Centers for Medicare & Medicaid Services, HHS § 410.18

preventive physical preventive exam- than or equal to 126 mg/dL on two dif- ination that is performed for an indi- ferent occasions; a 2-hour post-glucose vidual who is not an eligible bene- challenge greater than or equal to 200 ficiary as described in this section. mg/dL on two different occasions; or a random over 200 mg/dL for [69 FR 66420, Nov. 15, 2004, as amended at 71 FR 69783, Dec. 1, 2006; 73 FR 69932, Nov. 19, a person with symptoms of uncon- 2008] trolled . Pre-diabetes means a condition of ab- § 410.17 Cardiovascular disease normal glucose diagnosed screening tests. using the following criteria: a (a) Definition. For purposes of this glucose level of 100–125 mg/dL, or a 2- subpart, the following definition apply: hour post-glucose challenge of 140–199 Cardiovascular screening mg/dL. The term pre-diabetes includes means: the following conditions: (1) A lipid panel consisting of a total (1) Impaired fasting glucose. , HDL cholesterol, and (2) Impaired glucose tolerance. . The test is performed (b) General conditions of coverage. after a 12-hour fasting period. Medicare Part B covers diabetes (2) Other blood tests, previously rec- screening tests after a referral from a ommended by the U.S. Preventive physician or qualified nonphysician Services Task Force (USPSTF), as de- practitioner to an individual at risk for termined by the Secretary through a diabetes for the purpose of early detec- national coverage determination proc- tion of diabetes. ess. (c) Types of tests covered. The fol- (3) Other non-invasive tests, for indi- lowing tests are covered if all other cations that have a blood test rec- conditions of this subpart are met: ommended by the USPSTF, as deter- (1) Fasting blood glucose test. mined by the Secretary through a na- (2) Post-glucose challenges including, tional coverage determination process. but not limited to, an oral glucose tol- (b) General conditions of coverage. erance test with a glucose challenge of Medicare Part B covers cardiovascular 75 grams of glucose for non-pregnant disease screening tests when ordered by adults, a 2-hour post glucose challenge the physician who is treating the bene- test alone. ficiary (see § 410.32(a)) for the purpose (3) Other tests as determined by the of early detection of cardiovascular Secretary through a national coverage disease in individuals without apparent determination. signs or symptoms of cardiovascular (d) Amount of testing covered. Medi- disease. care covers the following for individ- (c) Limitation on coverage of cardio- uals: vascular screening tests. Payment may (1) Diagnosed with pre-diabetes, two be made for cardiovascular screening screening tests per calendar year. tests performed for an asymptomatic (2) Previously tested who were not di- individual only if the individual has agnosed with pre-diabetes, or who were not had the screening tests paid for by never tested before, one screening test Medicare during the preceding 59 per year. months following the month in which (e) Eligible risk factors. Individuals the last cardiovascular screening tests with the following risk factors are eli- were performed. gible to receive the benefit: (1) Hypertension. [69 FR 66421, Nov. 15, 2004] (2) Dyslipidemia. (3) Obesity, defined as a body mass § 410.18 Diabetes screening tests. index greater than or equal to 30 kg/m2. (a) Definitions. For purposes of this (4) Prior identification of impaired section, the following definitions fasting glucose or glucose intolerance. apply: (5) Any two of the following charac- Diabetes means diabetes mellitus, a teristics: condition of abnormal glucose metabo- (i) Overweight, defined as body mass lism diagnosed using the following cri- index greater than 25, but less than 30 teria: a fasting blood sugar greater kg/m2.

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