(a) Definitions. For purposes of this section, the following definitions apply:
Diabetes means diabetes mellitus, a condition of abnormal glucose metabolism diagnosed using the following criteria: a fasting blood sugar greater than or equal to 126 mg/dL on two different occasions; a 2-hour post-glucose challenge greater than or equal to 200 mg/dL on two different occasions; or a random glucose test over 200 mg/dL for a person with symptoms of uncontrolled diabetes.
Pre-diabetes means a condition of abnormal glucose metabolism diagnosed using the following criteria: a fasting glucose level of 100-125 mg/dL, or a 2-hour post-glucose challenge of 140-199 mg/dL. The term pre-diabetes includes the following conditions:
(1) Impaired fasting glucose.
(2) Impaired glucose tolerance.
(b) General conditions of coverage. Medicare Part B covers diabetes screening tests after a referral from a physician or qualified nonphysician practitioner to an individual at risk for diabetes for the purpose of early detection of diabetes.
(c) Types of tests covered. The following tests are covered if all other conditions of this subpart are met:
(1) Fasting blood glucose test.
(2) Post-glucose challenges including, but not limited to, an oral glucose tolerance test with a glucose challenge of 75 grams of glucose for non-pregnant adults, a 2-hour post glucose challenge test alone.
(3) Other tests as determined by the Secretary through a national coverage determination.
(d) Amount of testing covered. Medicare covers the following for individuals:
(1) Diagnosed with pre-diabetes, two screening tests per calendar year.
(2) Previously tested who were not diagnosed with pre-diabetes, or who were never tested before, one screening test per year.
(e) Eligible risk factors. Individuals with the following risk factors are eligible to receive the benefit:
(3) Obesity, defined as a body mass index greater than or equal to 30 kg/m2.
(4) Prior identification of impaired fasting glucose or glucose intolerance.
(5) Any two of the following characteristics:
(i) Overweight, defined as body mass index greater than 25, but less than 30 kg/m2.
(ii) A family history of diabetes.
(iii) 65 years of age or older.
(iv) A history of gestational diabetes mellitus or delivery of a baby weighing more than 9 pounds.
[69 FR 66421, Nov. 15, 2004]