Commercial

Preventive Care Services
00.06.02af



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.

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 or updated 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
      • Unhealthy Drug Use 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
    • Pre-exposure Prophylaxis for the Prevention of HIV Infection
    • 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
      • Anxiety Screening​
      • 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 August 11, 2020.

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 Schedule_FINAL.pdf and http://www.aap.org/en-us/professional-resources/practice-support/Periodicity/AllVisits.pdf. Accessed August 11, 2020.

Recommended Preventive Services. HealthCare.gov. Available at: https://www.healthcare.gov/what-are-my-preventive-care-benefits/. Accessed August 11, 2020.

Recommendations. Women's Preventive Services Initiative. Available at: https://www.womenspreventivehealth.org/recommendations/. Accessed August 11, 2020.

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 August 11, 2020.

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 August 11, 2020.

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 August 11, 2020.

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 August 11, 2020.

US Preventive Services Task Force. Available at: http://www.uspreventiveservicestaskforce.org/. Accessed August 11, 2020.

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 August 11, 2020.

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 August 11, 2020​.

Coding

CPT Procedure Code Number(s)
See Attachments A, B, and C.

ICD - 10 Procedure Code Number(s)
N/A

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


Policy History

7/1/2021
7/1/2021
00.06.02
Medical Policy Bulletin
Commercial
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No