What diagnosis will cover an A1C?


Editorial team Published on

Insurance and Medicare cover the hemoglobin A1c (HbA1c) test when billed with specific diagnostic codes that establish medical necessity or meet approved screening criteria.

Covered Diagnosis Codes (ICD-10)

To secure insurance coverage for CPT code 83036 (laboratory A1c test), the claim requires a matching, billable diagnosis code:

  • Diabetes Mellitus: Type 1 (E10.x), Type 2 (E11.x), and other specified forms (E13.x).
  • Complications or Uncontrolled Levels: Type 2 with hyperglycemia (E11.65) or other specified complications (E11.69).
  • Prediabetes & Abnormal Glucose: Impaired fasting glucose (R73.01), prediabetes (R73.03), and other abnormal glucose findings (R73.09).
  • Pregnancy: Gestational or pre-existing diabetes in pregnancy (O24.x).

Insurance and Medicare Rules

  • Screening vs. Monitoring: Major insurers and Medicare Coverage cover A1c tests both to monitor existing diabetes and to screen high-risk individuals for prediabetes and undiagnosed type 2 diabetes.
  • Frequency Limits: For routine monitoring of stable diabetes, testing is typically covered twice a year, while uncontrolled cases or specialized situations (such as pregnancy) permit more frequent testing under local medical policies.