Rule Categry: Medical ` Ref: N: 2013-MN-0012 Versin Cntrl: Versin N. 1.1 Effective Date: December 2013 Revisin Date: December 2014 Diabetes Mellitus Lab Tests (Screening, Diagnsis & Mnitring) Adjudicatin Rule Table f cntent Abstract Page 1 Scpe Adjudicatin Plicy Adjudicatin examples Denial cdes Page 3 Appendices Page 3 Abstract Fr Members Diabetes develps when the bdy cannt prduce r use insulin, an essential hrmne made in the pancreas. Insulin helps mve glucse (a frm f sugar) frm the bld int the cells f yur bdy. The criteria fr diagnsis is casual plasma glucse 200mg/dl r greater r fasting plasma glucse 126mg/dl r greater r a tw-hur plasma glucse ral tlerance test f 200mg r greater. When insulin is lacking, bld glucse (r bld sugar) rises in bld stream, causing a cnditin knwn as hyperglycemia. The mst cmmn symptms include; increased thirst, frequent urinatin, weight lss, increased hunger, blurred visin, wunds that d nt heal, extreme fatigue. DM is classified as: Type 1 (Insulin dependent r Juvenile); results frm cell destructin in pancreas, leading t insulin deficiency Type 2 (nn-insulin dependent); results frm a prgressive insulin secretary defect due t insulin resistance Gestatinal; diagnsed during pregnancy that is nt clearly vert Other types; like genetic defects/ diseases in pancreas r in insulin actin, and drug r chemical induced (treatment f HIV/AIDS r after rgan transplantatin) Daman cvers all the labs, if medically indicated t diagnse and mnitr diabetes mellitus as per plicy terms and cnditins. Fr Medical Prfessinals This adjudicatin rule aims t specify all the cverage details f the labratry tests required in Diabetes Mellitus (DM) withut cmplicatins/c-mrbidities, fr all health insurance plans administered by Daman as per the plicy terms and cnditins. Diabetes mellitus is a chrnic illness that requires cntinuing medical care and nging patient self-management educatin and supprt t prevent acute cmplicatins and t reduce the risk f lng-term cmplicatins. Daman cvers all the labs required (as mentined further belw in this guideline) fr screening, diagnsis and fr mnitring f diabetes mellitus fr all the health insurance plans as per the plicy terms and cnditins except fr visitr s plan. Apprved by: Daman Respnsible: Medical Strategy & Develpment Department Related Adjudicatin Rules: Nne Disclaimer By accessing these Daman Adjudicatin Rules (the AR ), yu acknwledge that yu have read and understd the terms f use set ut in the disclaimer belw: The infrmatin cntained in this AR is intended t utline the prcedures f adjudicatin f medical claims as applied by the Natinal Health Insurance Cmpany Daman PJSC (hereinafter Daman ). The AR is nt intended t be cmprehensive, shuld nt be used as treatment guidelines and shuld nly be used fr the purpse f reference r guidance fr adjudicatin prcedures and shall nt be cnstrued as cnclusive. Daman in n way interferes with the treatment f patient and will nt bear any respnsibility fr treatment decisins interpreted thrugh Daman AR. Treatment f patient is and remains at all times the sle respnsibility f the treating Healthcare Prvider. This AR des nt grant any rights r impse bligatins n Daman. The AR and all f the infrmatin it cntains are prvided "as is" withut warranties f any kind, whether express r implied which are hereby expressly disclaimed. Under n circumstances will Daman be liable t any persn r business entity fr any direct, indirect, special, incidental, cnsequential, r ther damages arising ut f any use f, access t, r inability t use r access t, r reliance n this AR, including but withut limitatin t, any lss f prfits, business interruptin, r lss f prgrams r infrmatin, even if Daman has been specifically advised f the pssibility f such damages. Daman als disclaims all liability fr any material cntained in ther websites linked t Daman website. This AR is subject t the laws, decrees, circulars and regulatins f Abu Dhabi and UAE. Any infrmatin prvided herein is general and is nt intended t replace r supersede any laws r regulatins related t the AR as enfrced in the UAE issued by any gvernmental entity r regulatry authrity, r any ther written dcument gverning the relatinship between Daman and its cntracting parties. This AR is develped by Daman and is the prperty f Daman and may nt be cpied, reprduced, distributed r displayed by any third party withut Daman s express written cnsent. This AR incrprates the Current Prcedural Terminlgy and Current Dental Terminlgy (CPT and CDT, which is a registered trademark f the American Medical Assciatin ( AMA ), and the American Dental Assciatin ( ADA ) respectively), and the CPT and CDT cdes and descriptins belng t the AMA. Daman reserves the right t mdify, alter, amend r bslete the AR at any time by prviding ne mnth prir ntice. Natinal Health Insurance Cmpany Daman (PJSC) (P.O. Bx 128888, Abu Dhabi, U.A.E. Tel N. +97126149555 Fax N. +97126149550) Dc Ctrl N.: TEMP/MSD-008 Versin N.: 1 Revisin N.: 0 Date f Issue: 08.05.2013 Page N(s).: 1 f 5
Diabetes Mellitus Lab Tests (Screening, Diagnsis & Mnitring) Scpe This adjudicatin rule aims t specify all the cverage details f the labratry tests required in Diabetes Mellitus (DM) withut cmplicatins/cmrbidities, fr all health insurance plans administered by Daman as per the plicy terms and cnditins except fr visitr s plan. Adjudicatin Plicy Eligibility / Cverage Criteria Daman cvers all the required labs (as mentined belw) fr screening, diagnsis and mnitring f Diabetes Mellitus (withut cmplicatins/cmrbidities) as per the Plicy terms and cnditins: 1. Screening: Belw given lab tests are cvered t screen fr diabetes mellitus nly fr thse plans having rutine medical checkup benefit Labs required fr DM screening Labs Frequency Additinal Inf Fasting Capillary bld glucse HbA1c OR OGTT (ral glucse tlerance test) Every 3rd year Mst cmmn & best indicatr fr DM prevalence and incidence If HBA1c is 6.1% then review after 1 year Nt recmmended as 1st test but rather a cnfirmatin test if abnrmal FBG Nte: In case f high risk/pre-diabetic cnditins, abve tests can be reviewed every year. 2. Diagnsis and Mnitring: All labratry tests medically indicated fr diagnsis and mnitring f DM (Diabetes Mellitus) are cvered fr all the health insurance plans as per the plicy terms and cnditins except fr visitr s Plan. (Please refer Table.1. n page 4 fr diagnsis and mnitring f DM) (Please refer Table.2. n page 5 fr diagnsis and mnitring f Gestatinal DM) Pstnatal care in GDM: Fasting plasma glucse prir t discharge Repeat plasma glucse 6 weeks pstpartum, then annually thereafter Retinal assessment at 6 mnths pstnatal, if signs f DM retinpathy present at 1st antenatal visit Nte: Fr diagnsing Diabetes Mellitus, FBG, HbA1c OR OGTT can be dne. OGTT and HbA1C tests tgether are nt recmmended t be dne at the same time fr diagnsing DM All the abve mentined tests can be dne mre ften than the given frequency, if uncntrlled DM OR with cmplicatins Requirements fr Cverage ICD and CPT cdes must be cded t the highest level f specificity. Nn-Cverage Daman des nt cver all the labs nt mentined/nt required as per the abve given tables unless any cmplicatins OR related ther medical cnditin is dcumented. Daman des nt cver rutine medical checkup (Health checkup)/health screening fr all thse Health Insurance Plans, nt having this benefit. Fr all Custmized Plans, screening benefit can be limited r restricted. All belw given tests are nt cvered fr DM wrk up, as efficacy f these tests is nt prven Genetic markers Insulin Pr-insulin C-peptide Insulin antibdies Payment and Cding Rules Please apply HAAD payment rules and regulatins and relevant cding manuals fr ICD, CPT, etc. Adjudicatin Examples Example 1 Questin: A claim received fr 35 years ld female, hlding Basic plan with the diagnsis f rutine examinatin (V70.0), secndary diagnsis screening diabetes mellitus (V77.1), HbA1c and FBG. Hw will yu adjudicate the claim? Answer: Reject the claim with NCOV-001. Example 2 Questin: A 36 year ld pregnant female hlding reginal plan with histry f GDM in previus pregnancy, visited the clinic fr her 1st rutine antenatal checkup at 16 th week f her pregnancy. Cnsulting dctr advised OGTT test fr her. Is this claim payable? Answer: Yes, this claim is payable. Natinal Health Insurance Cmpany Daman (PJSC) (P.O. Bx 128888, Abu Dhabi, U.A.E. Tel N. +97126149555 Fax N. +97126149550) Dc Ctrl N.: TEMP/MSD-008 Versin N.: 1 Revisin N.: 0 Date f Issue: 08.05.2013 Page N(s).: 2 f 5
Diabetes Mellitus Lab Tests (Screening, Diagnsis & Mnitring) Denial cdes Cde MNEC-003 MNEC-004 NCOV-001 NCOV-003 Cde descriptin Service is nt clinically indicated based n gd clinical practice. Service is nt clinically indicated based n gd clinical practice, withut additinal supprting diagnsis/activities. Diagnsis (es) is (are) nt cvered. Service(s) is (are) nt cvered. 11. American Medical Assciatin and PMIC CPT and ICD cding 12. Health Authrity Abu Dhabi HAAD. (2009). HAAD standards fr diagnsis, management and data reprting fr diabetes. Health Authrity - Abu Dhabi. PHP/PHPr/DC/02 (1), p1-11. 13. Health Authrity Abu Dhabi HAAD. (2012). HAAD standard fr diagnsis, management and data reprting fr diabetes mellitus in pregnancy. Health Authrity - Abu Dhabi. PHP/PHPr/DC/02 (0.9), p1-11. Appendices A. References 1. American Diabetes Assciatin. (2013). Standards f Medical Care in Diabetes. American Diabetes Assciatin. 36 (1), p1-56. 2. American Diabetes Assciatin. (2012). Standards f Medical Care in Diabetes. American Diabetes Assciatin. 35 (1), p1-56. 3. American Diabetes Assciatin. (May 2004). HbA1c Levels Are Significantly Lwer in Early and Late Pregnancy. American Diabetes Assciatin. 27 (5), p1-2. 4. Wrld Health Organizatin. (2002). Labratry Diagnsis and Mnitring f Diabetes Mellitus. Wrld Health Organizatin. 1 (1), p1-29. 5. American Diabetes Assciatin. (2012). Management f Hyperglycemia in Type 2 Diabetes: A Patient-Centered Apprach. Psitin Statement f the American Diabetes Assciatin (ADA) and the Eurpean Assciatin fr the Study f Diabetes (EASD). 1 (1), p1-16. 6. The Natinal Academy f Clinical Bichemistry. (2011). LABORATORY MEDICINE PRACTICE GUIDELINES. Guidelines and Recmmendatins fr labratry analysis in the diagnsis and management f diabetes mellitus. 1 (1), p1-120. 7. American Diabetes Assciatin. (June 2011). Guidelines and Recmmendatins fr Labratry Analysis in the Diagnsis and Management f Diabetes Mellitus. Diabetes Jurnals. 34 (1), p1-39. 8. Natinal Institute fr Health and Clinical Excellence. (2008). Diabetes in pregnancy. NICE clinical guideline. 63 (1), p1-38. 9. Wrld Health Organizatin. (2011). Use f Glycated Hemglbin (HbA1c) in the Diagnsis f Diabetes Mellitus. Abbreviated Reprt f a WHO Cnsultatin. 1 (1), p1-25. 10. Daman Schedule f Benefits B. Revisin Histry Date 1-11-13 N.A 15-07-14 Change(s) 1. V 1.1 2. Disclaimer updated as per system requirements Natinal Health Insurance Cmpany Daman (PJSC) (P.O. Bx 128888, Abu Dhabi, U.A.E. Tel N. +97126149555 Fax N. +97126149550) Dc Ctrl N.: TEMP/MSD-008 Versin N.: 1 Revisin N.: 0 Date f Issue: 08.05.2013 Page N(s).: 3 f 5
Diabetes Mellitus Lab Tests (Screening, Diagnsis & Mnitring) Table 1 Labs t Diagnse and t Mnitr DM (withut cmplicatins/c-mrbidities) Lab Indicatr Frequency Additinal Inf HBA1c FBG (fasting bld glucse) OGTT (ral glucse tlerance test) Diagnstic & Mnitring (in case f pregnancy, used nly as mnitring fr already diagnsed DM patients Diagnstic & Mnitring Diagnstic (majrdiagnstic tl fr GDM) Biannually OR (4 times a year fr patients whse therapy is changed r are nt meeting treatment gals) nce, t cnfirm the diagnsis If presence f symptms and A1C 6.5% OR FBG 126 mg/dl (7.0 mml) OR OGTT 200 mg/dl (11.1 mml/l), then DM is cnfirmed RBG (Randm bld glucse) Diagnstic & Mnitring Albumin excretin rate Mnitring & Management Annually* > 300 mg/24 h is clinical nephrpathy and mnitring shuld be mre ften in this cnditin depending n medical necessity Ketnes (Urine) Nt rutinely recmmended as t diagnse r mnitr SMBG (self-mnitring f bld glucse) 3 r mre times/day Only fr patients using multiple insulin injectins OR insulin pump therapy Lipid Prfile (fasting) T be repeated every 2 years with lw risk** (t start frm 10 years f age in Type 1 DM and t repeat every 2 years if nrmal) Liver Functin tests (nly SGOT, SGPT & GGT) Serum creatinine Mnitring & Management Annually Can be mnitred every 6 mnths r mre if dse adjustment required r with cmplicatins TSH (thyrid stimulating hrmne) Only in patients with type 1 DM, dyslipidemia r wmen ver 50 years f age Eye examinatin (Fundus phtgraphy) Retinpathy screening Annually *Annually in type 1 DM patients with duratin f 5 years & in Type 2 DM starting at the diagnsis ** Lw risk: LDL <100mg/dl, HDL >50 mg/dl, Triglycerides <150 mg/dl. Frm 10 years nwards (within 5 years after nset) fr Type 1 DM OR shrtly when diagnsed fr Type 2 DM Natinal Health Insurance Cmpany Daman (PJSC) (P.O. Bx 128888, Abu Dhabi, U.A.E. Tel N. +97126149555 Fax N. +97126149550) Dc Ctrl N.: TEMP/MSD-008 Versin N.: 1 Revisin N.: 0 Date f Issue: 08.05.2013 Page N(s).: 4 f 5
Diabetes Mellitus Lab Tests (Screening, Diagnsis & Mnitring) Table 2 Labs required fr Gestatinal Diabetes Mellitus (GDM) (withut cmplicatins/c-mrbidities) Labs required Indicatr Frequency Additinal Infrmatin OGTT Diagnstic nly At 16-18 weeks ( if High risk fr GDM*) and at 28 weeks (if previus result was nrmal) In Nn DM/n high risk fr GDM* mther at 24-28 weeks HBA1c Mnitring After 2-3 mnths Nt rutinely used fr glycemic cntrl in 2nd & 3rd trimester FBG (fasting bld glucse) Diagnstic & Mnitring RBG (Randm bld glucse) Diagnstic & Mnitring Urine Ketnes T test if Hyperglycemic r unwell Fr wmen with Type 1 DM Retinal assessment At 1st antenatal visit (if nt dne in previus 12 mnths) and at 28 weeks If signs f DM retinpathy present at 1st visit, additinal assessment als required at 16-20 weeks (als at 6 mnths pstnatal) Urine analysis At every visit SMBG (self-mnitring f bld glucse) Lipid Prfile (fasting) Mnitring 3 r mre times/day Only fr patients using multiple insulin injectins OR insulin pump therapy Liver Functin tests (nly SGOT, SGPT & GGT) Renal Functin At 1st antenatal visit (if nt dne in previus 12 mnths) TSH (thyrid stimulating hrmne) Only in type 1 DM, dyslipidemia r wmen ver 50 years f age * High Risk females fr GDM are: Age 35 years OR Previus raised HBA1C OR BMI 30kg/m2 OR Previus macrsmic baby ( 4.5 kg) OR Previus gestatinal diabetes OR First degree relative with diabetes OR Ethnicity with a high prevalence f diabetes: Middle Eastern, Suth Asian (India, Pakistan, Bangladesh), Afr- Caribbean, Black African Natinal Health Insurance Cmpany Daman (PJSC) (P.O. Bx 128888, Abu Dhabi, U.A.E. Tel N. +97126149555 Fax N. +97126149550) Dc Ctrl N.: TEMP/MSD-008 Versin N.: 1 Revisin N.: 0 Date f Issue: 08.05.2013 Page N(s).: 5 f 5