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Medical Policy Bulletin

Preventive Care Services
MA00.003aa



Policy

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.

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, Annual Physical Examination Screening, and Screening Electrocardiogram (EKG)
  • 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) and Papanicolou (PAP) Test 
  • 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
  • Administration at Home for Pneumococcal, Influenza, Hepatitis B, and COVID-19 Vaccination
Please refer to Attachments A-D of this policy, which include information on the following:
  • Coverage
  • Frequency of services
  • Procedure and diagnosis codes that are related to the above-listed services

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 healthcare 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). Advanced Care Planning. October 2020. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AdvanceCarePlanning.pdf​. Accessed March 8, 2022.

Centers for Medicare & Medicaid Services (CMS). Current Medicare Coverage of Diabetes Supplies. Available at: htttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18011.pdf. Accessed March 8, 2022.

Center for Medicare & Medicaid Services (CMS). Seasonal Influenza Vaccines Pricing. Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing. Accessed March 8, 2022.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15: Covered Medical and Other Health Services. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Accessed March 8, 2022.

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 March 8, 2022.

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 March 8, 2022.

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 March 9, 2022.

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 March 8, 2022.

Centers for Medicare & Medicaid Services (CMS). Review of Opioid Use During the Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV). 08/28/2018 Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18004.pdf. Accessed March 9, 2022.

Centers for Medicare & Medicaid Services (CMS). NCD 150.3 Bone (Mineral) Density Studies. 01/01/2007. Available at: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=256​ Accessed March 9, 2022.

Centers for Medicare & Medicaid Services (CMS). NCD 210.14 Lung Cancer Screening with Low Dose Computed Tomography. 02/05/2015. Available at: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=364&ncdver=1&bc=AgAAgAAAAAAA&. Accessed March 8, 2022.

Centers for Medicare & Medicaid Services (CMS). NCD 210.7 Screening for HIV. 04/13/2015. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=335&ncdver=2&bc=AgAAgAAAAAAAAA==& Accessed March 8, 2022.

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 March 8, 2022.

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 March 8, 2022.

Evidence of Coverage.

Coding

CPT Procedure Code Number(s)
Refer to Attachments A, B, C, and D.

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

ICD - 10 Diagnosis Code Number(s)
Refer to Attachments A, B, C, and D.

HCPCS Level II Code Number(s)
Refer to Attachments A, B, C, and D.

Revenue Code Number(s)
N/A




Cross Reference


Policy History


Revisions From MA00.003aa:
10/01/2024

Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

 

This policy has been identified for the HCPCS code update, effective 10/01/2024.

 

This policy has been identified for the ICD-10 CM code update, effective 10/01/2024.

 

The following ICD-10 CM codes have been added to this policy:

Attachment B - Z86.0100, Z86.0101, Z86.0102, Z86.0109

Attachment C - Z68.55, Z68.56,​           

Attachment C1 and D1 - E10.A0, E10.A1, E10.A2 

Attachment B - J1171, J2002, J2003, J2004   


The following ICD-10 CM code has been termed (no longer valid code) from this policy:
Attachment B - Z86.010 

The following HCPCS codes have been termed (no longer valid code) from this policy:

Attachment B - J1170, J2001

 

The following ICD-10 CM narrative has been revised in this policy: Z68.54




Revisions From MA00.003z:
07/01/2024This version of the policy will become effective 07/01/2024

Attachment A

Annual Wellness Visit (AWV), Advance Care Planning (ACP), Annual Physical Examination and Screening Electrocardiogram (EKG) 

  • The following procedure code was added: G0136 

Attachment B

Diabetes Screening Tests 

  • As previously communicated through a news article, the frequency was updated to twice within a 12-month period and updated to add procedure code 83036 

Screening Pelvic Exams (Including a Clinical Breast Exam) and Papanicolaou (PAP) Tests 

  • The following procedure code was added to this section: 99459 

Screening for Sexually Transmitted Infections (STIs) and High-intensity Behavioral Counseling (HIBC) to Preventive STIs 

  • As previously communicated through a news article, the following procedure code was added 0402U 

Medicare Diabetes Prevention Program 

  • The frequency was updated to indicate 22 sessions are covered over a year period​
  • The following codes were removed from this section: G9873, G9874, G9875, G9876, G9877, G9878, G9879, G9882, G9883, G9884, G9885, G9891 

 

Attachment D

Administration at Home for Pneumococcal, Influenza, Hepatitis B, and COVID-19 Vaccination 

  • As previously communicated through a news article, this section was added to the policy

The following HCPCS code has been added to this policy: 

To Associated Services for Colorectal Cancer Screening (Attachment B) : J1597


The following CPT code has been termed (no longer valid code) from this policy: 0353U 

The following HCPCS  codes have been termed (no longer valid code) from this policy:
J2780, S0164

Revisions From MA00.003y:

01/02/2024

Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time.


This policy has been identified for the  CPT and HCPCS  code update, effective 01/02/2024 

The following HCPCS codes have been added to the Medicare Diabetes Prevention Program on Attachment C of this policy: G9886, G9887, G9888  

 

As previously communicated through a Newsflash, the following CPT codes have been been termed (no longer valid codes) and removed ​from COVID-19 Vaccine Administration on Attachment D of this policy:


0001A, 0002A, 0003A, 0004A, 0011A, 0012A, 0013A, 0031A, 0034A, 0041A, 0042A, 0044A, 0051A, 0052A, 0053A, 0054A, 0064A, 0071A, 0072A, 0073A, 0074A, 0081A, 0082A, 0083A, 0091A, 0092A, 0093A, 0094A, 0111A, 0112A, 0113A, 0124A, 0134A, 0144A, 0154A, 0164A, 0173A, 0174A   ​


The following HCPCS narrative has been revised in this policy:M0201


Revisions From MA00.003x:
​01/01/2024

Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
01/01/2024

Attachment B
Bone Mass Measurements

  • ​The criteria for more frequent bone mass measurements to indicate this is for dual-energy X-ray absorptiometry (axial skeleton)) 

 Colorectal Cancer Screening
  • The criteria were updated for average risk individuals to remove the minimum age for screening colonoscopies.
  • A billing requirement was added to the policy to address a follow-up screening colonoscopy.
  • KX modifier was added to the coding section to address the follow-up colonoscopy.

Lung Cancer Counseling and Annual Screening using Low Dose Computed Tomography (LDCT)

  • The following criteria was updated to remove written order requirements for subsequent visits.

Prostate Cancer Screening

  • The following code was removed from this section: 0359U

Attachment C
Medicare Diabetes Prevention Program

  • The criteria for ongoing Maintenance Sessions were updated.

Attachment D
COVID Vaccine Administration

  • As previously communicated through a news article:
    • The following codes were removed from the policy:  0001A, 0002A, 0003A, 0004A, 0011A, 0012A, 0013A, 0031A, 0034A, 0051A, 0052A, 0053A, 0054A, 0064A, 0071A, 0072A, 0073A, 0074A, 0081A, 0082A, 0083A, 0091A, 0092A, 0093A, 0094A, 0111A, 0112A, 0113A
    • The following codes were added to the policy: 0121A, 0141A, 0142A, 0151A, 0171A, 0172A

Revisions From MA00.003w:
10/01/2023

Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time.


This policy has been identified for the ICD-10 CM code update, effective 10/01/2023.


The following ICD-10 CM code has been termed from Colorectal Cancer Screening section on attachment B of this policy: Z83.71​


The following ICD-10 CM codes have been added to Colorectal Cancer Screening section on attachment B of this policy: Z83.710, Z83.711, Z83.718, Z83.719


The following ICD-10 CM codes have been added to Medical Nutrition Therapy section on attachment C1 of this policy: O90.41, O90.49


Revisions From MA00.003v:

07/01/2023

Attachment B 

Bone mass measurements

  • The policy was updated to remove single photon absorptiometry, dual photon absorptiometry, and trabecular bone. These services will be incorporated into MA00.005ah Experimental/Investigational Services​ for trabecular bone score and MA00.001c Not Medically Necessary Services and Obsolete or Unreliable Diagnostic Tests for single photon absorptiometry and dual photon absorptiometry.​
  • The following codes were removed from the policy: 77089, 77090, 77091, 77092, 78350, 78351
Services performed in connection with a preventive colorectal cancer screening procedure
  • On attachment B, in the associated services section of the colorectal cancer screening section: 
    • The following codes have been termed : S0020; S0030; S0073; S0077​
    • ​The following codes have been added : J0457; J0665; J0736; J1836​​

Prostate Cancer Screening 

  • As previously communicated though a newsflash with a retroactively effective date of 01/01/2023, the following code was added to this section: 0359U
Screening for Sexually Transmitted Infections
  • As previously communicated though a newsflash with a retroactively effective date of 01/01/2023, the following code was added to this section: 0353U​​
Attachment C
Medical Nutrition Therapy
  • The policy criteria was updated to address preventive coverage for additional hours for a change in an individual's medical condition, diagnosis, or treatment regimen.​​
Attachment D
A​​s previously communicated though a news article, COVID- 19 vaccine administration was added to the policy as a preventive service. The following codes were added to this section: 0001A, 0002A, 0003A, 0004A, 0011A, 0012A, 0013A, 0031A, 0034A, 0041A, 0042A, 0044A, 0051A, 0052A, 0053A, 0054A, 0064A, 0071A, 0072A, 0073A, 0074A, 0081A, 0082A, 0083A, 0091A, 0092A, 0093A, 0094A, 0111A, 0112A, 0113A, 0124A, 0134A, 0144A, 0154A, 0164A, 0173A, 0174A, M0201

Revisions From MA00.003u:
01/01/2023

Attachment A 

  • Annual Wellness Visit, Advance Care Planning, and Annual physical examination
    • The name was changed to Annual Wellness Visit, Advance Care Planning, Annual Physcial Examination, and Screening Electrocardiogram
    • A screening electrocardiogram (EKG) was added as an optional preventive service as a result of an annual physical examination. 
    • The following codes were added to this section: 93000, 93005, 93010

Attachment B

  • Bone Mass Measurements
    • ​The following codes were removed from the policy: ​0508T, 0554T, 0555T, 0556T, 0557T, 0558T​
  • Colorectal cancer screening
    • The average risk criteria was updated to lower the inital screening age to 45 years. 
    • ​The following CPT narrative was revised in this policy: J0131
    • The following codes were added to the associated services section : J2311, J2401, J2402 
    • The following code was termed from the associated services section: J2400 
  • Screening and Counseling to Reduce Alcohol Misuse
    • ​The following CPT narrative was revised in this policy: G0442
  • Screening for Depression
    • The following CPT narrative was revised in this policy: G0444​​

Attachment C

  • Medicare Diabetes Prevention Program
    • The following criteria was updated to address the flexibilites made during the COVID-19 public health emergency for the once-per-lifetime limit for services. 
  • ​​Diabetes Self-Management Training (DSMT)
    • ​​Telehealth was added as an eligible setting.

Revisions From MA00.003t:
10/01/2022​Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time. 

This policy has been identified for the  ICD­10 code update, effective 10/01/2022 

The following ICD­10 CM code has been termed from this policy:  
D​68.0 
The following ICD­10 CM codes have been added to this policy: 

D68.00, D68.01, D68.020, D68.021, D68.022, D68.023, D68.029, D68.03, D68.04, 

D68.09


Revisions From MA00.003s:
07/01/2022

Attachment B

  • Bone Mass Measurements
    • The policy criteria was updated to add trabecular bone score as not medically necessary.
  • Lung Cancer Counseling and Annual Screening Using Low Dose Computed Tomography (LDCT)
    • As previously communicated, the policy criteria was updated to lower the initiation age to 50 years and to lower the minimum tobacco smoking history to at least 20 pack years.
  • Screening Mammography
    • The following diagnosis codes were added: C84.7A, N61.21, N61.22, N61.23
  • Screening Pelvic Exams
    • The following diagnosis codes were added: Z92.850, Z92.858, Z92.86

Attachment D

  • Pneumococcal Vaccine and Administration
    • The frequency of the pneumococcal vaccines was updated to align with the CDC's pneumococcal vaccine schedule. 
    • The following codes were added: 90671, 90677​

Revisions From MA00.003r:
01/01/2022On Attachment B, the colorectal cancer screening was updated to clarify that, when a colorectal cancer screening procedure turns into a diagnostic procedure, the procedure is still considered preventive. 

The following CPT codes have been added to bone mass measurement, on attachment B, as not medically necessary: 77089, 77090, 77091, 77092

The following CPT code has been added to Hepatitis B Vaccine, on attachment D, as preventive: 90759

Revisions From MA00.003q:
07/01/2021​On attachment B, blood-based biomarker test was added as a new colorectal cancer screening test with criteria. On attachment C, the policy criteria language for medical nutrition therapy was updated to address benefit application.
The following CPT code was added to the colorectal cancer screening on attachment B: G0327​

Revisions From MA00.003p:
01/01/2021​On attachment C, the policy criteria language for diabetes self-management training was updated. 

The following HCPCS code was termed from the policy: G0297

The following CPT code was added to the poilicy: 71271​


Revisions From MA00.003o:
10/01/2020
Inclusion of a policy in a Code Update memo does not imply that a full review 
of the policy was completed at this time.

This policy has been identified for the HCPCS and ICD­10 code update, 
effective 10/01/2020.

The following ICD­10 CM code has been termed from this policy: N18.3 Chronic kidney disease, stage 3 (moderate)

The following ICD­10 CM codes have been added to this policy:

Attachment D1

F11.13, F13.130, F13.131, F13.132, F13.139, F14.13, F15.13, 
F19.130, F19.131, F19.132, F19.139

Attachment C1

N18.30, N18.31, N18.32

The following HCPCS narrative has been revised in this policy:
G2011 (Attachment B) 
FROM: Alcohol and/or substance (other than tobacco) abuse structured 
assessment (e.g., audit, DAST), and brief intervention, 5­14 minutes TO: Alcohol and/or substance (other than tobacco) misuse structured 
assessment (e.g., audit, dast), and brief intervention, 5­14 minutes

The following narrative change (as indicated in bold) was made 
to ICD­10 CM codes:

Attachment C

Z68.23 Body mass index [BMI] 23.0­23.9, adult
Z68.24 Body mass index [BMI] 24.0­24.9, adult
Z68.25 Body mass index [BMI] 25.0­25.9, adult
Z68.26 Body mass index [BMI] 26.0­26.9, adult
Z68.27 Body mass index [BMI] 27.0­27.9, adult
Z68.28 Body mass index [BMI] 28.0­28.9, adult
Z68.29 Body mass index [BMI] 29.0­29.9, adult
Z68.30 Body mass index [BMI]30.0­30.9, adult
Z68.31 Body mass index [BMI] 31.0­31.9, adult
Z68.32 Body mass index [BMI] 32.0­32.9, adult
Z68.33 Body mass index [BMI] 33.0­33.9, adult
Z68.34 Body mass index [BMI] 34.0­34.9, adult
Z68.35 Body mass index [BMI] 35.0­35.9, adult
Z68.36 Body mass index [BMI] 36.0­36.9, adult
Z68.37 Body mass index [BMI] 37.0­37.9, adult
Z68.38 Body mass index [BMI] 38.0­38.9, adult
Z68.39 Body mass index [BMI] 39.0­39.9, adult
Z68.41 Body mass index [BMI]40.0­44.9, adult
Z68.42 Body mass index [BMI] 45.0­49.9, adult
Z68.43 Body mass index [BMI] 50.0­59.9, adult
Z68.44 Body mass index [BMI] 60.0­69.9, adult
Z68.45 Body mass index [BMI] 70 or greater, adult
Z68.52 Body mass index [BMI] pediatric, 
5th percentile to less than 85th percentile for age
Z68.53 Body mass index [BMI] pediatric, 
85th percentile to lesss than 95th percentile for age
Z68.54 body mass index [BMI] pediatric,
greater than or equal to 95th percentile for age​

Revisions From MA00.003n:
07/01/2020
    This version of the policy will become effective 07/01/2020.

    Attachment B
    • Colorectal Cancer Screening
      • The following diagnosis code was added to the high risk section of the recommendation: Z86.004
    • Screening Mammography
      • The following diagnosis codes were added to the recommendation: N63.15, N63.25
      • The following diagnosis codes were removed from the recommendation: N63.10, N63.20
    Attachment C
    • Counseling to Stop Smoking or Tobacco Use (Smoking and Tobacco Use Cessation)
      • The policy criteria were updated to remove the requirement of having toba​cco-related disease
    • Intensive Behavioral Therapy (IBT) for Obesity
      • The policy criteria were updated to address eligibility for additional face-to-face visits there must have been at least a 3 kg weight loss during the previous six months.
    • Medical Nutrition Therapy
      • The policy coverage criteria were updated to remove the limitation of not receiving dialysis.
    Attachment C1
    • The following codes were added to the attachment: E11.10, E11.10, I12.0, I12.9, I13.0, I13.10, I13.11, I13.2, N18.1, N18.2, N18.3, N18.4, N18.5, N18.6, N18.9, O10.211, O10.212, O10.213, O10.219, O10.22, O10.23, O10.311, O10.312, O10.313, O10.319, O10.32, O10.33, Z48.22

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: 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 9939​6, 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 MA00.003l:
10/01/2019This policy has been identified for the ICD-10 CM code update, effective 10/01/2019. This policy was updated to reflect the code narrative update for code Z68.43. The intent of the policy remains unchanged.

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
--------------------------------------------------------------------------------------
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)

10/01/2024
10/02/2024
N/A
MA00.003
Medical Policy Bulletin
Medicare Advantage
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No