Grok, I started Medicare part A and part B on 1/1/24 and have secondary insurance with Tricare for Life as I’m retired military and have a question about benefit coverage concerning medical testing. Medicare and Tricare for Life did not approve any payments for testing my blood sugars (hemoglobin AC1 levels) or blood tests for cholesterol, lipid and triglycerides. What is the policy for these tests with both Medicare and Tricare for life as both of these things have been covered in the past? Further, what tests are covered on page 44 of the Medicare & You 2025 hand book under the heading of Laboratory Tests?
 
 
Grok then says.
Let’s break this down step-by-step to address your concerns about Medicare Part A, Part B, and Tricare for Life coverage for specific medical tests like Hemoglobin A1C and cholesterol/lipid/triglyceride tests, as well as what’s covered under “Laboratory Tests” in the Medicare & You 2025 handbook.
1. Medicare Coverage for Hemoglobin A1C and Cholesterol/Lipid/Triglyceride Tests
Hemoglobin A1C Testing:

• Medicare Part B generally covers Hemoglobin A1C tests for beneficiaries with diabetes as part of diabetes management. This test is typically covered every 3 months for those diagnosed with diabetes to monitor blood sugar control.
• For individuals without a diabetes diagnosis, Medicare may cover the A1C test as a screening tool, but only under specific conditions. Since 2017, Medicare has covered diabetes screening tests (which can include A1C) for beneficiaries at risk of developing diabetes (e.g., those with a family history, obesity, or prediabetes). This screening is covered up to twice per year if you meet the criteria for being at risk.
• For the test to be covered, it must be ordered by a physician and deemed medically necessary. If the test was denied, it could be due to:
• Lack of a diabetes diagnosis or documented risk factors in your medical record.
• The test being ordered more frequently than Medicare’s guidelines allow (e.g., more than twice a year for screening or more often than every 3 months for diabetes management without additional justification).
• The provider not submitting the correct diagnosis codes to justify medical necessity.

Cholesterol, Lipid, and Triglyceride Testing:

• Medicare Part B covers cardiovascular disease screening tests, which include cholesterol, lipid, and triglyceride levels, every 5 years for all beneficiaries. This is considered a preventive service and is typically covered at no cost to you (no coinsurance or deductible) if the provider accepts Medicare assignment.
• If these tests are ordered more frequently or for diagnostic purposes (e.g., to monitor an existing condition like hyperlipidemia), Medicare will cover them as long as they are medically necessary. However, if the frequency exceeds Medicare’s guidelines or if the medical necessity isn’t clearly documented, the claim may be denied.
• Denials could also occur if:
• The tests were not coded properly by the provider.
• The tests were deemed not medically necessary based on your medical history or the frequency of testing.

2. Tricare for Life (TFL) Coverage for These Tests
Tricare for Life acts as a secondary payer to Medicare for retired military beneficiaries. Here’s how it typically works with these tests:

• General Rule: TFL covers services that Medicare approves, picking up most of the remaining costs (like coinsurance or deductibles) after Medicare pays its share. If Medicare denies a claim, TFL will generally not cover it either, unless the service is specifically covered under Tricare’s own rules.
• Hemoglobin A1C and Cholesterol/Lipid/Triglyceride Tests: Since these tests are typically covered by Medicare (as described above), TFL should cover any out-of-pocket costs (like the 20% coinsurance under Part B) after Medicare pays, provided the tests meet Medicare’s criteria for coverage. If Medicare denied the claim, TFL likely followed suit.
• Possible Reasons for Denial by Both Medicare and TFL:
• The tests may not have been deemed medically necessary based on your medical records or diagnosis codes.
• The frequency of testing may have exceeded Medicare’s guidelines (e.g., cholesterol screening more than once every 5 years for preventive purposes, or A1C testing more than twice a year for screening without a diabetes diagnosis).
• There may have been an issue with the provider’s billing, such as incorrect coding or lack of documentation.

3. Why Were These Tests Covered in the Past but Not Now?
If these tests were covered in the past but not now, a few things might have changed:

• Change in Medical Necessity: Your health status or diagnosis might have changed, affecting whether the tests are considered medically necessary. For example, if you no longer have a documented diagnosis of diabetes or prediabetes, Medicare might not cover A1C testing as frequently.
• Billing or Coding Errors: Providers sometimes change how they code or bill for tests, which can lead to denials if the codes don’t align with Medicare’s requirements.
• Policy Updates: While Medicare’s general policies for these tests haven’t changed significantly in recent years, there could be stricter enforcement of medical necessity or frequency guidelines. Additionally, if your secondary insurance (TFL) updated its coordination with Medicare, that might affect coverage.
• Provider Issues: If you switched providers or labs, the new provider might not be following Medicare’s billing guidelines as closely as your previous one.

4. Laboratory Tests Covered on Page 44 of the Medicare & You 2025 Handbook
The Medicare & You 2025 handbook provides an overview of covered services, and under the “Laboratory Tests” section (typically found around page 44 in recent editions), Medicare outlines the following:

• General Coverage: Medicare Part B covers medically necessary clinical diagnostic laboratory tests when ordered by a doctor. These tests are often covered at 100% (no coinsurance or deductible) if the lab accepts Medicare assignment.
• Examples of Covered Tests (Based on Historical Handbooks):
• Blood tests (e.g., complete blood count, cholesterol, lipid panels, triglycerides, as discussed above).
• Urinalysis.
• Tests for diabetes management (like Hemoglobin A1C for diagnosed patients).
• Tests for other conditions, such as thyroid function tests, liver function tests, or kidney function tests, when medically necessary.
• Certain cancer screenings (e.g., prostate-specific antigen [PSA] test for prostate cancer screening).
• Conditions for Coverage:
• The test must be ordered by a physician and deemed medically necessary.
• The lab must be Medicare-approved and accept assignment to avoid additional costs.
• Notable Exclusions: Tests that are experimental, investigational, or not medically necessary are not covered. Additionally, some tests may have frequency limitations (e.g., cholesterol screening every 5 years for preventive purposes).

Since I don’t have direct access to the 2025 edition of the handbook, this is based on the standard structure of previous editions. If you need the exact wording from page 44, you might want to refer to your copy or I can search for the 2025 handbook online if you’d like.
5. What Can You Do About the Denials?
Here are some steps you can take to address the denial of coverage for your A1C and cholesterol/lipid/triglyceride tests:

• Review the Explanation of Benefits (EOB): Check the EOB from Medicare and TFL to see why the claims were denied. Look for codes or reasons like “not medically necessary” or “frequency exceeded.”
• Contact Your Provider: Ask your doctor or the lab why the tests were denied. They may need to resubmit the claim with additional documentation (e.g., a diabetes diagnosis or justification for more frequent testing).
• Appeal the Denial: You have the right to appeal Medicare’s decision if you believe the tests should have been covered. The EOB will include instructions on how to file an appeal. TFL may also reconsider their coverage if Medicare approves the claim after an appeal.
• Confirm with Medicare and TFL: Call Medicare (1-800-MEDICARE) and Tricare for Life (1-866-773-0404) to confirm their policies and ensure the tests were billed correctly.
• Check for Preventive vs. Diagnostic Coding: Sometimes tests are coded as diagnostic (e.g., to monitor a condition) when they should be coded as preventive (e.g., a cholesterol screening every 5 years), or vice versa, which can affect coverage.

6. Summary of Coverage Policies

• Medicare Part B:
• Hemoglobin A1C: Covered for diabetes management (every 3 months) or screening (up to twice a year for at-risk individuals).
• Cholesterol/Lipid/Triglyceride: Covered every 5 years for preventive screening, or more often if medically necessary for diagnosis or monitoring.
• Tricare for Life: Covers remaining costs after Medicare pays, but only if Medicare approves the claim. If Medicare denies, TFL typically denies as well.
• Laboratory Tests (Medicare & You 2025, Page 44): Covers medically necessary diagnostic lab tests (e.g., blood tests, urinalysis, A1C, cholesterol) at 100% if the lab accepts Medicare assignment.

If you’d like me to search for the exact text from the 2025 Medicare & You handbook or look into recent policy changes for Medicare or TFL, let me know, and I can do a web search for you!