of microvascular disease. However, the benefits of tight glycemic control on microvascular clinical outcomes, such as severe visual impairment or end-stage renal disease, take years to become apparent. There is inadequate evidence that early diabetes control as a result of screening provides an incremental benefit for microvascular clinical outcomes compared with initiating treatment after clinical diagnosis.
 
Screening Tests: Three tests have been used to screen for diabetes: fasting plasma glucose, 2-hour postload plasma glucose, and hemoglobin A1c. Each has advantages and disadvantages. The American Diabetes Association has recommended the fasting plasma glucose test for screening because it is easier and faster to perform, more convenient and acceptable to patients, and less expensive than other screening tests. The fasting plasma glucose test has more reproducible results than does the 2-hour postload plasma glucose test, has less intraindividual variation, and has similar predictive value for development of microvascular complications of diabetes. The American Diabetes Association defines diabetes as a fasting plasma glucose level of 126 mg/dL or greater and recommends confirmation with a repeated screening test on a separate day, especially for people with borderline results.
 
Blood pressure targets should be lower for persons who have type 2 diabetes mellitus than for those who do not. Lower blood pressure targets for persons with diabetes and high blood pressure reduce CVD events compared with higher targets. Attention to other risk factors for CVD, such as physical inactivity, lipid levels, diet, and obesity, is also important, both to decrease risk for CHD and to improve glucose control.
 
The optimal screening interval is not known. The American Diabetes Association, on the basis of expert opinion, recommends a 3-year interval.
 
There is no evidence of benefit in health outcomes from screening for impaired glucose tolerance (IGT) or impaired fasting glucose (IFG). However, intensive programs of lifestyle modification (diet, exercise, and behavior) do reduce the incidence of diabetes. Regardless of whether the clinician and patient decide to screen for diabetes, people should eat a healthful diet, be active, and maintain a healthy weight-these behaviors have other benefits in addition to preventing or forestalling type 2 diabetes. The USPSTF recommends intensive interventions for obese persons who desire to lose weight. Population-based approaches to increasing physical activity and reducing obesity, as recommended by the Task Force on Community Preventive Services, should be supported.
 
Accuracy of Screening Tests: The assessment of screening tests for type 2 diabetes mellitus is complicated by uncertainty regarding the most appropriate gold standard for comparison. Definitions of diabetes were originally developed by using results of 2-hour postload plasma glucose testing to identify a population at substantially increased risk for retinopathy. The criterion for an abnormal fasting plasma glucose level was developed on the basis of 2-hour postload plasma glucose testing and revised downward (from 140 mg/dL to 126 mg/dL) to make the sensitivity of fasting plasma glucose testing comparable with that of 2-hour postload plasma glucose testing. However, a study using NHANES III data has demonstrated that, compared with fasting plasma glucose testing, the 2-hour postload plasma glucose screening test leads to diagnosis of diabetes in more individuals.
 
Large population-based studies have examined the test characteristics of 2-hour postload plasma glucose, fasting plasma glucose, and hemoglobin A1c for identifying individuals with retinopathy. Sensitivity and specificity for detecting retinopathy were in the range of 75% to 80% for all 3 tests when using the following thresholds: fasting plasma glucose test, 126 mg/dL or greater; 2-hour postload plasma glucose test, 200 mg/dL or greater; or hemoglobin A1c test, 6.4% or greater.  Other studies have examined whether these tests predict future CVD events.
 
A meta-regression analysis of 20 observational studies found that the results of both fasting plasma glucose and 2-hour postload plasma glucose tests were statistically significantly associated with future CVD events in a continuously graded fashion, beginning at levels consistent with IGT and IFG and increasing more steeply at the highest glucose levels.
 
In the past, the utility of hemoglobin A1c testing was limited in part by relatively poor reproducibility and lack of standardization across laboratories. More recently, widespread adoption of standardized hemoglobin A1c measurements has occurred, and newer techniques for measurement are generally highly reproducible.  A systematic review in 1996 found that a hemoglobin A1c cutoff value of 6.4% was 66% sensitive and 98% specific and was associated with a positive predictive value of 63% in a population with a diabetes prevalence of 6%.  Increasing the cutoff value to 7.0% increased the positive predictive value to 90%. Hemoglobin A1c values in the high-normal range (5.6% to 6.0%) seem to predict a higher incidence of future diabetes.
 
2022 Update
According to the Centers for Disease Control and Prevention 2020 National Diabetes Statistics Report, an estimated 13% of all US adults (18 years or older) have diabetes, and 34.5% meet criteria for prediabetes (CDC, 2020). The prevalence of prediabetes and diabetes are higher in older adults. Of persons with diabetes, 21.4% were not aware of or did not report having diabetes, and only 15.3% of persons with prediabetes reported being told by a health professional that they had this condition (CDC, 2020). Estimates of the risk of progression from prediabetes to diabetes vary widely, perhaps because of differences in the definition of prediabetes or the heterogeneity of prediabetes (Jonas, 2021).  A large cohort study of 77,107 persons with prediabetes reported that the risk of developing diabetes increased with increasing hemoglobin A1c (HbA1c) level and with increasing body mass index (BMI) (Glauber, 2018).
 
Diabetes is the leading cause of kidney failure and new cases of blindness among adults in the US. It is also associated with increased risks of cardiovascular disease (CVD), nonalcoholic fatty liver disease, and nonalcoholic steatohepatitis and was estimated to be the seventh leading cause of death in the US in 2017 (Leon, 2015; Portillo-Sanchez, 2015; Younossi, 2019; CDC, 2020).  Screening asymptomatic adults for prediabetes and type 2 diabetes may allow earlier detection, diagnosis, and treatment, with the ultimate goal of improving health outcomes.
 
This recommendation replaces the 2015 USPSTF recommendation statement on screening for abnormal blood glucose levels and type 2 diabetes in asymptomatic adults. In 2015, the USPSTF recommended screening for abnormal blood glucose levels as part of cardiovascular risk assessment in adults aged 40 to 70 years who have overweight or obesity. The USPSTF also recommended that clinicians should offer or refer patients with abnormal blood glucose levels to intensive behavioral counseling interventions to promote a healthful diet and physical activity (Siu, 2015). For the current recommendation statement, the USPSTF recommends screening for prediabetes and type 2 diabetes in adults aged 35 to 70 years who have overweight or obesity, and that clinicians should offer or refer patients with prediabetes to effective preventive interventions. Based on data suggesting that the incidence of diabetes increases at age 35 years compared with younger ages and on the evidence for the benefits of interventions for newly diagnosed diabetes, the USPSTF has decreased the age at which to begin screening to 35 years (Chung, 2014).
 
The USPSTF found inadequate direct evidence that screening for type 2 diabetes or prediabetes leads to improvements in mortality or cardiovascular morbidity.
 
The USPSTF found adequate evidence that interventions for newly diagnosed diabetes have a moderate benefit in reducing all-cause mortality, diabetes-related mortality, and risk of myocardial infarction after 10 to 20 years of intervention.
 
The USPSTF found convincing evidence that preventive interventions, in particular lifestyle interventions, in persons identified as having prediabetes have a moderate benefit in reducing the progression to type 2 diabetes, as well as reducing other CVD risk factors such as blood pressure and lipid levels. Other preventive interventions are also effective in reducing the progression to type 2 diabetes without necessarily reducing other CVD risk factors.
 
The USPSTF found adequate evidence to bound the harms of screening for prediabetes and type 2 diabetes and treatment of screen-detected or recently diagnosed prediabetes and type 2 diabetes as no greater than small.
 
The USPSTF concludes with moderate certainty that screening for prediabetes and type 2 diabetes and offering or referring patients with prediabetes to effective preventive interventions has a moderate net benefit.
 

CPT/HCPCS:
82947Glucose; quantitative, blood (except reagent strip)
82950Glucose; post glucose dose (includes glucose)
83036Hemoglobin; glycosylated (A1C)
99401Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes
99402Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes
99403Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 minutes
99404Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 60 minutes
G0447Face to face behavioral counseling for obesity, 15 minutes
G0473Face to face behavioral counseling for obesity, group (2 10), 30 minutes

References: Centers for Disease Control and Prevention (CDC).(2020) National Diabetes Statistics Report, 2020. Accessed June 29, 2021. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf

Chung S, Azar KM, Baek M, Lauderdale DS, Palaniappan LP.(2014) Reconsidering the age thresholds for type II diabetes screening in the U.S. Am J Prev Med. 2014;47(4):375-381. Medline:25131213 doi:10.1016/j.amepre.2014.05.012

Glauber H, Vollmer WM, Nichols GA.(2018) A simple model for predicting two-year risk of diabetes development in individuals with prediabetes. Perm J. 2018;22:17-050. Medline:29309270

Jonas D, Crotty K, Yun JD, et al.(2021) Screening for Abnormal Blood Glucose and Type 2 Diabetes Mellitus: An Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 207. Agency for Healthcare Research and Quality; 2021. AHRQ publication 21-05276-EF-1.

Leon BM, Maddox TM.(2015) Diabetes and cardiovascular disease: epidemiology, biological mechanisms, treatment recommendations and future research. World J Diabetes. 2015;6(13):1246-1258. Medline:26468341 doi:10.4239/wjd.v6.i13.1246

Portillo-Sanchez P, Bril F, Maximos M, et al.(2015) High prevalence of nonalcoholic fatty liver disease in patients with type 2 diabetes mellitus and normal plasma aminotransferase levels. J Clin Endocrinol Metab. 2015;100(6):2231-2238. Medline:25885947 doi:10.1210/jc.2015-1966

PPACA & HECRA: Public Laws 111-148 & 111-152. The Patient Protection and Affordable Care Act

Screening for Type 2 Diabetes Mellitus in Adults Topic Page, June, 2008: U.S. Preventive Services Task Force http://www.uspreventiveservicestaskforce.org/uspstf08/type2/type2rs.htm

Siu AL; US Preventive Services Task Force.(2015) Screening for abnormal blood glucose and type 2 diabetes mellitus: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015;163(11):861-868. Medline:26501513 doi:10.7326/M15-2345

U.S. Preventive Services Task Force (USPSTF).(2021) Final Recommendation Statement Prediabetes and Type 2 Diabetes: Screening. August 24, 2021. Accessed December 8, 2022. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-for-prediabetes-and-type-2-diabetes

Younossi ZM, Golabi P, de Avila L, et al.(2019) The global epidemiology of NAFLD and NASH in patients with type 2 diabetes: a systematic review and meta-analysis. J Hepatol. 2019;71(4):793-801. Medline:31279902 doi:10.1016/j.jhep.2019.06.021


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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