P05.19 — Newborn small for gestational age, other
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Glycated serum protein testing (for example, hemoglobin (HbA1c), albumin, or fructosamine) testing is consideredmedically necessaryfor any of the following indications (A-F):
- The individual is between the ages of 35 and 71 and has overweight or obesity*;or
- The individual is of any age and is from a population with disproportionately high prevalence of diabetes mellitus**;or
- Hyperglycemia has been found on other testing;or
- To test individuals who are pregnant and considered to be at high risk for type 2 diabetes mellitus;or
- Prior testing at least 3 months previously showed results near diabetes mellitus diagnostic thresholds;or
1 Active Policy
ANTHEM-CG-LAB-25 — CG-LAB-25 Outpatient Glycated Hemoglobin and Protein Testing
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