[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR410.18]



[Page 321-322]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 410_SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS--Table of Contents

 

               Subpart B_Medical and Other Health Services

 

Sec. 410.18  Diabetes screening tests.



    (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.



[[Page 322]]



    (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:

    (1) Hypertension.

    (2) Dyslipidemia.

    (3) Obesity, defined as a body mass index greater than or equal to 

30 kg/m\2\.

    (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/m\2\.

    (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]