Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Preventive Care Services
Policy #:MA00.003m

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.

Refer to the following News Articles:

Preventive Care Services: Bone Mass Measurements

In accordance with the Centers for Medicare & Medicaid Services (CMS) and Medicare Advantage Evidence of Coverage, the services listed below are considered preventive services based on outlined criteria.

VISITS AND PHYSICAL EXAMINATIONS (ATTACHMENT A)
  • Annual Wellness Visit (AWV), Advance Care Planning, and Annual Physical Examination Screening
  • Initial Preventative Physical Examination (IPPE) and Screening Electrocardiogram (EKG)
  • Miscellaneous
    • Prolonged Preventive Services

SCREENING SERVICES (ATTACHMENT B)
  • Bone Mass Measurement
  • Cardiovascular Disease Screening Blood Tests
  • Colorectal Cancer Screening
  • Diabetes Screening Test
  • Glaucoma Screening
  • Hepatitis B Virus Screening (HBV)
  • Hepatitis C Virus Screening (HCV)
  • Human Immunodeficiency Virus (HIV) Screening
  • Lung Cancer Screening
  • Prostate Cancer Screening
  • Screening for Depression
  • Screening and Counseling to Reduce Alcohol Misuse
  • Screening Mammography
  • Screening Pelvic Exams (including a Clinical Breast Exam), Papanicolou (PAP) Test and Human Papillomavirus (HPV) Screening
  • Screening for Sexually Transmitted Infections (STIs) and High-Intensity Behavioral Counseling (HIBC) to Prevent STIs
  • Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)
  • Miscellaneous
    • Prolonged Preventive Services

THERAPY AND COUNSELING (Attachment C)
  • Counseling to Stop Smoking or Tobacco Use (Smoking and Tobacco Use Cessation)
  • Diabetes Prevention Program
  • Diabetes Self Management Training (DSMT)
  • Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (also referred to as Cardiovascular Disease Risk Reduction Visit)
  • Intensive Behavioral Therapy (IBT) for Obesity
  • Medical Nutrition Therapy
  • Miscellaneous
    • Prolonged Preventive Services

VACCINES (Attachment D)
  • Hepatitis B Virus (HBV) Vaccine and Administration
  • Influenza Virus Vaccine and Administration
  • Pneumococcal Vaccine and Administration

Please refer to Attachments A-D of this policy, which include information on the following:
  • Coverage
  • Frequency of services
  • Procedure and diagnosis codes which are related to the above listed services

Policy Guidelines

This policy is consistent with Medicare's coverage determination. The Company's reimbursement methodology may differ from Medicare.

BENEFIT APPLICATION

Coverage is subject to the terms, conditions, and limitations of the applicable Evidence of Coverage.

Description

Preventive care services generally describe health care services performed to detect the early warning signs of health problems. Preventive care services may lead to early diagnosis and prompt therapy to shorten the duration of illness and reduce the severity of disease.

Preventive care services may include the evaluation and management of an individual, which may consist of any of the following: physical examination, review of medical history, risk factor reduction intervention(s), counseling, and the ordering of appropriate immunization(s) and laboratory/diagnostic procedures.
References

Centers for Medicare & Medicaid Services (CMS). 2018-2019 Influenza (Flu) Resources for Health Care Professionals. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18015.pdf. Accessed June 1, 2019.

Centers for Medicare & Medicaid Services (CMS). Advanced Care Planning. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9271.pdf. Accessed June 1, 2019.

Centers for Medicare & Medicaid Services (CMS). Current Medicare Coverage of Diabetes Supplies. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18011.pdf. Accessed June 1, 2019.

Centers for Medicare & Medicaid Services (CMS) Decision Memo for Screening for Lung Cancer Using Low-Dose Computed Tomography. Effective 2/5/2015. Available at:http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=274. Accessed June 1, 2019.

Centers for Medicare & Medicaid Services (CMS). Influenza Vaccines Payment Allowances- Annual Update for 2018-2019 Season. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10914.pdf. Accessed June 1, 2019.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 18: Preventive and Screening Services. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c18.pdf. Accessed June 1, 2019.

Centers for Medicare & Medicaid Services (CMS). Medicare Coverage of Screening for Lung Cancer with Low Dose Computed Tomography (LDCT). Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM9246.pdf. Accessed June 1, 2019.

Centers for Medicare & Medicaid Services (CMS). Medicare Fee-For-Service Preventive Services. Quick Reference Information. Available at:http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdf
https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html. Accessed June 1, 2019.

Centers for Medicare & Medicaid Services (CMS). MLN Matters ICD 10's Bone Mass Measurement. Available at:https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1525.pdf. Accessed June 1, 2019.

Centers for Medicare & Medicaid Services (CMS). MLN Matters Screening for HIV. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9403.pdf. Accessed June 1, 2019.

Centers for Medicare & Medicaid Services (CMS). Quarterly Influenza Virus Vaccine Code Update-January 2019. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10871.pdf. Accessed June 1, 2019.

Centers for Medicare & Medicaid Services (CMS). Replacement of Mammography HCPCS Codes, Waiver of Coinsurance and Deductible for Preventive and Other Services, and Addition of Anesthesia and Prolonged Preventive Services. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10181.pdf. Accessed June 1, 2019.

Centers for Medicare & Medicaid Services (CMS). Review of Opioid Use During the Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV). Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18004.pdf. Accessed June 1, 2019.

Centers for Medicare & Medicaid Services (CMS). Screening for Hepatitis B Virus (HBV) Infection. Effective 9/28/2016. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM9859.pdf. Accessed June 1, 2019.

Centers for Medicare & Medicaid Services (CMS). NCD 210.7 Screening for HIV. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=335&ncdver=2&bc=AgAAgAAAAAAAAA%3d%3d& Accessed June 1, 2019.

Centers for Medicare & Medicaid Services (CMS). Screening for Human Immunodeficiency Virus (HIV) Infection. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM9980.pdf. Accessed June 1, 2019.

Centers for Medicare & Medicaid Services (CMS). Screening for Human Papillomavirus (HPV). Available at: :https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9434.pdf. Accessed June 1, 2019.

Centers for Medicare & Medicaid Services (CMS). Two New “K” Codes for Therapeutic Continuous Glucose Monitor. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM10013.pdf. Accessed June 1, 2019.

Centers for Medicare & Medicaid Services (CMS). Updating Calendar Year (CY) 2019 Medicare Diabetes Prevention Program (MDPP) Payment Rates. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10970.pdf. Accessed June 1, 2019.

Evidence of Coverage.

Novitas Solutions. Medicare Reference Manual Chapter 25. Preventive Services. Available at: http://www.novitas-solutions.com/webcenter/faces/oracle/webcenter/page/scopedMD/sad60252a_5537_4c5d_9350_ca405e36e159/Page128.jspx?wc.contextURL=%2Fspaces%2FMedicareJL&wc.originURL=%2Fspaces%2FMedicareJL%2Fpage%2Fpagebyid&contentId=00008244&_afrLoop=688493769458588#%40%3F_afrLoop%3D688493769458588%26wc.contextURL%3D%252Fspaces%252FMedicareJL%26wc.originURL%3D%252Fspaces%252FMedicareJL%252Fpage%252Fpagebyid%26contentId%3D00008244%26_adf.ctrl-state%3D159b2yfhba_65. Accessed June 1, 2019.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

Refer to Attachments A-D


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

Refer to Attachments A-D


HCPCS Level II Code Number(s)

Refer to Attachments A-D


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Preventive Care Services
Description: Visits and Examinations

Attachment B: Preventive Care Services
Description: Screening Services

Attachment C1: Preventive Care Services
Description: Medical Nutrition Therapy ICD 10 Codes

Attachment C: Preventive Care Services
Description: Therapy and Counseling

Attachment D1 : Preventive Care Services
Description: Hepatitis B Vaccine ICD 10 Coding

Attachment D: Preventive Care Services
Description: Vaccines







Policy History

Revisions from MA00.003m

01/01/2020Attachment A
  • Annual Wellness Visit (AWV) / Advance Care Planning (ACP) and Annual Physical Examination: Annual wellness visit, advance care planning, and annual physical exam was changed from once every 12 months to once a calendar year

Attachment B
  • Pelvic Exams (including Clinical Breast Exams)
    • The following CPT codes were added to the recommendation: 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397

Attachment D
  • Influenza Vaccines
    • The following code was added to the recommendation: Q2037
_______________________________________________________

Note: On 01/22/2020, Attachment D of this policy was updated to incorporate coding changes effective 01/01/2020.
  • The following CPT code has been added to Attachment D of this policy: 90694


Revisions from MA00.003k
07/01/2019Attachment B
  • Screening Mammography: The following codes were added to the policy: N63.10, N63.20
  • Screening Pelvic Exams (including a Clinical Breast Exam) and Pap tests: The policy criteria was updated to clarify the time intervals to the next screening test. The following codes were removed from the policy: Z72.89, Z77.22. The following diagnosis codes were added to the policy: Z77.29, Z92.89

Attachment D
  • Influenza Virus Vaccine and Administration: The following codes were added to the policy: 90654, 90660, Q2034


Revisions from MA00.003j
01/01/2019This version of the policy will become effective 01/01/2019.

Attachment A
  • Annual Wellness Visit (AWV), Advance Care Planning (ACP), and Annual Physical Examination; and Initial Preventive Physcial Examination (IPPE) and Screening Electrocardiogram (EKG)
    • The following code was added to the policy: G0468

Attachment B
  • Bone Mass Measurement:
    • The policy criteria was updated.
    • The following codes were added to the policy: 0508T, 77085

  • Colorectal Cancer Screening:
    • The following procedure codes were added to the policy: 45330, 45331, 45333, 45338, 45346, 45349, 44388, 44389, 44392, 44394, 44401, 44403, 44406, 44407, 45378, 45380, 45381, 45384, 45385, 45388, 45390
    • The following diagnosis code was added to the policy: D12.6, Z12.11, Z12.11
    • The following code was removed from the policy: G0464
    • The following modifiers were added to the policy: PT 33
  • Hepatitis B Virus Screening
    • The following diagnosis codes were removed to the medical policy: Z11.4
  • Hepatitis C Virus Screening
    • The following diagnosis code was added to the policy: Z11.59
  • Lung Cancer Counseling and Annual Screening Low Dose Computed Tomography:
    • The following diagnosis codes were added to the policy: F17.210, F17.211, F17.213, F17.218, F17.219
  • Screening Mammography:
    • The policy criteria language was updated.
    • The following codes were added to the medical policy: 77061, 77062, 77065, 77066, G0279
    • The following diagnosis codes have been added to the policy: R92.0, R92.1, R92.2,R92.2, R92.8
  • Screening Pelvic Exams(including a clinical breast exam) and papanicolau (PAP) tests:
    • The following diagnosis codes were added to the medical policy: R87.615, R87.616, R87.618, R87.625, R87.629
  • Screening for Sexually Transmitted Infections and High Intensity Behavioral Counseling to Prevent STIs:
    • The following diagnosis codes were added to the policy: Z72.51, Z72.52, Z72.53

Attachment B1
  • Attachment B1 was deleted with all of the diagnosis codes for bone mass measurements.

Attachment C
  • Counseling to Stop Smoking or Tobacco Use
    • The policy criteria language was updated.
    • The following diagnosis codes were added to the policy: F17.213, F17.218, F17.219, F17.223, F17.228, F17.229, F17.293, F17.298, F17.299, T65.211A, T65.212A, T65.213A, T65.214A, T65.221A, T65.222A, T65.223A, T65.224A, T65.291A, T65.292A, T65.293A, T65.294A

Attachment D
  • Influenza Vaccine and Administration
    • The following codes were added to the policy: 90672 90756

Attachment D1
  • The following language and code was removed from the policy:
    INFLUENZA VIRUS VACCINE AND ADMINISTRATION
    Z23 Encounter for immunization
  • The following codes were removed from the policy:
    F66, F12.20, F12.21, F12.22, F12.220, F12.221, F12.222, F12.229, F12.25, F12.250, F12.251, F12.259, F12.28, F12.280, F12.288, F12.29, F13.20, F13.21, F13.220, F13.221, F13.229, F13.230, F13.231, F13.232, F13.239, F13.24, F13.26, F13.27, F13.29, F13.250, F13.251, F13.259, F13.280, F13.281, F13.282, F13.288, F18.10, F18.11, F18.12, F18.120, F18.121, F18.129, F18.14, F18.15, F18.150, F18.151, F18.159, F18.17, F18.18, F18.180, F18.188, F18.19, F18.2, F18.20, F18.21, F18.22, F18.220, F18.221, F18.229, F18.24, F18.25, F18.250, F18.251, F18.259, F18.27, F18.28, F18.280, F18.288, F18.29, F18.9, F18.90, F18.92, F18.920, F18.921, F18.929, F18.94, F18.95, F18.950, F18.951, F18.959, F18.97, F18.98, F18.980, F18.988, F18.99, F19, F19.1, F19.12, F19.15, F19.18, F19.2, F19.22, F19.23, F55.0, F55.1, F55.2, F55.3, F55.4, F55.8, F72, F73, F78, F79, Q90.0, Q90.1, Q90.2, Q90.9
  • The following codes were added to the policy:
    D68.0, F11.10, F11.11, F11.120, F11.121, F11.122, F11.129, F11.14, F11.150, F11.151, F11.159, F11.181, F11.182, F11.188, F11.19, F11.90, F11.920, F11.921, F11.922, F11.929, F11.93, F11.94, F11.950, F11.951, F11.959, F11.981, F11.982, F11.988, F11.99, F14.10, F14.11, F14.120, F14.121, F14.122, F14.129, F14.14, F14.150, F14.151, F14.159, F14.180, F14.181, F14.182, F14.188, F14.19, F15.10, F15.11, F15.120, F15.121, F15.122, F15.129, F15.14, F15.150, F15.151, F15.159, F15.180, F15.181, F15.182, F15.188, F15.19, F16.10, F16.11, F16.120, F16.121, F16.122, F16.129, F16.14, F16.150, F16.151, F16.159, F16.180, F16.183, F16.188, F16.19, F19.239, F19.24, F19.250, F19.251, F19.259, F19.26, F19.27, F19.280, F19.281, F19.282, F19.288, F19.29, F19.90, F19.920, F19.921, F19.922, F19.929, F19.930, F19.931, F19.932, F19.939, F19.94, F19.950, F19.951, F19.959, F19.96, F19.97, F19.980, F19.981, F19.982, F19.988, F19.99, Z20.5, Z72.52


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Note: The policy in Notification was updated on 12/26/2018 with the following changes.

The following code was added to the policy to screening and counseling to reduce alcohol misuse:
G2011 Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., audit, dast), and brief intervention, 5-14 minutes

The following codes were removed from the policy on attachment D1: F14.22, F14.25, F14.28, F15.22, F15.25, F15.28, F16.22, F16.25, F16.28

The following codes were added to attachment D: 90630, 90655, 90657, 90658, 90661, 90673, 90689


Revisions from MA00.003i
04/01/2018
    This version of the policy will become effective 04/01/2018. The policy was updated to include Medicare diabetes prevention program as a new preventive service.


Revisions from MA00.003h
01/01/2018This version of the policy will become effective 01/01/2018.

Attachment B
  • Associated services list for colorectal cancer screening was added to the policy.
  • The following diagnosis code was removed from Hepatitis B Screening recommendation: Z11.4.
  • The policy criteria for Hepatitis B Virus Screening was updated.
  • The policy criteria for Hepatitis C Virus Screening was updated.
  • The policy criteria for HIV Screening was updated.

Attachment C
  • The diabetes self-management training recommendation was updated to include the most current organizations that credential the training programs.

Attachment D
  • The following code was removed from Hepatitis B virus vaccine section: 90739.
  • The following codes were removed from Influenza virus vaccine section: 90654, 90660, Q2034.
  • The following code was added to the Influenza virus vaccine section: 90662.

Through a New Article effective 12/19/2017 The following code was added to Hepatitis B vaccines: 90739 Hepatitis B vaccine (HepB), adult dosage 2 dose schedule, for intramuscular use

**As of 12/19/2017 this policy in notification has been updated to incorporate:
  • A new section was added for prolonged preventive services. The following codes were included: G0513, G0514
  • Code Updates
    • The following codes were added: 00811, 00812, 00813, 90756
    • The following codes were deleted: 00810, G0202

Revisions from MA00.003g
10/01/2017This policy has been identified for the ICD-10 CM code update, effective 10/01/2017.

The following ICD-10 CM codes have been added to this policy:
E11.10 Type 2 diabetes mellitus with ketoacidosis without coma
E11.11 Type 2 diabetes mellitus with ketoacidosis with coma
F18.11 Inhalant abuse, in remission
F19.11 Other psychoactive substance abuse, in remission


Revisions from MA00.003f
01/01/2017This version of the policy will become effective 01/01/2017

The following was added:
Coverage for Hepatitis B screening added to Attachment B.
Language was added to the Influenza Vaccine section in Attachment D.
CPT, HCPCS, & ICD 10 codes added to various Attachments of the policy.

Revisions from MA00.003e
09/30/2016This policy will become effective 10/01/2016.

In accordance with the 10/1/2016 ICD-10 CM code update, the following changes occurred in this policy.
  • The following ICD 10 codes codes have been revised:

O24.011, O24.012, O24.013, O24.019, O24.02, O24.03, O24.111, O24.112, O24.113, O24.119, O24.12, O24.13.
  • The following ICD-10 CM codes have been deleted from this policy:

E08.321, E08.329, E08.331, E08.339, E08.341, E08.349, E08.351, E08.359,E09.321, E09.329, E09.331, E09.339 E09.341, E09.349, E09.351, E09.359, E10.321, E10.329, E10.331 E10.339, E10.341, E10.349 E10.351, E10.359, E11.321, E11.329, E11.331, E11.339, E11.341, E11.349, E11.351, E11.359, E13.321, E13.329, E13.331, E13.339, E13.341, E13.349, E13.351, E13.359
  • The following ICD-10 CM codes have been added to this policy:

E08.3211, E08.3212, E08.3213, E08.3219, E08.3291, E08.3292, E08.3293, E08.3299, E08.3311, E08.3312, E08.3313, E08.3319, E08.3391, E08.3392, E08.3393, E08.3399, E08.3411, E08.3412, E08.3413, E08.3419, E08.3491, E08.3492, E08.3493, E08.3499, E08.3511, E08.3512, E08.3513 E08.3519, E08.3521, E08.3522, E08.3523, E08.3529, E08.3531, E08.3532, E08.3533, E08.3539 E08.3541, E08.3542, E08.3543, E08.3549, E08.3551, E08.3552, E08.3553, E08.3559, E08.3591, E08.3592, E08.3593, E08.3599, E08.37X1, E08.37X2, E08.37X3, E08.37X9, E09.3211, E09.3212, E09.3213, E09.3219, E09.3291, E09.3292, E09.3293, E09.3299, E09.3311, E09.3312, E09.3313, E09.3319, E09.3391, E09.3392, E09.3393, E09.3399, E09.3411, E09.3412, E09.3413, E09.3419, E09.3491, E09.3492, E09.3493, E09.3499, E09.3511, E09.3512, E09.3513, E09.3519, E09.3521, E09.3522, E09.3523, E09.3529, E09.3531, E09.3532, E09.3533, E09.3539, E09.3541, E09.3542, E09.3543, E09.3549, E09.3551, E09.3552, E09.3553, E09.3559, E09.3591, E09.3592, E09.3593, E09.3599, E09.37X1, E09.37X2, E09.37X3, E09.37X9, E10.3211, E10.3212, E10.3213, E10.3219, E10.3291, E10.3292, E10.3293, E10.3299, E10.3311, E10.3312, E10.3313, E10.3319, E10.3391, E10.3392, E10.3393, E10.3399, E10.3411, E10.3412, E10.3413, E10.3419, E10.3491, E10.3492, E10.3493, E10.3499, E10.3511, E10.3512, E10.3513, E10.3519, E10.3521, E10.3522, E10.3523, E10.3529, E10.3531, E10.3532, E10.3533, E10.3539, E10.3541, E10.3542, E10.3543, E10.3549, E10.3551, E10.3552, E10.3553, E10.3559, E10.3591, E10.3592, E10.3593, E10.3599, E10.37X1 E10.37X2, E10.37X3, E10.37X9, E11.3211, E11.3212, E11.3213, E11.3219, E11.3291, E11.3292, E11.3293, E11.3299, E11.3311, E11.3312, E11.3313, E11.3319, E11.3391, E11.3392, E11.3393, E11.3399, E11.3411, E11.3412, E11.3413, E11.3419, E11.3491, E11.3492, E11.3493, E11.3499, E11.3511, E11.3512, E11.3513, E11.3519, E11.3521, E11.3522, E11.3523, E11.3529, E11.3531 E11.3532, E11.3533, E11.3539, E11.3541, E11.3542, E11.3543, E11.3549, E11.3551, E11.3552, E11.3553, E11.3559, E11.3591, E11.3592, E11.3593, E11.3599, E11.37X1, E11.37X2, E11.37X3, E11.37X9, E13.3211, E13.3212, E13.3213, E13.3219, E13.3291, E13.3292, E13.3293, E13.3299, E13.3311, E13.3312, E13.3313, 13.3319, E13.3391, E13.3392, E13.3393, E13.3399, E13.3411, E13.3412, E13.3413, E13.3419, E13.3491, E13.3492, E13.3493, E13.3499, E13.3511, E13.3512, E13.3513, E13.3519, E13.3521, E13.3522, E13.3523, E13.3529, E13.3531, E13.3532, E13.3533, E13.3539, E13.3541, E13.3542, E13.3543, E13.3549, E13.3551, E13.3552, E13.3553, E13.3559, E13.3591, E13.3592, E13.3593, E13.3599, E13.37X1, E13.37X2, E13.37X3, E13.37X9, O24.415, O24.425, O24.435.

The following HCPCS codes have been deleted: G0436, G0437 & S8032

Revisions from MA00.003d
04/20/2016This policy will become effective 04/20/2016

Coverage added for the following:
  • Advanced care planning
  • FDA-approved influenza vaccine-90653
  • Human Papillomavirus (HPV) Screening
  • Additional high risk factors added for HIV screening
  • ICD 10 codes added to attachments A-D

Revisions from MA00.003c
01/01/2016This policy has been identified for CPT/HCPCS code update effective 01/01/2016

The following CPT code was added 81528

The following HCPCS codes have been added to the policy: G0296, G0297 & G0475

The following CPT codes have been revised in this policy: 77057, 87320, 87340, 87341, 90739

Revisions from MA00.003b
10/01/2015This policy has been identified for ICD-10 code update effective 10/01/2015

Revisions from MA00.003a
07/012015This version of the policy will become effective 07/01/2015.

The following have been added:
  • Coverage for lung cancer screening
  • Coverage for screening 3D mammography
  • Coverage of anesthesia related to screening colonoscopy
  • Coverage of Hepatitis B vaccine for individuals with Diabetes
  • New coverage/frequency for HIV screening
  • New coverage/frequency recommendation for the pneumococcal vaccine

Code S0195 has been removed.

The Company has changed the coverage position for code 90669 from Covered to Not Eligible for Reimbursement.

The Company has changed the coverage position for code 90603 from Experimental/Investigational to Medically Necessary.

The following immunization codes have narrative changes effective 7/1/2015:
90653, 90655, 90656, 90657, 90658, 90660, 90661, 90662, 90669, 90670, 90672, 90673, 90685, 90686, 90687, 90688, 90732, 90739, 90740, 90743, 90744, 90746, 90747.

Revisions from MA00.003
01/01/2015This is a new policy.

12/15/2014 the following changes were made to this policy Notification.
    Coding section:
    This policy has been identified for the CPT/HCPCS code update effective 01/01/2015.
    • The following codes have been added: 90630, G0472, G0473 & G0464
    • The following code has been revised: 90654
    Attachment B:
    • Coverage/Criteria for DNA stool Testing using the Cologuard Test was added to the Colorectal Cancer Screening Section.
    • Coverage/Criteria added addressing Ultrasound Screening for Abdominal Aortic Aneursym (AAA)




Version Effective Date: 01/01/2020
Version Issued Date: 12/31/2019
Version Reissued Date: N/A