Medical Policy

Effective Date:04/07/2010

Title:Preventive Health Benefit

Revision Date:10/01/2021

Document:BI062:00

CPT Code(s):See Attached Table

Public Statement

Effective Date:

a) This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1) QualChoice preventive health benefits are intended for the early detection and/or treatment of diseases by screening for their presence in an individual who has neither symptoms nor findings suggestive of those diseases. In addition to typical age and gender based screening recommendations, this also includes preventive coverage of validated screening tests the Center for Disease Control and Public Health Departments deem necessary to prevent pandemic spread of new/emerging infectious diseases.

a) For example, tests performed for the following reasons are not considered to be screening tests:

i) Investigating a symptom;

ii) Investigating an abnormal finding on physical examination, or in a laboratory or imaging test;

iii) Testing to rule out or confirm the presence of a diagnosis suggested by symptoms or abnormal findings in physical examination, laboratory or imaging tests;

iv) Testing to assess the status or progress of a diagnosed problem;

v) Testing to check for the recurrence of a disease previously diagnosed and treated.

b) Many services are NOT covered as part of the preventive health screening benefit because they are not recommended by the United States Preventive Services Task Force (USPSTF) for this use. These tests may be covered under the standard medical benefit, in accordance with standard medical benefit rules, when they are used to investigate abnormal findings in the history or physical examination or to make or confirm a diagnosis or to gather follow-up information after treatment of a medical condition.

Examples:

i) Chest x-rays.

ii) Electrocardiograms.

iii) Treadmill (exercise) cardiograms.

2) QualChoice covers preventive health services as detailed in the member’s health benefit plan coverage document. Reference to the member’s coverage documents and benefit summary is necessary to determine specific preventive health benefit coverage. The Enrollee should be aware of special benefits, limits, and/or restrictions on preventive treatments, in particular whether the service is obtained out of network.

NOTE: The way that your physician submits a claim for services may affect the way the claim is paid. We will only consider a particular service to be preventive if the physician bills that service with a diagnosis that describes a preventive service, as defined below.

3) QualChoice follows the A and B recommendations of the US Preventive Services Task Force (USPSTF) of the Agency for Healthcare Research and Quality and the recommendations of the Bright Futures program supported by the Maternal and Child Health Bureau of the Health Resources and Services Administration and other legal mandates in determining what tests and examinations are covered as preventive or screening services.

a) The range of testing is designed to maximize the effectiveness of the preventive health benefit.

b) Certain tests, such as PSA, are mandated as preventive screenings by Arkansas law.

c) Some of the tests listed may not be appropriate for screening based on age, gender etc. Consult with your physician as to whether you should have a particular test.

d) This policy details what screening tests are covered under the preventive benefit. It is up to you and your physician to decide what screening tests you will undergo.

e) The USPSTF and Bright Futures update their recommendations at irregular intervals. Screening tests may be added or removed from recommendations, or intervals may change. QualChoice periodically reviews these recommendations and updates this policy on the basis of such review. Changes in recommendations are not incorporated into QualChoice benefits until they are detailed in this policy.

4) Immunizations are covered based on the recommendations of the Advisory Committee on Immunization Practices (ACIP) as outlined in BI022 Immunization Coverage.

5) The attached table details the screening tests that are considered part of the preventive benefit.

Medical Statement

1) QualChoice believes that a well-designed, evidence-based health maintenance program is an important benefit to our members and cost-effective for premium payers.

2) QualChoice has adopted the preventive testing recommended by the US Preventive Service Task Force of the Agency for Healthcare Research and Quality in the Department of Health and Human Services as a standard benefit, as well as the Bright Futures Periodicity Table Recommendations.

3) There may be a limit on the preventive medicine benefit (the amount may vary from plan to plan) in other plans as well. This means that careful and conservative use of this benefit is essential to be sure that all patients receive the maximum benefit from this coverage.

4) QualChoice is publishing this policy in order to have the coverage rules spelled out as explicitly as possible.

5) For preventive colon cancer screening (meeting age and frequency requirements), preventive coverage is possible in one of three ways:

a) Medical CPT codes with preventive modifier 33

b) Medical CPT codes with preventive Dx codes

c) Preventive HCPCS (G codes)-regardless of modifier or Dx codes

Covered Services	USPSTF Recommendation	Claim Statement
Recommended by United States Preventive Services Task Force (USPSTF)
Abdominal Aortic Aneurysm	One-time screening for abdominal aortic aneurysm by ultrasound in men ages 65 to 75 years old who have ever smoked	76706 covered once per lifetime as preventive for men ages 65 through 75 with diagnosis code Z87.891 or F17.210-F17.219. If billed at a shorter interval, it will be denied as non-covered, exceeding benefit limit; member responsibility. If billed with any other diagnosis code, will be denied as inappropriate code.
Anxiety Disorders in Adults: Screening: adults 64 years or younger, including pregnant and postpartum persons	The USPSTF recommends screening for anxiety disorders in adults, including pregnant and postpartum persons.
Anxiety in Children and Adolescents: Screening: children and adolescents aged 8 to 18 years	The USPSTF recommends screening for anxiety in children and adolescents aged 8 to 18 years.
Aspirin Use to Prevent Preeclampsia and Related Morbidity and Mortality: Preventive Medication: pregnant persons at high risk for preeclampsia	The USPSTF recommends the use of low-dose aspirin (81 mg/day) as preventive medication after 12 weeks of gestation in persons who are at high risk for preeclampsia. See the Practice Considerations section for information on high risk and aspirin dose.
Asymptomatic Bacteriuria in Adults: Screening: pregnant persons	The USPSTF recommends screening for asymptomatic bacteriuria using urine culture in pregnant persons.
BRCA-Related Cancer: Risk Assessment, Genetic Counseling, and Genetic Testing: women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or an ancestry associated with brca1/2 gene mutation	The USPSTF recommends that primary care clinicians assess women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with breast cancer susceptibility 1 and 2 (BRCA1/2) gene mutations with an appropriate brief familial risk assessment tool. Women with a positive result on the risk assessment tool should receive genetic counseling and, if indicated after counseling, genetic testing.	Counseling provided by primary care providers is considered to be preventive and is not separately reimbursed. See BI508
		• 96040 covered as preventive for diagnosis of Z15.01, Z15.02, or Z80.3. Otherwise, covered under medical benefit. · 81162-81166, 81212, 81215-81217, require pre-authorization; if authorized, covered under preventive medicine benefit for diagnoses Z15.01, Z15.02, or Z80.3. If authorized and billed with any other diagnosis, covered under medical benefit.
Breast Cancer: Medication Use to Reduce Risk: women at increased risk for breast cancer aged 35 years or older	The USPSTF recommends that clinicians offer to prescribe risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, to women who are at increased risk for breast cancer and at low risk for adverse medication effects.
Breast Cancer: Screening: women aged 50 to 74 years	The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. †
Breastfeeding: Primary Care Interventions: pregnant women, new mothers, and their children	The USPSTF recommends providing interventions during pregnancy and after birth to support breastfeeding.
Cervical Cancer: Screening women aged 21 to 65 years	The USPSTF recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years. For women aged 30 to 65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting). See the Clinical Considerations section for the relative benefits and harms of alternative screening strategies for women 21 years or older.	• G0123, G0124, G0141, G0143, G0144, G0145, G0147, and G0148 covered as preventive once every 36 months; If billed at a shorter interval, it will be denied as non-covered, exceeding benefit limit; member is responsible. · 88141-88153, 88164-88167, and 88174, 88175 covered as preventive once every 36 months when billed with diagnosis codes Z00.00, Z00.01, Z01.411, Z01.419, or Z12.4; If billed as preventive at a shorter interval, it will be denied as non-covered, exceeding benefit limit; member responsibility. If billed with any other diagnosis, covered under medical benefit. · HPV screening (87623 or 87624) covered as preventive once every 60 months (if age 30 or greater) if billed with diagnosis codes Z00.00, Z00.01, Z01.411-Z10.42, Z11.51, or Z12.4. If billed as preventive at a shorter interval, it will be denied as non-covered, exceeding benefit limit; member responsibility. See BI238 for details regarding HPV testing covered under the medical benefit. • 87625 is not covered.
Chlamydia and Gonorrhea: Screening sexually active women, including pregnant persons	Screen sexually active women age 24 and younger and older women who are at increased risk for infection for chlamydia and gonorrhea.	· 87110, 87270, 87320, 87490, 87491, and 87810 are covered as preventive for women with diagnosis code of Z00.00, Z00.01, Z11.3 or Z11.8, Z11.9; otherwise covered under the medical benefit. Always covered under medical benefit in men.
Colorectal Cancer Screening: Adults aged 45 to 49 years	The USPSTF recommends screening for colorectal cancer in adults aged 45 to 49 years. See the "Practice Considerations" section and Table 1 for details about screening strategies.	Age 45 through 75: · 00811-00813 (and associated supplies or medicines) covered as preventive if billed with diagnosis codes Z00.00, Z00.01, Z12.10-Z12.12, Z80.0, Z83.71, and Z83.7. Covered as medical with any other codes. · 74280 (radiological exam, colon, incl scout abd radiograph(s) and delayed image(s), when performed; double contrast (eg, high density barium and air study, incl glucagon, when administered) (code revised eff 01/01/2020) and G0106 (flexible sigmoidoscopy/barium enema) are no longer covered as preventive. · 81327 (Methylated SEPT9) is not covered. · 81528 (Cologuard) is covered once every three years as preventive if billed with diagnosis codes Z00.00, Z00.01, Z12.10-Z12.12, Z80.0, Z83.71, Z83.79. If billed at a shorter interval with a preventive code, it will be denied as non-covered, exceeding benefit limit; member responsibility. If billed with a medical code, it will be denied as non-covered. as · 82270, 82272 (guaiac hemoccult) or 82274 (Fecal Immunochemistry Test) covered annually as preventive regardless of diagnosis. · 88304 or 88305 (surgical pathology) covered as preventive if billed on the same date as a preventive colonoscopy. · 45330, 45331, 45333, 45338, or 45346, billed with modifier33 or with diagnosis codes Z00.00, Z00.01, Z12.10-Z12.12, Z80.0, Z83.71, Z83.79; G0104 (flexible sigmoidoscopy) with or without modifier PT; or preauthorized 74263 (CT colonography) every five years; · 44401, 44388, 44389, 44392, 44394, 45378, 45380, 45384 45385, or 45388, billed with modifier 33 or with diagnosis codes Z00.00, Z00.01, Z12.10-Z12.12, Z80.0, Z83.71, Z83.79; G0105, G0120, G0121, or G0122 with or without modifier PT every ten years. If billed with a preventive code at a shorter interval, will be denied as non-covered, exceeding benefit limit; member responsibility. If billed with a medical code, paid under medical benefit regardless of interval. Covered as preventive if billed with diagnosis codes Z00.00, Z00.01, Z12.10-Z12.12, Z80.0, Z83.71, Z83.79: 82270 · If any of above codes are billed with Z00.00, Z00.01, Z12.10-Z12.12, Z80.0, Z83.71, Z83.79 younger than age 45, will be denied as non-covered; not part of preventive benefit; member is responsible. If billed with other diagnoses, covered under medical benefit.

Colorectal Cancer: Screening: adults aged 50 to 75 years	The USPSTF recommends screening for colorectal cancer in all adults aged 50 to 75 years. See the "Practice Considerations" section and Table 1 for details about screening strategies.
Depression and Suicide Risk in Adults: Screening: adults, including pregnant and postpartum persons, and older adults (65 years or older)	The USPSTF recommends screening for depression in the adult population, including pregnant and postpartum persons, as well as older adults.
Depression and Suicide Risk in Children and Adolescents: Screening: adolescents aged 12 to 18 years	The USPSTF recommends screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years.
Falls Prevention in Community-Dwelling Older Adults: Interventions: adults 65 years or older	The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls.
Folic Acid Supplementation to Prevent Neural Tube Defects: Preventive Medication: persons who plan to or could become pregnant	The USPSTF recommends that all persons planning to or who could become pregnant take a daily supplement containing 0.4 to 0.8 mg (400 to 800 mcg) of folic acid.
Gestational Diabetes: Screening: asymptomatic pregnant persons at 24 weeks of gestation or after	The USPSTF recommends screening for gestational diabetes in asymptomatic pregnant persons at 24 weeks of gestation or after.
Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: Behavioral Counseling Interventions: adults with cardiovascular disease risk factors	The USPSTF recommends offering or referring adults with cardiovascular disease risk factors to behavioral counseling interventions to promote a healthy diet and physical activity.
Healthy Weight and Weight Gain In Pregnancy: Behavioral Counseling Interventions: pregnant persons	The USPSTF recommends that clinicians offer pregnant persons effective behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy.
Hepatitis B Virus Infection in Adolescents and Adults: Screening: adolescents and adults at increased risk for infection	The USPSTF recommends screening for hepatitis B virus (HBV) infection in adolescents and adults at increased risk for infection. See the Practice Considerations section for a description of adolescents and adults at increased risk for infection.	87340 covered as preventive for any of the following diagnosis codes: Z00.00, Z00.01, or Z11.59; otherwise, covered under medical benefit.
Hepatitis B Virus Infection in Pregnant Women: Screening: pregnant women	The USPSTF recommends screening for hepatitis B virus (HBV) infection in pregnant women at their first prenatal visit
Hepatitis C Virus Infection in Adolescents and Adults: Screening: adults aged 18 to 79 years	The USPSTF recommends screening for hepatitis C virus (HCV) infection in adults aged 18 to 79 years	G0472 covered over age 18-79 as preventive once per lifetime. 86803 and 86804 covered under medical benefit.
Human Immunodeficiency Virus (HIV) Infection: Screening: adolescents and adults aged 15 to 65 years	The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk of infection should also be screened. See the Clinical Considerations section for more information about assessment of risk, screening intervals, and rescreening in pregnancy.	86701-86703 covered as preventive for any of the following diagnosis codes: Z00.00, Z00.01, Z11.3 or Z11.4; otherwise, covered under medical benefit.
Human Immunodeficiency Virus (HIV) Infection: Screening: pregnant persons	The USPSTF recommends that clinicians screen for HIV infection in all pregnant persons, including those who present in labor or at delivery whose HIV status is unknown.
Hypertension in Adults: Screening: adults 18 years or older without known hypertension	The USPSTF recommends screening for hypertension in adults 18 years or older with office blood pressure measurement (OBPM). The USPSTF recommends obtaining blood pressure measurements outside of the clinical setting for diagnostic confirmation before starting treatment.
Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: Screening: women of reproductive age	The USPSTF recommends that clinicians screen for intimate partner violence (IPV) in women of reproductive age and provide or refer women who screen positive to ongoing support services. See the Clinical Considerations section for more information on effective ongoing support services for IPV and for information on IPV in men.
Latent Tuberculosis Infection in Adults: Screening: asymptomatic adults at increased risk of latent tuberculosis infection (ltbi)	The USPSTF recommends screening for LTBI in populations at increased risk. See the "Assessment of Risk" section for additional information on adults at increased risk.
Lung Cancer: Screening: adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years	The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.
Obesity in Children and Adolescents: Screening: children and adolescents 6 years and older	The USPSTF recommends that clinicians screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status.
Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum: Preventive Medication: newborns	The USPSTF recommends prophylactic ocular topical medication for all newborns to prevent gonococcal ophthalmia neonatorum.	Administration of ocular topical medication is part of hospital care; separately reimbursable. Covered as preventive for members up to 90 days of age for newborn screening (Z00.110-Z00.111): V5008, 92551, 92558, 92586-92588, 84437, 84443, 84030, S3850, 83020, 83021. If billed otherwise, covered under medical benefit.
Osteoporosis to Prevent Fractures: Screening: postmenopausal women younger than 65 years at increased risk of osteoporosis	The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in postmenopausal women younger than 65 years who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool. See the Clinical Considerations section for information on risk assessment. (see BI216).	77080 and 77081 covered as preventive every 24 months for women age 65 or older when billed with diagnoses Z00.00, Z00.01, Z13.820, or Z82.62. If billed as preventive at a shorter interval, it will be denied as non-covered, exceeding benefit limit; member responsibility. For any other billing for these codes, see Medical Coverage Policy BI216.
Osteoporosis to Prevent Fractures: Screening: women 65 years and older	The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older.
Perinatal Depression: Preventive Interventions: pregnant and postpartum persons	The USPSTF recommends that clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions.
Prediabetes and Type 2 Diabetes: Screening: asymptomatic adults aged 35 to 70 years who have overweight or obesity	The USPSTF recommends screening for prediabetes and type 2 diabetes in adults aged 35 to 70 years who have overweight or obesity. Clinicians should offer or refer patients with prediabetes to effective preventive interventions.
Preeclampsia: Screening: pregnant woman	The USPSTF recommends screening for preeclampsia in pregnant women with blood pressure measurements throughout pregnancy.
Prevention of Acquisition of HIV: Preexposure Prophylaxis: adolescents and adults at increased risk of HIV	The USPSTF recommends that clinicians prescribe preexposure prophylaxis using effective antiretroviral therapy to persons who are at increased risk of HIV acquisition to decrease the risk of acquiring HIV. See the Practice Considerations section for more information about identification of persons at increased risk and about effective antiretroviral therapy.
Prevention of Dental Caries in Children Younger Than 5 Years: Screening and Interventions: children younger than 5 years	The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride.
Prevention of Dental Caries in Children Younger Than 5 Years: Screening and Interventions: children younger than 5 years	The USPSTF recommends that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption.

Rh(D) Incompatibility: Screening: pregnant women, during the first pregnancy-related care visit	The USPSTF strongly recommends Rh(D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care.
Rh(D) Incompatibility: Screening: unsensitized rh(d)-negative pregnant women	The USPSTF recommends repeated Rh(D) antibody testing for all unsensitized Rh(D)-negative women at 24 to 28 weeks` gestation, unless the biological father is known to be Rh(D)-negative.
Sexually Transmitted Infections: Behavioral Counseling: sexually active adolescents and adults at increased risk	The USPSTF recommends behavioral counseling for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections (STIs). See the Practice Considerations section for more information on populations at increased risk for acquiring STIs.
Skin Cancer Prevention: Behavioral Counseling: young adults, adolescents, children, and parents of young children	The USPSTF recommends counseling young adults, adolescents, children, and parents of young children about minimizing exposure to ultraviolet (UV) radiation for persons aged 6 months to 24 years with fair skin types to reduce their risk of skin cancer.
Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medication: adults aged 40 to 75 years who have 1 or more cardiovascular risk factors and an estimated 10-year cardiovascular disease (cvd) risk of 10% or greater	The USPSTF recommends that clinicians prescribe a statin for the primary prevention of CVD for adults aged 40 to 75 years who have 1 or more CVD risk factors (i.e. dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year risk of a cardiovascular event of 10% or greater.
Syphilis Infection in Pregnant Women: Screening: pregnant women	The USPSTF recommends early screening for syphilis infection in all pregnant women.
Tobacco Smoking Cessation in Adults, Including Pregnant Persons: Interventions: nonpregnant adults	Clinicians should ask all adults about tobacco use, advise them to stop, and provide behavioral interventions and U.S. Food and Drug Administration (FDA)-approved pharmacotherapy for cessation to nonpregnant adults who use tobacco.	See Medical Coverage Policy BI183.
Tobacco Use in Children and Adolescents: Primary Care Interventions: school-aged children and adolescents who have not started to use tobacco	The USPSTF recommends that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school-aged children and adolescents.
Prostate Cancer Screening	USPSTF recommends against prostate-specific antigen (PSA)-based screening for prostate cancer. However, Arkansas state law mandates coverage for PSA screening in men over age 40.	G0103 or 84153 covered annually as preventive for men at least 40 years old when billed with diagnoses Z00.00, Z00.01, Z12.5, or Z80.42. If billed with a preventive code at a shorter interval, it will be denied as non-covered, exceeding benefit limit; member responsibility. If billed with any other diagnoses (regardless of frequency), will be covered under medical benefit.
Unhealthy Alcohol Use in Adolescents and Adults: Screening and Behavioral Counseling Interventions: adults 18 years or older, including pregnant women	The USPSTF recommends screening for unhealthy alcohol use in primary care settings in adults 18 years or older, including pregnant women, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use.
Unhealthy Drug Use: Screening: adults age 18 years or older	The USPSTF recommends screening by asking questions about unhealthy drug use in adults age 18 years or older. Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred. (Screening refers to asking questions about unhealthy drug use, not testing biological specimens.)
Vision in Children Ages 6 months to 5 years: Screening in Children aged 3 to 5 years	Screen all children at least once between the ages of 3 and 5 years, to detect the presence of amblyopia or its risk factors.	99173 covered as preventive yearly between the ages of 3 and 5 years and every two years between the ages of 8 and 15 years. Otherwise considered to be incidental to an evaluation and management visit: not separately reimbursable.
Weight Loss to Prevent Obesity-Related Morbidity and Mortality in Adults: Behavioral Interventions: adults	The USPSTF recommends that clinicians offer or refer adults with a body mass index (BMI) of 30 or higher (calculated as weight in kilograms divided by height in meters squared) to intensive, multicomponent behavioral interventions.
Wellness Exams	No recommendation regarding wellness examinations in asymptomatic individuals.	99381 and 99391 covered up to 6 times (aggregate) in members under age 1 year. 99382 and 99392 covered 3 times (aggregate) in members 1 year old, and 4 times (aggregate) in members age 2 through 4 years. 99383- 99387 and 99393-99397 covered annually (aggregate) in members over the age of 4. If billed as preventive at a shorter interval, it will be denied as non-covered, exceeding benefit limit; member responsibility. Age-specific screening and brief counseling included in preventive medicine visit; not separately reimbursed. Counseling beyond that included in preventive visit may be reimbursed with documentation of that counseling as a separate and identifiable service.
Covered Services	Bright Futures Periodicity Table Recommendations
Anemia Screening in Children	Recommended at 12 months; may be performed other times if indicated.	85014 or 85018 covered as preventive annually through age 3 if billed with diagnosis codes Z00.121, Z00.129 or Z13.0. If billed with any other diagnosis or interval, covered as medical benefit.
Hearing Tests	Recommended at newborn and ages 4, 5, 6, 8, 10, 11-14, 15-17 and 18-21; may be performed other times if indicated.	92551 covered as preventive annually, ages 4 through 10 plus every three years for ages 11 through 21 if billed with diagnosis codes Z00.121, Z00.129, or Z01.10. If billed with any other diagnosis or interval, covered as medical benefit.
Developmental/Autism	Recommended at age 9 months, 18 months, 24 months, and 30 months.	96110 covered as preventive every 6 months under age 3, with diagnosis codes Z00.121, Z00.129, or Z13.4. If billed as preventive at a shorter interval, it will be denied as non-covered, exceeding benefit limit; member responsibility. If billed with any other code will be denied as non-covered for that diagnosis.
Screenings
Behavioral/Social/Emotional Screening	Annually from newborn to 21 years
Lead Screening	Recommended at age 12 months and 24 months.	83655 covered as preventive every 12 months under the age of 3 years, with diagnosis codes Z00.121, Z00.129, or Z77.011. If billed with any other code or interval, covered under medical benefit.
TB Testing	Not recommended on a routine basis.	86580 are covered under the medical benefit.
Dyslipidemia Screening	Dyslipidemia (cholesterol) screening recommended once between age 9-11, and at 17 and 21 year visits.	CPT codes 80061, 82465, 83718, 83719, 83721, 84478 are covered as preventive once between ages of 9 and 11, at age 17, and at age 21 if billed with diagnosis codes Z00.121, Z00.129, or Z13.220. If billed at any other interval or age under the age of 22 with these diagnoses, will be denied as non-covered, exceeding benefit limit; member responsibility. If billed with any other diagnosis, covered under medical benefit.
Hepatitis B Virus Infection	See USPSTF recommendations above
HIV Screening	See USPSTF recommendations above.
Sudden Cardiac arrest and Sudden Cardiac Death	Assessing risk for sudden cardiac and sudden cardiac death for ages 11 to 21 years
Vision Screening	See USPSTF recommendations above.
Depression and Suicide Risk Screening	See Depression and Suicide Risk above
Cervical Dysplasia Screening	See "Cervical Cancer Screening" above.
Fluoride Varnish/Supplementation	See Prevention of Dental Caries above
Physical Examination	See "Wellness Exams" above.

Limits

1) Many diagnostic examinations are not covered under the preventive health benefit because their effectiveness as screening tests has not been demonstrated. If these tests are billed with a diagnosis code indicating that they are being performed as screening examinations, they will be denied as exceeding the benefit limit, with the member responsible for the full cost of the tests. If they are billed with a diagnosis indicating that the test is done for diagnostic reasons, they will be covered under the medical benefit, with the member required to meet contractual payment requirements. Examples of examinations which are sometimes done in conjunction with screening physical examinations which are not covered as screening tests are:

a) Chest X-Rays,

b) EKGs,

c) Treadmill EKGs

2) Colorectal cancer screening performed using fecal DNA (CPT 81528) is covered every three years.

3) Screening for colorectal cancer by testing serum for methylated SEPT9 DNA (CPT 81327) is not covered. Even though this test is recognized by the USPSTF, the low sensitivity for detecting colorectal cancer makes it less effective than other screening tests.

4) The USPSTF now also recognizes virtual colonoscopy (CT colonography) as another scientifically validated tool that may be used to screen for colorectal cancer. However, CT colonography requires preauthorization and is only approved if there is a contraindication or intolerance to conventional colonoscopy (see BI148).

Reference

Addendum:

1) Effective 04/01/17: Added updates on Cologuard and CT colonography to reflect most current USPSTF recommendations for colorectal cancer screening. Updated on methylated SEPT9 test for colorectal cancer screening.

2) Effective 08/01/2017: Made reference to BI508 for BRCA testing. Added 81162 BRCA w full dup/del analysis is covered and 81213 uncommon BRCA dup/del variants are no longer covered.

3) Effective 08/01/2017: HPV test (87623 Low risk types 6/11,42, 43 and 44) is covered as preventive once every 60 months if billed with certain diagnosis codes and 87625 (HPV types 16 and 18 only) is not covered.

4) Effective 09/01/2017: Colonoscopy (45378) and colonoscopy with biopsy (45380) or ablation (44401, 45346, and 45388) are covered as preventive once every 10 years if billed concurrently with preventive code or modifier.

5) Effective 12/01/2017: Updated cholesterol screening guidelines and added preventive low-moderate intensity statin guidelines

6) Effective 12/12/2017: Updated osteoporosis screening guidelines.

7) Effective 02/02/2018: Removed deleted codes 88154 & G0202 as part of 2018 Code Update process. G0202 was replaced with 77067; 88154 has no replacement code.

8) Effective 10/01/2018: Clarified diagnosis/modifier requirements with screening sigmoidoscopy and colonoscopy.

9) Effective 01/01/2019: 2019 Code Updates. CPT codes 81211-81214 deleted & replaced with new codes 81162-81166.

10) Effective 01/01/2019: Diabetic eye exam are covered once every year under preventive benefit for diabetics without any known eye complications.

11) Effective 05/01/2019: Added Cologuard, code for screening for Depression, code for Vision Screening in Children, and new age coverage for Hearing Tests under age 21.

12) Effective 8/1/2019: Grouped pregnancy related testing together; additional code for PSA testing; adjusted code range for HPV screening

13) Effective 1/1/2020: Further clarification of diagnosis/modifier requirements with screening sigmoidoscopy and colonoscopy. Also revised code 74280 effective 1/1/2020.

14) Effective 07/01/2019: PSA for prostate cancer screening (G0103 or 84153) is covered annually under preventive benefit for men at least 40 years old when billed with diagnoses Z00.00, Z00.01, Z12.5, or Z80.42. If billed more frequently as preventive, will be denied as non-covered, exceeding the benefit limit; member responsibility. If billed with any other diagnoses (regardless of frequency), will be covered under medical benefit.

15) Effective 04/01/2020: Updated Hepatitis C screening per new USPSTF recommendations.

16) Effective 07/01/2020: Expanded coverage for Cologuard (81528) to be covered once every 3 years for colorectal cancer screening, as preventive if billed with diagnosis codes Z00.00, Z00.01, Z12.10-Z12.12, Z80.0, Z83.71, Z83.79. If billed at a shorter interval with a preventive code, it will be denied as non-covered, exceeding benefit limit; member responsibility. If billed with a medical code, it will be denied as non-covered.

Updated diagnosis codes for screening in pediatrics from Z00.120 to Z00.121. Diagnosis code Z00.129 remains the same

17) Effective 03/01/2020: 99382 and 99392 are covered 4 times (aggregate) in members age 2 through 4 years.

18) Effective 1/1/2020: Added codes (G0447 and G0473) to the verbiage for obesity counselling being part of visits and not separately reimbursable when billed with the following codes: 99383 – 99387 or 99393 – 99397.

19) Effective 1/1/2021: Colorectal cancer screening is covered under the preventive benefit starting at age 45.

G0389 deleted as of 01/01/2017 and replaced by 76706.

20) Effective 10/01/2021: Dyslipidemia (cholesterol) screening recommended once between age 9-11, and at 17 and 21 year visits.

21) Effective 01/01/2022: Updated per recommendations of US Preventive Services Task Force, that clinicians screen all asymptomatic pregnant people at or after 24 weeks of pregnancy.

22) Effective 09/01/2023: Updated to align with USPSTF recommendations A and B.

Application to Products

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.