Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

High-Tech Imaging: High-Tech Imaging services are administered by National Imaging Associates, Inc. (NIA). For coverage information and authorizations, click here.

Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

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.

Alcohol Use Screening

Screen adults age 18 or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling intervention to reduce alcohol misuse. Bright Futures Periodicity Schedule recommends alcohol use assessment begin at age 11.

99408 covered annually as preventive benefit for members at least 18 years old. If billed at a shorter interval, it will be denied as non-covered, exceeding benefit limit; member responsibility. Alcohol use assessment in children is considered part of wellness exams, and is not separately reimbursed.

Behavioral Counseling to Promote Healthful Diet

Offer or refer overweight or obese adults with additional cardiovascular disease (CVD) risk factors intensive behavioral counseling and physical activity to promote a healthy diet and prevent CVD.

97802, 97803, G0270, S9470 covered up to four units annually as preventive for members with diagnosis of E66.3 or Z68.25-Z68.45 AND diagnosis of R73.01, E88.81, E78.0-E78.5, I10, I15.0-I15.9, F17.200-F17.299, Z72.0, Z82.49, Z87.891, or E08.00-E13.9. If billed as preventive at a shorter interval, it will be denied as non-covered, exceeding benefit limit; member responsibility. For billing with other diagnosis codes, see BI 342.

BRCA Risk Assessment and Genetic Counseling

Primary care providers should screen women with family history of breast, ovarian, tubal, or peritoneal cancer to identify an increased risk for potentially harmful mutations in breast cancer susceptibility genes BRCA1 or BRCA2. Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA 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.    

Cardiovascular Disease Prevention

Adults without a history of cardiovascular disease (CVD) (i.e., symptomatic coronary artery disease or thrombotic stroke) should use a low- to moderate-dose statin for the prevention of CVD events when all of the following criteria are met:

For adults who meet the criteria described to the left, Lovastatin 20-40 mg daily or Simvastatin 10-40 mg daily will be covered under the preventive benefit without copay or cost share (see BI448 – Preventive Care Medications).

• They are ages 40 to 75 years
• They have one or more CVD risk

factors (i.e., dyslipidemia, diabetes, hypertension, or smoking)  

•They have a calculated 10-year risk of a cardiovascular event of 10% or greater (use http://www.cvriskcalculator.com/ )
• Identification of dyslipidemia (LDL≥130 or HDL<40) and calculation of 10-year CVD event risk requires universal lipid screening in adults ages 40 to 75 years (see Cholesterol Screening)

Cervical Cancer Screening

Screen women ages 21 to 65 years with cytology (Pap smear) every 3 years. For women ages 30 or greater who want to lengthen the screening interval, screen with cytology and human papillomavirus (HPV) testing every 5 years.

•  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 Infection Screening

Screen sexually active women age 24 and younger and older women who are at increased risk for infection.

·  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.

Cholesterol Screening

Screen men ages 20 to 34 or women ages 20-39 years for lipid disorders if they are at increased risk for coronary heart disease. Strongly recommended to screen all men 35-75 and all women age 40-75 for lipid disorders.

·  80061, 82465, 83718, 83719, 83721, 84478 covered annually as preventive if they meet one of the conditions below; otherwise, covered under medical benefit. 

·  Men ages 35-75 or women ages 40-75 with diagnosis of Z00.00, Z00.01, or Z13.220.

·  Men ages 20 through 34 annually with diagnosis of Z00.00, Z00.01, Z13.220 AND any of the following diagnoses:  Z72.0, Z82.49, Z87.891, E66.0-E66.9, Z68.41-Z68.45, I10-I15.9, F17.210-F17.219, I25.10-I25.9, I70.0-I70.92, and E08.01-E13.9.                                                                  

·  Women ages 20 through 39 annually with diagnosis of Z00.00, Z00.01, Z13.220 AND any of the following diagnoses:  Z72.0, Z82.49, Z87.891, E66.0-E66.9, Z68.41-Z68.45, I10-I15.9, F17.210-F17.219, I25.10-I25.9, I70.0-I70.92, and E08.01-E13.9.
                                                                                      ·                                                                                ·                                                                                     

Colorectal Cancer Screening

Screen starting at age 45 until age 75.

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.

 

Counseling to Prevent Skin Cancer

Counsel children, adolescents, and young adults’ ages 10 to 24 years who have fair skin about minimizing exposure to ultraviolet radiation.

Included in wellness visits or focused evaluation and management visits; not separately reimbursable.

Counseling to Prevent STD`s

Intensive behavioral counseling for all sexually active adolescents and adults who are at increased risk for sexually transmitted infections.

G0445 covered twice a year as preventive; if billed at a shorter interval, will be denied as non-covered, exceeding benefit limit; member is responsible.

Diabetes

Screen for abnormal blood glucose as part of cardiovascular risk assessment in overweight or obese adult’s age 40 to 70. Clinicians should offer or refer patients with abnormal blood glucose intensive behavioral counseling to promote a healthy diet and physical activity.

One of CPT codes 82947, 82948, 82950, or 83036 is covered as preventive if billed with the following diagnosis codes:                                                                                     
• Z00.00, Z00.01, or Z13.1, AND E66.01-E66.9; OR

·  Z00.00, Z00.01 or Z11.59; otherwise, covered under medical benefit.

Diabetic Eye Screening

American Diabetic Association recommendations: Initial eye exam for type 1 diabetics should be within 5 years of diagnosis. Type 2 diabetics should have initial eye exam at the time of diagnosis. If there is no evidence of retinopathy for one or more annual eye exam and glycemia is well controlled, then exams every 1–2 years may be considered.

Diabetic eye exam are covered once every year under preventive benefit for diabetics without any known diabetic eye disease.

CPT 92002-92014, 92314, 92250, 99203-99205, 99213-99215, 2022F-2026F are covered only when billed by ophthalmologist or optometrist (92227 only may also be billed by primary care providers).

 

These CPT codes will be covered under preventive benefit, when billed with diagnosis codes: E10.10-E10.29, E10.40-E11.01, E11.21-E11.29, E11.40-E13.29, O24.011-O24.33, and O24.811-O24.83.

 

CPT 92002-92014, 92314, 92250, 99203-99205, 99213-99215, 2022F-2026F, will be covered under medical benefit when billed with diagnosis codes E10.311- E10.39 (Type 1 DM with ophthalmic complications) and E11.311- E11.39 (Type 2 DM with ophthalmic complications).

Fluoride Application in Primary Care

Primary care practices: apply fluoride varnish to the primary teeth of all children starting at the age of primary tooth eruption. Primary care clinicians: prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is fluoride deficient.

99188 covered as preventive up to three times per 12 months for members under the age of 7 years; otherwise will be denied as non-covered service; member responsibility.

Gonorrhea Screening

Screen sexually active women age 24 years and younger and older women who are at increased risk for infection.

87590, 87591, and 87850 covered as preventive with diagnosis code of Z00.00, Z00.01, Z11.3, Z11.8 or Z11.9; otherwise, covered under medical benefit.

Hepatitis B Screening

Screen for hepatitis B virus infection in persons at high 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 C Screening

Screen for hepatitis C virus (HCV) infection in persons at high risk for infection. Offer one-time screening for HCV infection to adults born between 1941 and 2002.

G0472 covered over age 18-79 as preventive once per lifetime. 86803 and 86804 covered under medical benefit.

High Blood Pressure Screening

Screen adults aged 18 or older. Obtain measurements outside clinical setting for diagnostic confirmation before starting treatment.

Part of wellness and focused evaluation visits; not separately reimbursable.

HIV (AIDS) Screening

Screen for HIV infection in adolescents and adults ages 15 to 65 years and younger adolescents and older adults who are at increased risk.

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.

Mammography

Screen women age 40 years and older, with or without clinical breast examination, every 1 to 2 years.

77067 covered as preventive annually for women at least 40 years old. If billed at a shorter interval, it will be denied as non-covered, exceeding benefit limit; member is responsible.  Breast ultrasounds (76641 and 76642) are not used for routine breast cancer screening.  However, breast ultrasound is covered under preventive benefit when it is performed as an adjunct to screening mammography for dense breast tissue (Diagnosis code: R92.2) or masses found on mammogram.

Newborn Screening

Prophylactic ocular topical medication for the prevention of gonococcal ophthalmic neonatorum; screen for hearing loss, sickle cell disease, congenital hypothyroidism, phenylketonuria.

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.

Obesity Screening

Screen children age 6 years and older for obesity and offer or refer to comprehensive, intensive behavioral interventions to promote healthy weight. Screen all adults for obesity. Clinicians should offer or refer patients with a body mass index of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions.

Obesity counseling (G0447 and G0473) are considered part of preventive medicine and focused evaluation visits; and are not separately reimbursable when billed with the following codes: 99383 – 99387 or 99393 – 99397.

 

Osteoporosis

Screen women age 65 and older and women 55 – 64 with increased fracture risk due to specific medical conditions (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.

Pregnancy

 

 

Iron Deficiency Anemia

Screening no longer recommended for pregnant women (Sept 2015).

 

Bacteriuria

Screen for asymptomatic bacteriuria with urine culture in pregnant women at 12 to 16 weeks` gestation or at first prenatal visit, if later.

81007 or 87081 covered as preventive for any of the following diagnosis codes: O09.00- O41.93X9, O43.011-O48.1, or Z34.0-Z36; otherwise, covered under medical benefit.

Chlamydia

Screen pregnant women for chlamydia.

 87110, 87270, 87320, 87490, 87491, and 87810 are covered as preventive for women with diagnosis code of O09.00-O41.93X9, O43.011-O48.1 or Z34.0-Z36; otherwise covered under the medical benefit.

Gonorrhea

Screen pregnant women for gonorrhea.

87590, 87591, and 87850 covered as preventive with diagnosis code of are covered as preventive for women with diagnosis code of O09.00-O41.93X9, O43.011-O48.1 or Z34.0-Z36; otherwise covered under the medical benefit.

Hepatitis B Screening

Screen pregnant women at first prenatal visit.

87340 covered as preventive for any of the following diagnosis codes: O09.00-O41.93X9, O43.011-O48.1, or Z34.0-Z36; otherwise covered under the medical benefit.

HIV (AIDS) Screening

Clinicians should screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown.

86701-86703 are covered as preventive for any of the following diagnosis codes: O09.00- O41.93X9, O43.011-O48.1, or Z34.0-Z36; otherwise covered under the medical benefit.

Rh Incompatibility

Screening strongly recommended for Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy care.  Repeat Rh (D) antibody testing for all un-sensitized Rh (D)-negative women at 24 to 28 weeks` gestation, unless the biological father is known to be Rh (D)-negative.

86901 covered as preventive for any of the following diagnosis codes: O09.00-O41.93X9, O43.011-O48.1, or Z34.0-Z36; otherwise covered under medical benefit.

Syphilis

Screen all pregnant women.

86592 and 86593 are covered as preventive for any of the following diagnosis codes: O09.00-O41.93X9, O43.011-O48.1, or Z34.0-Z36; otherwise, covered under the medical benefit.

Gestational Diabetes

Screen asymptomatic pregnant women at or after 24 weeks of gestation.

82947, 82948, 82950, 82951, 82952 covered as preventive for any of the following diagnosis codes:  O09.00-O41.93X9, O43.011-O48.1, or Z34.0-Z36; otherwise, covered under medical benefit.

 

Dx Z36.89 Encounter for other specified antenatal screening

 

The following CPT codes are used for GDM screening:

82947 Glucose; quantitative, blood (except reagent strip)

This test is often called a fasting blood sugar (FBS).

82951 Glucose; tolerance test (GTT), three specimens (includes glucose)

82952 Glucose; tolerance test, each additional beyond three specimens (List separately in addition to code for primary procedure)

82962 Glucose; blood by glucose monitoring device(s) cleared by the FDA specifically for home use

Promotion of Breastfeeding

Intervention recommended during pregnancy and after birth to promote and support breastfeeding.

Included in primary care and OB/GYN office visits. When provided by a trained non-physician provider, S9443 is covered as preventive up to twice per 12 months. If billed at a shorter interval, it will be denied as non-covered, exceeding benefit limit; member is responsible.

Tobacco Smoking Cessation

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.

See Medical Coverage Policy BI183.

Prevention of Falls in Elders

Recommend exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling adults age 65 years and older who are at increased risk for falls.

Included in wellness or focused evaluation and management visits; not separately reimbursable.

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.

Rubella Screening

No active recommendation.

86762 covered under medical benefit.

Screening for Depression

Screen for major depressive disorder (MDD) in adolescents aged 12 to 18 years. Screen for depression in the general adult population, including pregnant and postpartum women. Implement with adequate systems to ensure accurate diagnosis, effective treatment, and appropriate follow-up.

G0444 or 96127 covered as preventive annually in members at least 12 years of age. If billed at a shorter interval, it will be denied as non-covered, exceeding benefit limit; member is responsible.

Screening for Intimate Partner Violence

Clinicians should screen women of childbearing age for intimate partner violence such as domestic violence, and provide or refer women who screen positive to intervention services. Applies to women who do not have signs or symptoms of abuse.

Included in wellness visits or focused evaluation and management visits; not separately reimbursable.

Screening for Lung Cancer with Low Dose CT

Annual screening with low-dose computed tomography in adults’ ages 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Discontinue after 15 years of not smoking, or if a health problem develops that substantially limits life expectancy or the ability or willingness to have curative lung surgery.

S8032 requires pre-authorization; see BI450.

Syphilis

Screen people who are at increased risk for infection.

86592 and 86593 covered as preventive for any of the following diagnosis codes: Z00.00, Z00.01, Z11.2, Z11.3 or Z11.9; otherwise covered under medical benefit.

Tobacco Smoking Cessation

Clinicians should ask all adults about tobacco use, advise them to stop using it, and provide behavioral interventions and U.S. Food and Drug Administration (FDA)–approved pharmacotherapy for cessation to adults who use tobacco.

See BI183.

Tobacco Use Prevention

Clinicians should provide interventions, including education or brief counseling, to prevent initiation of tobacco use in school-aged children and adolescents.

99406 covered as preventive annually for members below the age of 18. For any other billing, see BI183.

Vision Screening in Children

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.

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

 

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.

HIV Screening

See USPSTF recommendations above.

 

Vision Screening

See USPSTF recommendations above.

 

Depression Screening

See "Screening for Depression" above.

 

Cervical Dysplasia Screening

See "Cervical Cancer Screening" above.

 

Fluoride Varnish

See "Fluoride Application in Primary Care" 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

EOC:

 

Addressed in the Preventive Health Services section.

 

 

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.


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.
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