Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
| Contract | Contractor | Type | States |
|---|---|---|---|
| 11201 | Palmetto GBA | A and B and HHH MAC | SC |
| 11301 | Palmetto GBA | A and B and HHH MAC | VA |
| 11401 | Palmetto GBA | A and B and HHH MAC | WV |
| 11501 | Palmetto GBA | A and B and HHH MAC | NC |
| 11202 | Palmetto GBA | A and B and HHH MAC | SC |
| 11302 | Palmetto GBA | A and B and HHH MAC | VA |
| 11402 | Palmetto GBA | A and B and HHH MAC | WV |
| 11502 | Palmetto GBA | A and B and HHH MAC | NC |
| 10111 | Palmetto GBA | A and B MAC | AL |
| 10211 | Palmetto GBA | A and B MAC | GA |
| 10311 | Palmetto GBA | A and B MAC | TN |
| 10112 | Palmetto GBA | A and B MAC | AL |
| 10212 | Palmetto GBA | A and B MAC | GA |
| 10312 | Palmetto GBA | A and B MAC | TN |
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A56872 (Billing and Coding: GlycoMark® Testing for Glycemic Control) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A56872: Billing and Coding: GlycoMark® Testing for Glycemic Control (Billing and Coding, effective 2023-07-27)
- Covered ICD-10-CM codes
- 0
- 0 groups
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 2
- Full article
- cms.gov record
Procedure codes: 84378, 84999.
Coverage indications, limitations and medical necessity
This is a non-coverage policy for the GlycoMark® assay (aka 1,5-anhydroglucitol [1,5-AG]; developed by Nippon Kayaku, Co., Ltd).
Summary of evidence (opening)
Current Diabetes Testing
Hemoglobin A1C measurement, reflecting hemoglobin glycation over the erythrocyte life span, is proportional to the mean glucose concentration over the preceding 2-3 months. A1C testing is recommended by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) consensus guideline for pharmacotherapy to control hyperglycemia in type 2 diabetes. 1 In addition to A1C, fasting plasma glucose is used by patients and physicians to monitor diabetes. However, recent evidence strongly suggests that control of post-prandial hyperglycemia (PPG) may be necessary to achieve A1C targets 2
Several landmark clinical trials have convincingly demonstrated that individuals with diabetes are at increased risk of developing microvascular complications including retinopathy, nephropathy, and neuropathy, as well as cardiovascular (CV) disease. 3-5 The importance of tight glycemic control for protection against microvascular and CV disease in diabetes was established in the Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) study. 6 The role of glycemic control on microvascular disease in type 2 diabetes was documented in the United Kingdom Prospective Diabetes Study (UKPDS). 7 In addition, improving glycemic control improves microvascular outcomes, as illustrated by the findings of a meta-analysis of randomized trials (34,912 participants). 8
Considerable data indicates that elevated PPG levels, even in the absence of fasting hyperglycemia, increases the risk for CV disease. 9-11 Numerous epidemiological studies have demonstrated a correlation between risk for CVD and both fasting and postprandial plasma glucose levels or A1C values. 11 The UKPDS, 3 the DCCT, 5 the Action to Control Cardiovascular Risk in Diabetes (ACCORD), 12 and the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) 13 were landmark controlled clinical trials that evaluated the benefits of intensive glucose control on diabetes complications. Both the DCCT and UKPDS primary intervention studies also demonstrated long-term macrovascular benefits (>10-year follow-up). 6,14 These studies illustrate that intensive glycemic control early in the course of diabetes is important in achieving CV benefit and provides guidance in terms of stratification of patients’ target glycemic control. The fact that postprandial glucose control is essential to optimize blood glucose levels has been confirmed by randomized controlled trials where therapeutic agents primarily target postprandial hyperglycemia. 15-17
the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2016-10-17
- Current revision effective
- 2023-07-27
- Last reviewed by the contractor
- 2023-06-20
- MCD version
- 20
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Palmetto GBA hub lists every other active policy from the same contractor.
The same policy title at other contractors
Contractors often adopt each other's policies and then revise them separately, so the criteria and the diagnosis lists drift apart. The topic comparison lines up every version.
Frequently asked questions
What does LCD L36761 cover?
This is a non-coverage policy for the GlycoMark® assay (aka 1,5-anhydroglucitol [1,5-AG]; developed by Nippon Kayaku, Co., Ltd). The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L36761 apply to?
Palmetto GBA applies it to Medicare claims in AL, GA, NC, SC, TN, VA, WV. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L36761?
The current export links no billing and coding article with a diagnosis list to this LCD, so coverage is decided on the indications in the policy text and the documentation in the record rather than by an automated diagnosis edit.
How do I appeal a denial under LCD L36761?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.