Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Preventive Care Services (Independence)

Policy #:00.06.02ab

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates and their clarifications do not automatically apply to self-funded groups, but may be included or excluded at the option of the group; therefore, individual group benefits must be verified.

Refer to the following News Articles:

Updated Preventive Coverage of Human Papillomavirus (HPV) Vaccine and Serogroup B Meningococcal (MenB) Vaccines

Preventive Care Services: Fluoride Varnish Application

Pre-procedure Consultations for Colorectal Cancer Screening Procedures

Coverage of Preventive Well Visits through Telemedicine in Response to COVID-19 for Independence Commercial Members



Subject to the terms of the member's benefit contract, $0 cost share will be applied when the preventive service is performed at a participating provider, and there is specific direction from regulatory laws, such as the Affordable Care Act, to adjudicate the preventive service claim at $0 cost share.

The services listed in this policy are considered preventive care services when the criteria in this policy are met, when they are identified as preventive services in the Company’s benefit contracts, when they are mandated by state or federal law, or when they are included as a recommendation in any of the following:
  • US Preventive Services Task Force (USPSTF), A and B Recommendations
  • Health Resources and Services Administration (HRSA), American Academy of Pediatrics/Bright Futures
  • Centers for Disease Control and Prevention (CDC), Advisory Committee for Immunization Practices (ACIP), Adult and Pediatric Immunization Schedules
  • US Department of Health and Human Services Secretary's Advisory Committee on Heritable Disorders in Newborns and Children
  • US Department of Health and Human Services, Women's Preventive Services: Required Health Plan Coverage Guidelines Supported by the Health Resources and Services Administration

Changes to coverage and cost-sharing requirements based on a new recommendation or guideline will go into effect the first plan year beginning on or after the date that is one year after the effective date of the new recommendation or guideline.

When a recommendation or guideline for a preventive service is downgraded in the middle of a plan year, coverage for the preventive service will continue to apply through the end of the plan year, except in certain limited circumstances, such as significant safety concerns with the downgraded preventive service or a drop from an "A" or "B" USPSTF recommendation to a "D" USPSTF recommendation.

Cost-share (i.e., copayment, deductible, coinsurance) application is in accordance with the terms of the member's benefit contract.

The preventive services are organized within this policy as follows:

ADULT PREVENTIVE SERVICES (ATTACHMENT A)
  • Visits
    • Preventive Exams
  • Screenings
    • Abdominal Aortic Aneurysm (AAA) Screening
    • Abnormal Blood Glucose and Type 2 Diabetes Mellitus Screening and Intensive Behavioral Counseling Interventions
    • Colorectal Cancer Screening
      • Services performed in connection with a preventive colorectal cancer screening procedure
    • Depression Screening
    • Hepatitis B Virus Screening
    • Hepatitis C Virus Screening
    • High Blood Pressure Screening
    • Human Immunodeficiency Virus (HIV) Screening
    • Latent Tuberculosis Infection Screening
    • Lipid Disorder Screening
    • Lung Cancer Screening
    • Syphilis Screening
    • Unhealthy Alcohol Use Screening and Behavioral Counseling Interventions
  • Therapy and Counseling
    • Services Included as Part of the Comprehensive Preventive Exam
      • Behavioral Counseling for Skin Cancer Prevention
      • High Blood Pressure Screening (Office-based)
      • Obesity Screening
    • Behavioral Counseling for Prevention of Sexually Transmitted Infections
    • Behavioral Interventions for Weight Loss
    • Exercise Interventions for the Prevention of Falls
    • Intensive Behavioral Counseling to Promote a Healthful Diet and Physical Activities for Cardiovascular Disease Prevention
    • Nutritional Counseling for Weight Management
    • Tobacco Use Counseling
  • Medications
    • Low-dose Aspirin
    • Prescription Bowel Preparation Medication
    • Statins for the Primary Prevention of Cardiovascular Disease
    • Tobacco cessation medication
  • Miscellaneous
    • Immunizations
    • Prolonged Preventive Services

FEMALE PREVENTIVE SERVICES (ATTACHMENT B)
  • Visits
    • Pre-natal Visits
    • Well-woman visits
  • Screenings
    • Sexually Transmitted Infections Screenings
      • Chlamydia Screening
      • Gonorrhea Screening
      • Human Immunodeficiency Virus (HIV) Screening
      • Syphilis Screening
    • Cancer Screenings
      • Breast and Ovarian Cancer Screenings, Genetic Risk Assessment Counseling, and BRCA Mutation Testing
      • Breast Cancer Screening (Mammography)
      • Cervical Cancer Screening
    • Pregnancy-related Screenings
      • Bacteriuria Screening
      • Counseling Interventions to Prevent Perinatal Depression
      • Depression Screening
      • Diabetes Mellitus Screening after Pregnancy
      • Gestational Diabetes Mellitus Screening
      • Iron-deficiency Anemia Screening
      • RhD Incompatibility Screening
      • Unhealthy Alcohol Use Screening and Behavioral Counseling Interventions
    • Other Preventive Screenings
      • Hepatitis B Virus Screening
      • Human Papilloma Virus (HPV) Screening
      • Osteoporosis (Bone Mineral Density) Screening
  • Therapy and Counseling
    • Comprehensive Preventive Evaluation and Management Services
      • Primary Care Interventions to Promote and Support Breastfeeding
      • Discussion of Chemoprevention for Breast Cancer
      • Instruction in fertility awareness-based methods, including the lactation amenorrhea method
      • Intimate Partner Violence Screening
      • Urinary Incontinence Screening
    • Tobacco Use Screening and Counseling
  • Medication
    • Low-Dose Aspirin for Preeclampsia
    • Breast Cancer Preventive Medicine
    • Folic Acid
  • Miscellaneous
    • Reproductive Education and Counseling, Contraception, and Sterilization
      • Associated Services for Contraceptive Surgery
    • Breastfeeding Support/Counseling and Supplies
    • Prolonged Preventive Services

PEDIATRIC PREVENTIVE SERVCES (ATTACHMENT C)
  • Visits
    • Prebirth Exams
    • Preventive Exams
  • Screenings
    • Alcohol Use/Misuse Screening and Behavioral Counseling Intervention
    • Autism and Developmental Screening
    • Bilirubin Screening
    • Chlamydia Screening
    • Depression Screening
    • Dyslipidemia Screening
    • Gonorrhea Screening
    • Hearing Screening for Newborns
    • Hearing Screening (All children 29 days or older)
    • Hepatitis B Virus Screening
    • Human Immunodeficiency Virus (HIV) Screening
    • Iron Deficiency Screening
    • Lead Poisoning Screening
    • Newborn Screening Panel
    • Syphilis Screening
    • Vision Screening
  • Additional Screening Services and Counseling
    • Behavioral Counseling for Prevention of Sexually Transmitted Infections
    • Obesity Screening and Behavioral Counseling
    • Recommended Services Included as Part of the Comprehensive Preventive Evaluation and Management Exam or Newborn Care
      • Behavioral Counseling for Skin Cancer Prevention
      • Blood Pressure Screening
      • Congenital Heart Defect Screening
      • Counseling and Education Provided by Healthcare Providers to Prevent Initiation of Tobacco Use
      • Developmental Surveillance
      • Obesity Screening
      • Psychosocial/Behavioral Assessment
  • Medication
    • Fluoride
    • Prophylactic Ocular Topical Medication for Gonorrhea
  • Miscellaneous
    • Fluoride Varnish Application
    • Hemoglobin/Hematocrit Testing
    • Immunizations and Administration
    • Prolonged Preventive Services
    • Tuberculosis Testing

TRANSGENDER PREVENTIVE SERVICES

Gender-specific preventive services as identified in this policy are covered for transgender individuals as determined by the individual's healthcare provider as medically appropriate.
Guidelines

This policy is consistent with applicable state and federal mandates, including the Patient Protection and Affordable Care Act (PPACA) of 2010 and the Health Care and Education Reconciliation Act (HCERA) of 2010.

Coverage is subject to the terms and conditions of the applicable benefit plan. Individual benefits must be verified.

Description

Preventive care services generally describe health care services performed to defend against illness or detect the early warning signs of health problems, including preventive visits, screenings, therapy and counseling, appropriate immunizations, contraception, and other laboratory tests.
References


Department of Health and Human Services. Centers for Disease Control and Prevention (CDC). Vaccines and Immunizations. Recommendations and Guidelines: Advisory Committee on Immunization Practices (ACIP). Available at: http://www.cdc.gov/vaccines/acip/index.html. Accessed April 5, 2019.

Recommendations for Preventive Pediatric Health Care/Bright Futures. American Academy of Pediatrics. Available at: http://www.aap.org/en-us/professional-resources/practice-support/Periodicity/Periodicity%20Schedule_FINAL.pdf and http://www.aap.org/en-us/professional-resources/practice-support/Periodicity/AllVisits.pdf. Accessed April 5, 2019.

Recommended Preventive Services. HealthCare.gov. Available at: https://www.healthcare.gov/what-are-my-preventive-care-benefits/. Accessed April 5, 2019.

Recommendations. Women's Preventive Services Initiative. Available at: https://www.womenspreventivehealth.org/recommendations/. Accessed April 5, 2019.

State of New Jersey. New Jersey General and Permanent Statutes. [New Jersey State Web site.]. Available at:
http://lis.njleg.state.nj.us/nxt/gateway.dll?f=templates&fn=default.htm&vid=Publish:10.1048/Enu. Accessed April 5, 2019.

Unnanuntana A, Gladnick BP, Donnelly E, Lane JM. Current concepts review: the assessment of fracture risk. J Bone Joint Surg Am. 2010;92:743-53.

US Department of Health and Human Services. Secretary's Advisory Committee on Heritable disorders in Newborns and Children. Available at: http://www.hrsa.gov/advisorycommittees/mchbadvisory/heritabledisorders/. Accessed April 5, 2019.

US Department of Health and Human Services. Women's Preventive Services: Required Health Plan Coverage Guidelines Supported by the Health Resources and Services Administration. Available at: https://www.hrsa.gov/womens-guidelines/index.html. Accessed April 5, 2019.

US Department of Labor. Affordable Care Act Frequently Asked Questions website. Available at: https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/aca-implementation-faqs. Accessed April 5, 2019.

US Preventive Services Task Force. Available at: http://www.uspreventiveservicestaskforce.org/. Accessed April 5, 2019.

Vaccines Licensed for Use in the United States. U.S. Food and Drug Administration. Available at: https://www.fda.gov/biologicsbloodvaccines/vaccines/approvedproducts/ucm093833.htm. Accessed April 5, 2019.

World Health Organization Collaborating Center for Metabolic Bone Diseases. Calculation Tool. FRAX WHO Fracture Risk Assessment Tool. Available at: http://www.shef.ac.uk/FRAX/tool.jsp?locationValue=9. Accessed on April 5, 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)

See Attachments A, B, C


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)

See Attachment A, B, and C


HCPCS Level II Code Number(s)

See Attachment A, B, and C


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Preventive Care Services (Independence)
Description: Adult Preventive Services

Attachment B: Preventive Care Services (Independence)
Description: Female Preventive Care Services

Attachment C: Preventive Care Services (Independence)
Description: Pediatric Preventive Care Services




Policy History

00.06.02ab
01/01/2020
    Attachment A
    • Hepatitis B Virus Screening
      • Applicable ICD-10 diagnosis codes have been added to the policy due to criteria changes.
    • Hepatitis C Virus Screening
      • Applicable ICD-10 diagnosis codes have been added to the policy due to criteria changes.
    • Syphilis Screening
      • The policy criteria were updated to include risk factors for increased risk.
      • Applicable ICD-10 diagnosis codes have been added to the policy due to criteria changes.
    • Immunizations
      • The following codes were removed from the policy: 90649, 90650

    Attachment B
    • Chlamydia Screening
      • The policy criteria were updated to include risk factors for increased risk.
      • Applicable ICD-10 diagnosis codes have been added to the policy due to criteria changes.
    • Gonorrhea Screening
      • The policy criteria were updated to include risk factors for increased risk.
      • Applicable ICD-10 diagnosis codes have been added to the policy due to criteria changes.
    • Syphilis Screening
      • The policy criteria were updated to include risk factors for increased risk.
      • Applicable ICD-10 diagnosis codes have been added to the policy due to criteria changes.
    • Hepatitis B Virus Screening
      • Applicable ICD-10 diagnosis codes have been added to the policy due to criteria changes.
    • Counseling interventions to prevent perinatal depression is a new recommendation to the policy.

    Attachment C
    • Chlamydia Screening
      • The policy criteria were updated to include risk factors for increased risk.
      • Applicable ICD-10 diagnosis codes have been added to the policy due to criteria changes.
    • Gonorrhea Screening
      • The policy criteria were updated to include risk factors for increased risk.
      • Applicable ICD-10 diagnosis codes have been added to the policy due to criteria changes.
    • Hepatitis B Virus Screening
      • Applicable ICD-10 diagnosis codes have been added to the policy due to criteria changes.
    • Syphilis Screening
      • The policy criteria were updated to include risk factors for increased risk.
      • Applicable ICD-10 diagnosis codes have been added to the policy due to criteria changes.
    • Immunizations
      • The following codes were removed from the policy: 90649, 90650
_________________________________________________________


Note: On 01/22/2020, Attachments A and C of this policy were updated to incorporate coding changes effective 01/01/2020.
  • The following CPT codes have been added to Attachments A and C of this policy: 90694, 99473, 99474


00.06.02aa
10/01/2019
    This version of the policy will become effective 10/01/2019. The following ICD-10 code has been added to this policy: Z11.7.


00.06.02z
07/01/2019
    This version of the policy will become effective 07/01/2019.
    Attachment A
    • Alcohol use/misuse screening and behavioral counseling intervention
      • The title was changed to Unhealthy Alcohol Use Screening and Behavioral Counseling Interventions
    • Obesity screening and behavioral counseling
      • The title was changed to Behavioral Interventions for Weight Loss
      • Obesity Screening was added to Services Included as Part of the Comprehensive Preventive Exam
    • Counseling for the Prevention of Falls
      • The title was changed to Exercise Interventions for the Prevention of Falls
      • The following codes were removed from the recommendation: 99401, 99402, 99403, 99404
      • The following CPT codes were added to the recommendation: 97110, 97112, 97116, 97150, 97161, 97162, 97163, 97164, 97530
      • The following ICD-10 diagnosis codes were added to the recommendation: R26.0, R26.1, R26.2, R26.81, R26.89, R26.9, R29.6, Z91.81
      • The following modifier was added to the recommendation: 33
    • Nutritional Counseling
      • The policy criteria was updated to not limit to PA plans only.
    • Prescription Bowel Preparation Medication
      • The policy criteria was updated to add PEG3350 as a preventive drug.
    • Medications
      • The policy criteria for bowel preparation medication was updated to include specific drugs.
      • The policy criteria for tobacco cessation medication was updated to include specific drugs.
    • Immunizations
      • The following codes were added to the policy: 90654, 90660, Q2034
    Attachment B
    • Chlamydia
      • The following code was added to the policy: 99000
    • Gonorrhea
      • The following code was added to the policy: 99000
    • HIV Screening
      • The policy criteria was updated to address the frequency of testing.
    • Cervical Cancer Screening
      • Additional criteria was added to the recommendation.
    • Unhealthy Alcohol Use Screening and Behavioral Counseling Interventions
      • This is a new recommendation to this attachment.
      • The following codes were added for this recommendation: 99408,99409,G0442, G0443, G2011
    • Human Papillomavirus (HPV) Screening
      • The following code was added to the recommendation: 99000
    • Osteoporosis (Bone Mineral Density) Screening
      • The policy criteria was updated to lower the level of risk from high risk to increased risk.
    • Medications
      • The policy criteria for breast cancer chemoprevention was updated to include tamoxifen.
    Attachment C
    • Alcohol and Drug Use/Misuse Screening and Behavioral Counseling
      • The title was updated to Alcohol and Drug Use Screening and Behavioral Counseling Intervention
    • Chlamydia Screening
      • The following code was added to the policy: 99000
    • Hemoglobin/Hematocrit Testing
      • The title was changed to iron deficiency anemia screening.
    • Newborn Screening Panel
      • The policy criteria was updated to include spinal muscular atrophy
    • Visual Impairment Screening
      • The title was changed to Vision Screening
    • Fluoride
      • The age criteria was expanded to align with Bright Futures recommendations. The dosage was included in the policy criteria.
    • Immunizations
      • The following codes were added to the policy: 90654, 90660, Q2034

00.06.02y
01/02/2019This version of the policy will become effective 01/02/2019.

The following CPT codes have been termed from this policy:
81211 81213 81214

The following CPT codes have been added to this policy:
81163 81164 81165 81166 81167

00.06.02x
01/01/2019This version of the policy will become effective 01/01/2019.

Attachment A
  • Barium enema was removed as a screening tool for colorectal cancer screening. The following codes were removed: 74270, 74280, G0106, G0120, G0122.
  • Vitamin D supplements was removed as a preventive service.
  • The following codes were added to the immunizations recommendation: 90672, 90739, 90750.

Attachment B
  • The following codes were removed from breast cancer screening (mammography): 77061, 77062, 77065, 77066, G0279.
  • Diabetes mellitus screening after pregnancy was added as a preventive service.
  • Urinary incontinence screening was added as a preventive service as part of a preventive exam or well-woman visit.
  • Breastfeeding Support/Counseling and Supplies: The following codes were added to the recommendation: 99401, 99402, 99403, 99404, 99411, 99412.

Attachment C
  • The following codes were added to the immunizations recommendation: 90672, 90739.
  • Iron supplements was removed as a preventive service.

_______________________________________________________

Note: the policy in Notification was updated 12/26/2018 to include the following changes:
  • The following HCPCS code has been added to the policy: G2011, 90689
  • The policy criteria for Autism and Developmental Screening has been updated to increase the frequency of screenings for the recommended age range.
  • The heading for the diagnosis codes in the Depression Screening service was added.

00.06.02w
10/01/2018The following ICD-10 CM codes have been added to this policy:
On Attachment B under Depression Screening
    F53.0 Postpartum depression
    F53.1 Puerperal psychosis
    Z13.32 Encounter for screening for maternal depression
On Attachment A and C under Depression Screening
    Z13.31 Encounter for screening for depression

The following ICD-10 CM code has been termed from this policy:
    F53 Puerperal psychosis

00.06.02v
07/01/2018No changes have been made to this version of the policy.


Effective 10/05/2017 this policy has been updated to the new policy template format.


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

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