TL;DR: The Centers for Medicare & Medicaid Services modified NCD 98, the national coverage determination governing blood glucose testing under Medicare, effective March 7, 2026. Here's what billing teams need to do.
This update to the CMS blood glucose testing coverage policy clarifies medical necessity criteria, testing frequency limits, and the range of covered clinical indications under NCD 98 Medicare. The policy does not list specific CPT or HCPCS codes, so your team needs to map applicable codes to the documented criteria. Blood glucose billing touches a wide range of specialties — endocrinology, primary care, infectious disease, cardiology — and the documentation requirements here are strict enough to create real claim denial exposure if your teams aren't aligned.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | CMS (Centers for Medicare & Medicaid Services) |
| Policy | Blood Glucose Testing |
| Policy Code | NCD 98 |
| Change Type | Modified |
| Effective Date | March 7, 2026 |
| Impact Level | Medium |
| Specialties Affected | Endocrinology, Primary Care, Internal Medicine, Infectious Disease, Cardiology, Nephrology |
| Key Action | Audit your blood glucose testing documentation to confirm diagnosis codes align with covered indications before billing |
CMS Blood Glucose Testing Coverage Criteria and Medical Necessity Requirements 2026
NCD 98 is the National Coverage Determination governing Medicare coverage of blood glucose testing. The Centers for Medicare & Medicaid Services uses this policy to define when glucose testing is medically necessary, what methods qualify, and how frequently testing can occur without triggering a denial.
The coverage policy covers blood glucose determination using whole blood, serum, or plasma. Testing method doesn't disqualify a claim — fingerstick capillary puncture, venipuncture, arterial sampling, meter assay, color-comparison indicator sticks, and laboratory assay systems using serum or plasma all qualify. The key variable is medical necessity, not method.
Core Covered Indications
The most straightforward medical necessity cases are patients with diabetes mellitus. Hyperglycemia and hypoglycemia management are explicitly covered under this policy. That's not new — but what matters for blood glucose billing is the breadth of additional indications that also qualify.
NCD 98 covers glucose testing in patients with:
| # | Covered Indication |
|---|---|
| 1 | Impaired fasting glucose (FPG 110–125 mg/dL) |
| 2 | Insulin resistance syndrome or carbohydrate intolerance |
| 3 | Hypoglycemia disorders including nesidioblastosis or insulinoma |
| 4 | Catabolic states or malnutrition |
Beyond those metabolic conditions, CMS also covers glucose testing for patients with tuberculosis, unexplained chronic or recurrent infections, alcoholism, coronary artery disease (especially in women), and unexplained skin conditions including pruritis, local skin infections, ulceration, and gangrene without an established cause.
That last group surprises a lot of billing teams. Dermatology and infectious disease practices should check whether they're capturing these indications correctly. If you're billing glucose testing for a patient with unexplained ulceration, document the absence of an established cause explicitly.
Frequency Limits Are Where Claims Break Down
For stable, non-hospitalized patients who can't or won't do home monitoring, CMS considers up to four glucose tests per year reasonable and necessary. That's the baseline.
More frequent testing is covered depending on: the patient's age, type of diabetes, degree of glycemic control, diabetes-related complications, and other co-morbid conditions. There's no hard cap stated for diabetic patients who need closer monitoring — but "more frequent" requires documented clinical justification. If your notes don't connect the testing frequency to one of those five factors, expect a denial.
Nonspecific Presentations — One Test, Then Stop
When a patient presents with nonspecific signs or symptoms not normally associated with glucose metabolism disturbances, CMS covers a single blood glucose test. Repeat testing is not covered unless the first result is abnormal or the patient's clinical condition changes.
If you do repeat testing in this scenario, a specific diagnosis code — diabetes, for example — must appear on the claim to support medical necessity. The exception: repeat testing is covered for patients with a confirmed continuing risk of glucose metabolism abnormality, such as those on glucocorticoid therapy, even if results are normal.
This is where prior authorization isn't always a factor, but documentation absolutely is. You won't get a prior auth denial — you'll get a medical necessity denial on audit if the record doesn't support why a second test was ordered.
Medications That Affect Carbohydrate Metabolism
CMS explicitly covers glucose evaluation for patients on medications known to affect carbohydrate metabolism. This matters for oncology, transplant, and rheumatology practices prescribing corticosteroids, immunosuppressants, or certain antipsychotics. Document the medication and its known metabolic effects in the record. Don't assume the connection is obvious to a reviewer.
Diabetic Screening Under 42 CFR 410.18
Effective January 1, 2005, Medicare expanded coverage to include diabetic screening services. Some forms of blood glucose testing under NCD 98 are covered for screening purposes subject to specific frequency rules. For the full description of the screening benefit, refer to 42 CFR 410.18 and section 90, chapter 18, of the CMS Claims Processing Manual. Your billing team should be billing screening encounters differently than diagnostic encounters — mixing those up is a common reimbursement mistake.
Coverage Indications at a Glance
| Indication | Status | Relevant Codes | Notes |
|---|---|---|---|
| Diabetes mellitus — hyperglycemia/hypoglycemia management | Covered | Report applicable ICD-10 for diabetes type | Standard indication; document type, control status, complications |
| Impaired fasting glucose (FPG 110–125 mg/dL) | Covered | Report applicable ICD-10 for prediabetes | Document FPG value in record |
| Insulin resistance syndrome / carbohydrate intolerance | Covered | Report applicable ICD-10 | Document clinical basis for insulin resistance diagnosis |
| Hypoglycemia disorders (nesidioblastosis, insulinoma) | Covered | Report applicable ICD-10 | Rare; document confirmed or suspected diagnosis |
| Catabolic states or malnutrition | Covered | Report applicable ICD-10 | Connect glucose testing to metabolic management in notes |
| Tuberculosis | Covered | Report applicable ICD-10 | Less common indication — document clinical necessity explicitly |
| Unexplained chronic or recurrent infections | Covered | Report applicable ICD-10 | "Unexplained" is key — document absence of established cause |
| Alcoholism | Covered | Report applicable ICD-10 | Document relationship between alcohol use and glucose monitoring need |
| Coronary artery disease (especially women) | Covered | Report applicable ICD-10 | Sex-specific note in policy — document patient demographics |
| Unexplained skin conditions (pruritis, ulceration, gangrene without established cause) | Covered | Report applicable ICD-10 | Must document that cause is unestablished |
| Comas, seizures, confusion, abnormal hunger, weight changes, loss of sensation | Covered | Report applicable ICD-10 | Covered as consequences of sustained glucose abnormality |
| Patients on medications affecting carbohydrate metabolism | Covered | Report applicable ICD-10 + medication in record | Document specific medication and its metabolic effects |
| Nonspecific signs/symptoms — initial test | Covered | Report applicable ICD-10 | Single test covered; repeat requires abnormal result or changed condition |
| Nonspecific signs/symptoms — repeat testing, normal result, no condition change | Not Covered | N/A | Specific diagnosis code required if repeat testing is performed |
| Diabetic screening — per 42 CFR 410.18 | Covered (frequency limits apply) | See Claims Processing Manual, Chapter 18 | Frequency limits apply; bill separately from diagnostic testing |
| Stable, non-hospitalized patients unable/unwilling to self-monitor | Covered up to four times/year | Report applicable ICD-10 | More frequent testing requires documented clinical justification |
CMS Blood Glucose Testing Billing Guidelines and Action Items 2026
This policy has medium impact but high documentation risk. The coverage categories are broad, but the frequency rules and repeat-testing restrictions create real exposure. Here's what to do before March 7, 2026.
| # | Action Item |
|---|---|
| 1 | Audit your diagnosis code mapping against the covered indications. Pull the last 90 days of blood glucose claims and confirm each one maps to a listed covered indication. Pay special attention to claims for non-diabetic patients — tuberculosis, infections, skin conditions, and CAD are covered, but only with the right diagnosis codes and clinical documentation. |
| 2 | Review your repeat testing documentation protocols. For patients with nonspecific presentations, confirm your clinicians document what changed — abnormal result, new clinical finding, confirmed ongoing risk — before ordering a repeat test. Set up a documentation prompt in your EHR if you don't already have one. |
| 3 | Separate screening claims from diagnostic claims. Diabetic screening under 42 CFR 410.18 has its own frequency limits and billing rules. If your team is billing screening and diagnostic glucose testing under the same workflow, fix that before the effective date of March 7, 2026. |
| 4 | Flag patients on medications that affect carbohydrate metabolism. Work with your clinical team to build a list of those medications — corticosteroids are the most common trigger — and confirm the medication is documented on claims where glucose testing is billed for that reason. |
| 5 | Update your clinical documentation templates for frequency justification. For diabetic patients needing more than four tests annually, the record must support it with patient age, diabetes type, control level, complications, or co-morbidities. A template field that prompts for one of those five factors will prevent denials downstream. |
| 6 | Verify home monitoring documentation for non-hospitalized patients. The four-times-per-year limit applies to stable, non-hospitalized patients who are unable or unwilling to do home monitoring. If your practice manages patients in that category, confirm the record documents their monitoring status — "unable" and "unwilling" are different, and both should be stated explicitly. |
| 7 | If your patient mix includes infrequent glucose testing indications — tuberculosis, unexplained infections, unexplained skin conditions — talk to your compliance officer about documentation standards specific to those cases. The coverage policy allows it, but auditors will scrutinize anything outside the diabetes-and-prediabetes core. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Blood Glucose Testing Under NCD 98
Applicable Codes
The NCD 98 policy document as modified on March 7, 2026 does not list specific CPT or HCPCS codes. This is not unusual for a foundational NCD — the policy defines coverage criteria, and code assignment is handled through your local Medicare Administrative Contractor (MAC) guidance and standard coding references.
Your billing team should map applicable glucose testing codes — including laboratory quantitative glucose assays, point-of-care testing codes, and home monitoring-related codes — against the indications documented in NCD 98. If you're uncertain which codes your MAC expects for specific indications, contact your MAC directly or review their local coverage determination (LCD) guidance. Some MACs publish companion LCDs that list specific billing codes for NCD-covered services.
Work with your coding team or billing consultant to confirm the correct CPT codes for:
- Quantitative glucose, blood (laboratory assay)
- Point-of-care glucose testing
- Glucose tolerance testing (where relevant to covered indications)
- Diabetic screening services per 42 CFR 410.18
Do not assume a code is covered under NCD 98 without confirming your MAC's position. MAC-level guidance can add requirements or frequency restrictions beyond what the NCD states.
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