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Printer Friendly Version Preventive Health Services

Preventive Health Services

DESCRIPTION

This policy outlines the criteria for coverage of preventive health services under the Federal
Healthcare Reform, Patient Protection and Affordable Care Act (PPACA). The goals of preventive
health services are to avoid the development of disease and to diagnose disease in its early
stages before it results in significant morbidity.

Blue Cross & Blue Shield of Mississippi currently covers annual health screenings and immunizations
based on age and gender under our Healthy You! wellness benefit. Healthy You! Wellness Procedures
are addressed in a separate policy. Under PPACA, Blue Cross & Blue Shield of Mississippi will
provide coverage for additional preventive health services based on –

Services recommended by the US Preventive Services Task Force
Immunizations recommended by the Advisory Committee on Immunization Practices of the CDC
Preventive care and screenings for infants, children and adolescents supported by the Health Resources and Services Administration
Preventive care and screenings for women supported by the Health Resources and Services Administration

The “Policy” section below provides the specific coverage guidelines for each preventive health service that must be covered under PPACA without cost-sharing when delivered by a Network Provider. It also outlines the preventive health services covered as part of the Healthy You! wellness benefit without cost-sharing when provided by a Network Provider.

A. Pregnant Women
The following preventive services are covered for pregnant women.
*An asterisk denotes preventive services with associated risk factors that must be documented to support medical necessity. The risk factors are outlined in the Policy section.
1. Screening for anemia during pregnancy
2. Breast feeding support
3. Breast feeding equipment
4. Chlamydia Screening*
5. Syphilis Screening*
6. Gonorrhea Screening*
7. Hepatitis B Screening*
8. HIV Screening*
9. Rh (D) Incompatibility
10. Bacteriuria Screening
11. Gestational Diabetes Screening
12. Folic Acid Supplementation

B. Newborns
The following preventive services are covered for newborns.
1. Hemoglobinopathy Screening (Sickle Cell Disease)
2. Congenital Hypothyroidism Screening
3. Phenylketonuria (PKU) Screening
4. Newborn Hearing Screening
5. Prophylactic Medication to Prevent Gonorrhea in Newborns

C. Individuals Ages 0 – 21 Years
The following preventive services are covered for individuals age 0 -21 years.
*An asterisk denotes preventive services with associated risk factors that must be documented to support medical necessity. The risk factors are outlined in the Policy section.
1. Lead Screening*
2. TB Testing*
3. Vision Screening
4. Hearing Screening
5. Developmental Screening
6. Autism Screening
7. Depression Screening
8. Chlamydia Screening*
9. Syphilis Screening*
10. Gonorrhea Screening*
11. HIV Screening*
12. Iron Supplementation*
13. Fluoride Supplementation*
14. Immunizations

D. Women 21 Years and Older
The following preventive services are covered for women 21 years and older.
*An asterisk denotes preventive services with associated risk factors that must be documented to support medical necessity. The risk factors are outlined in the Policy section.
1. Chlamydia Screening*
2. Syphilis Screening*
3. Gonorrhea Screening*
4. HIV Screening and Counseling
5. Human papillomavirus (HPV) DNA Testing
6. BRCA Counseling
7. Preventive Aspirin Therapy*
8. Folic Acid Supplementation
9. Depression Screening

E. High Risk Population 21 Years and Older
The following preventive services are covered for high risk population 21 years and older.
*An asterisk denotes preventive services with associated risk factors that must be documented to support medical necessity. The risk factors are outlined in the Policy section.
1. Screening for Abdominal Aortic Aneurysm*
2. Syphilis Screening*
3. HIV Screening*
4. Preventive Aspirin Therapy*
5. Depression Screening
6. Immunization

F. Other Preventive Health Services
1. Tobacco cessation counseling - Pregnancy
2. Tobacco cessation counseling - Adults 21+
3. Alcohol misuse counseling - Pregnancy and Adults 21+
4. Obesity Counseling - Children 0-18
5. Obesity Counseling - Adults 19+
6. Sexually Transmitted Infection Counseling
7. Healthy Diet Counseling
8. Screening and counseling for domestic violence

G. Contraception Coverage and Counseling

1. Patient education and counseling of contraceptive methods
2. Prescription Drug Contraception
3. Other Food and Drug Administration (FDA) approved contraceptive methods
4. Intrauterine Devices (IUDs)
5. Inpatient tubal ligation with c- section delivery
6. Inpatient tubal ligation post vaginal delivery
7. Outpatient tubal ligation

POLICY

Services billed outside of the preventive health services guidelines will be denied as a not medically necessary preventive procedure.

A.	Coverage of Preventive Health Services for Pregnant Women
Service	Age/Sex	Interval/Limits	Policy	Risk Factors	Procedure Code(s)	Diagnosis Code(s)
1. Screening for anemia during pregnancy USPSTF Recommendation: Routine screening for iron deficiency anemia in asymptomatic pregnant women	Pregnant women	1 screening per pregnancy	Screening for anemia during pregnancy will be covered once per pregnancy.	None	80055 85025 85027 85013 85014 85018	V22.0 V22.1 V22.2 V23.0 V23.2 V23.49 V23.81 V23.82 V23.85 V23.89 V23.9 V28.0 V28.89 V28.9 V72.42 V72.69
2. Lactation/ breastfeeding support and counseling USPSTF Recommendation: Interventions to promote & support breastfeeding	Pregnant women and new mothers		Covered under Healthy You! wellness benefit. Lactation/breast feeding support and interventions will be covered when provided by the inpatient hospital nursing staff and at the infant’s first Healthy You! visit at 2 weeks of age by the Healthy You! primary care provider. Note: Breast feeding classes are offered at no-cost at many hospitals.	None	N/A	N/A
3. Breastfeeding equipment USPSTF Recommendation: Interventions to promote & support breastfeeding	Breastfeeding mothers	1 per pregnancy	One manual breast pump will be covered per pregnancy.	None	E0602	V24.1
4. Chlamydia Screening USPSTF Recommendation: Recommends screening for chlamydial infection for all pregnant women aged 24 and younger and for older pregnant women who are at increased risk.	All pregnant women 24 and younger and older pregnant women at increased risk	1 screening at the 1st prenatal visit	Chlamydia screening will be covered once for pregnant women aged 24 and younger and for older pregnant women who are at increased risk.	All sexually active women 24 years of age or younger, including adolescents, are at increased risk for chlamydial infection. In addition to sexual activity and age, other risk factors for chlamydial infection include - a history of chlamydial or other sexually transmitted infection new or multiple sexual partners inconsistent condom use exchanging sex for money or drugs	87110 87270 87320 87490 87491 87492 87810	V20.81 V22.0 V22.1 V22.2 V23.81 V23.82 V23.89 V23.9 V28.0 V28.89 V28.9 V72.42
	All pregnant women with continued risk or new risk factor	2nd screening must be performed in the 3rd trimester	A second chlamydia screening may be conducted in the 3rd trimester for pregnant women with new or continued risk. Risk factors must be documented by the healthcare provider.	For pregnant women who remain at increased risk and for those who acquire a new risk factor, such as a new sexual partner, a screening should be conducted during the third trimester.	87110 87270 87320 87490 87491 87492 87810	V23.0 V23.2 V23.49 V23.81 V23.82 V23.85 V23.9
5. Syphilis Screening USPSTF Recommendation: Recommends that clinicians screen all pregnant women for syphilis infection.	All pregnant women	1 screening at the 1st prenatal visit	Syphilis screening will be covered for all pregnant women at the first prenatal visit.	None	86592 86593 80055	V22.0 V22.1 V22.2 V23.9 V28.0 V28.89 V28.9 V72.42
	High-risk pregnant women	2nd screening in the 3rd trimester AND 3rd screening at time of delivery included within the hospital DRG	For women in high-risk groups, repeat serologic testing for syphilis is recommended in the third trimester and at delivery. Risk factors must be documented by the healthcare provider.	Populations at increased risk for syphilis infection may include – commercial sex workers persons who exchange sex for drugs those in adult correctional facilities	86592 86593 80055	V23.0 V23.2 V23.49 V23.81 V23.82 V23.85 V23.89 V23.9
6. Gonorrhea Screening USPSTF Recommendation: Recommends that clinicians screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection (that is, if they are young or have other individual or population risk factors).	Sexually active women at increased risk	1 screening at the 1st prenatal visit 2nd screening in the 3rd trimester	Gonorrhea screening will be covered for all pregnant women at increased risk for infection. The screening may be conducted twice during pregnancy according to documented risk factors by the healthcare provider.	Risk factors for gonorrhea include – a history of previous gonorrhea infection other sexually transmitted infections new or multiple sexual partners inconsistent condom use sex work drug use	87590 87591 87592 87850	V22.0 V22.1 V22.2 V23.0 V23.2 V23.49 V23.81 V23.82 V23.85 V23.89 V23.9 V28.9 V72.42 V73.99
7. Hepatitis B Screening USPSTF Recommendation: Recommends screening for hepatitis B virus (HBV) infection in pregnant women at their first prenatal visit.	Pregnant women	1 screening at the 1st prenatal visit	Hepatitis B screening will be covered for all pregnant women at the first prenatal visit.	None	87340 80055	V22.0 V22.1 V22.2 V23.9 V28.0 V28.89 V28.9 V72.42
	High-risk pregnant women	Repeat screening at delivery Re-screen women with unknown status or new or continuing risk factors at admission to hospital/birth center	A second Hepatitis B screening may be conducted at admission to hospital/birth center according to documented risk factors by the healthcare provider. This is included within the hospital DRG.	Risk factors for a second hepatitis B screening include – Have unprotected sex with more than one partner Have unprotected sex with someone who's infected with HBV Have a sexually transmitted disease such as gonorrhea or chlamydia Share needles during intravenous (IV) drug use Share a household with someone who has a chronic HBV infection Have a job that exposes you to human blood Receive hemodialysis for end-stage kidney (renal) disease Travel to regions with high infection rates of HBV, such as Africa, Central and Southeast Asia, and Eastern Europe
8. HIV Screening USPSTF Recommendation: Recommends that clinicians screen for human immunodeficiency virus (HIV) all adolescents and adults at increased risk for HIV infection.	Pregnant women	1 screening at the 1st prenatal visit	HIV screening will be covered for all pregnant women at increased risk. The screening is to be conducted once during pregnancy according to documented risk factors by the healthcare provider.	Risk factors for HIV include - Unprotected sex with multiple partners Injection drug user Sex worker History of sex partners who are HIV+, bisexual, or injection drug users History of STDs Transfusion between 1978-85 Patient requests an HIV test	86701 86702 86703	V22.0 V22.1 V22.2 V23.0 V23.2 V23.49 V23.81 V23.82 V28.89 V28.9 V72.42 V23.85 V23.89 V23.9 V28.0
9. Rh (D) Incompatibility USPSTF Recommendation: Recommends Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care.	Pregnant women	1 antibody testing at the 1st prenatal visit	Rh Incompatibility screening will be covered for all pregnant women.	None	86901 86850 80055	V22.0 V22.1 V22.2 V23.2 V23.81 V23.9 V28.89 V28.9 V72.42
USPSTF Recommendation: The USPSTF recommends repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at 24-28 weeks' gestation, unless the biological father is known to be Rh (D)-negative.	Unsensitized Rh (D)-negative pregnant women	Repeat antibody testing at 24-28 weeks’ gestation	Repeated Rh (D) antibody testing will be covered for all unsensitized Rh (D)-negative women at 24-28 weeks' gestation, unless the biological father is known to be Rh (D)-negative.	Unsensitized Rh (D)-negative women	86901 86850 80055	V22.0 V22.1 V22.2 V23.2 V23.81 V23.9 V28.89 V28.9 V72.42
10. Bacteriuria Screening USPSTF Recommendation: Recommends screening for asymptomatic bacteriuria with urine culture for pregnant women at 12 to 16 weeks' gestation or at the first prenatal visit, if later.	Pregnant women	1 screening per pregnancy	Bacteriuria screening will be covered for all pregnant women. The screening is to be conducted once during pregnancy, preferably at the first prenatal visit or 12-16 weeks gestation.	None	87077 87084 87086 87088	V22.0 V22.1 V22.2 V23.0 V23.2 V23.49 V23.81 V23.82 V23.85 V23.89 V23.9 V28.0 V28.4 V28.8 V28.81 V28.89 V28.9 V72.42
11. Gestational Diabetes Mellitus (GDM) Screening USPSTF Recommendation: Gestational diabetes mellitus screening at the first prenatal visit and between 24-28 weeks	Pregnant women identified to be at high risk for developing gestational diabetes mellitus	1 screening at the 1st prenatal visit	Gestational diabetes screening will be covered at the first prenatal visit for pregnant women identified to be at high risk for developing diabetes mellitus	Risk factors for developing gestational diabetes mellitus include women who – Are obese Are older than 25 years Have a family history of diabetes Have a history of gestational diabetes mellitus Are of certain ethnic groups (Hispanic, American Indian, Asian, or African-American)	82947 82948 82950 82962	V22.0 V22.1 V22.2 V23.0 V23.1 V23.2 V23.3 V23.41 V23.42 V23.49 V23.5 V23.7 V23.81 V23.82 V23.83 V23.84 V23.85 V23.86 V23.87 V23.89 V23.9
	All pregnant women	1 screening between 24-28 weeks’ gestation	Gestational diabetes screening will be covered for all pregnant women between 24-28 weeks of pregnancy.	None	82947 82948 82950 82962	V22.0 V22.1 V22.2 V23.0 V23.1 V23.2 V23.3 V23.41 V23.42 V23.49 V23.5 V23.7 V23.81 V23.82 V23.83 V23.84 V23.85 V23.86 V23.87 V23.89 V23.9
12. Folic Acid Supplementation USPSTF Recommendation: Recommends that all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid.	Women planning or capable of pregnancy	1 tablet per day by prescription	Folic acid supplementation may be covered at least 1 month before conception and may continue up to 3 months of pregnancy. Prescription is required.	Prescriptions will be required at the pharmacy to obtain folic acid supplements.	N/A	N/A

B.	Coverage of Preventive Health Services for Newborns
Service	Age/Sex	Interval/Limits	Policy	Risk Factors	Procedure Code(s)	Diagnosis Code(s)
1. Hemoglobinopathy Screening (Sickle Cell Disease) USPSTF Recommendation: Recommends screening for sickle cell disease in newborns.	All newborns	1 screening	Hemoglobinopathy screening will be covered for all newborns. This is included within the hospital DRG.	None	N/A	N/A
2. Congenital Hypothyroidism Screening USPSTF Recommendation: Recommends screening for congenital hypothyroidism (CH) in newborns	All newborns	1 screening	Congenital hypothyroidism screening will be covered for all newborns. This is included within the hospital DRG.	None	N/A	N/A
3. PKU Screening USPSTF Recommendation: Recommends screening for phenylketonuria (PKU) in newborns.	All newborns	1 screening	PKU screening will be covered for all newborns. This is included within the hospital DRG.	None	N/A	N/A
4. Newborn Hearing Screening USPSTF Recommendation: Recommends screening for hearing loss in all newborn infants.	All newborns	1 screening	Newborn hearing screening will be covered for all newborns. This is included within the hospital DRG.	None	N/A	N/A
5. Prophylactic Medication to Prevent Gonorrhea in Newborns USPSTF Recommendation: Recommends screening prophylactic ocular topical medication for all newborns against gonococcal ophthalmia neonatorum.	All newborns	1 administration	Prophylactic medication to prevent Gonorrhea will be covered for all newborns. This is included within the hospital DRG.	None	N/A	N/A

C.	Coverage of Preventive Health Services for Individuals Ages 0-21 Years
Service	Age/Sex	Intervals/Limits	Policy	Risk Factors	Procedure Code(s)	Diagnosis Code(s)
1. Lead Screening AAP Recommendation: Lead exposure assessment from ages 6 months-7 yrs. If the assessment indicates lead exposure, screening should be completed.	6 months – 7 years	0-9 screenings depending upon assessment	Lead screening will be covered for children at risk of lead exposure as documented by the healthcare provider.	Risk factors for increased blood lead levels include – minority race/ethnicity urban residence low income low educational attainment older (pre-1950) housing recent or ongoing home renovation or remodeling pica exposure use of ethnic remedies certain cosmetics, and exposure to lead-glazed pottery occupational and paraoccupational exposures recent immigration	83655	V15.86 V82.5
2. TB Testing AAP Recommendation: TB exposure assessment from ages 1 month-21 yrs. If the assessment indicates TB exposure, screening should be completed.	1 month -21 years	0-24 screenings depending upon assessment	Covered as part of the Healthy You! preventive wellness visit	N/A	N/A	N/A
3. Vision Screening AAP Recommendation: Vision screening to include visual acuity screening and opthalmoscopy for ocular assessment.	3-18 years	1 screening per year for a total of 9 screenings	Covered as part of the Healthy You! preventive wellness visit	N/A	N/A	N/A
4. Hearing Screening AAP Recommendation: Hearing screening to include physical, subjective, and objective screening methods.	3-10 years	1 screening per year for a total of 6 screenings	Covered as part of the Healthy You! preventive wellness visit	N/A	N/A	N/A
5. Developmental Screening AAP Recommendation: Developmental screening to include milestones of motor, cognitive, and behavioral skills.	9 months – 2.5 years	3 screenings during the ages of 9 months-2.5 years	Covered as part of the Healthy You! preventive wellness visit Developmental screening will be covered at 9 months, 18 months, and 2 years.	N/A	N/A	N/A
6. Autism Screening AAP Recommendation: Autism screening to include subjective & objective assessment for autistic characteristics.	18 months -2 years	2 screenings during the ages of 18 months-2 years.	Covered as part of the Healthy You! preventive wellness visit Autism screening will be covered at 18 months and 2 years.	N/A	N/A	N/A
7. Depression Screening AAP Recommendation: Depression screening of adolescents (12-18 years of age) for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up. USPSTF Recommendation: Recommends screening adults age 18 and older for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up.	12-20 years	1 per calendar year	Covered as part of the Healthy You! preventive wellness visit	N/A	N/A	N/A
8. Chlamydia Screening USPSTF Recommendation: Recommends screening for chlamydial infection for all sexually active non-pregnant young women aged 24 and younger and for older non-pregnant women who are at increased risk.	All sexually active non-pregnant young women aged 24 and younger	1 screening per calendar year	Chlamydia screening will be covered for all sexually active non-pregnant women ages 24 and younger.	All sexually active women 24 years of age or younger, including adolescents, are at increased risk for chlamydial infection. In addition to sexual activity and age, other risk factors for chlamydial infection include – a history of chlamydial or other sexually transmitted infection new or multiple sexual partners inconsistent condom use exchanging sex for money or drugs	87110 87270 87320 87490 87491 87492 87810	V01.6 V01.79 V01.89 V01.9 V15.85 V15.89 V65.45 V69.2 V72.31 V72.41 V72.62 V72.69 V73.88 V73.89 V73.98 V73.99 V74.5 V75.9
9. Syphilis Screening USPSTF Recommendation: Recommends that clinicians screen persons at increased risk for syphilis infection.	Men and women at increased risk	1 screening per calendar year	Syphilis screening will be covered for adolescents & adults at increased risk for syphilis infection. The screening may be conducted once per calendar year with documented risk factors by the healthcare provider.	Populations at increased risk for syphilis infection (as determined by incident rates) include - men who have sex with men and engage in high-risk sexual behavior commercial sex workers persons who exchange sex for drugs those in adult correctional facilities	86592 86593	V01.6 V01.79 V01.89 V01.9 V15.85 V15.89 V65.45 V69.2 V72.31 V72.62 V72.69 V73.89 V73.99 V74.5 V75.9 V82.89
10. Gonorrhea Screening USPSTF Recommendation: Recommends that clinicians screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection (that is, if they are young or have other individual or population risk factors	Sexually active women at increased risk	1 screening per calendar year	Gonorrhea screening will be covered for females at increased risk for gonorrhea infection. The screening may be conducted once per calendar year with documented risk factors by the healthcare provider.	Risk factors for gonorrhea include – a history of previous gonorrhea infection other sexually transmitted infections new or multiple sexual partners inconsistent condom use sex work drug use	87590 87591 87592 87850	V01.6 V01.79 V01.89 V01.9 V15.85 V15.89 V65.45 V69.2 V72.62 V73.89 V72.31 V72.41 V72.69 V73.99 V74.5 V75.9
11. HIV Screening USPSTF Recommendation: Recommends that clinicians screen for human immunodeficiency virus (HIV) all adolescents and adults at increased risk for HIV infection.	All sexually active women Adolescents and men at increased risk for HIV infection	1 screening per calendar year	HIV screening will be covered for all sexually active women. HIV screening will be covered for men & women at increased risk HIV infection. The screening may be conducted once per calendar year with documented risk factors by the healthcare provider.	Risk factors for HIV include - Men having sex with men (MSM) Unprotected sex with multiple partners Injection drug user Sex worker History of sex partners who are HIV+, bisexual, or injection drug users History of STDs Transfusion between 1978-85 Patient requests an HIV test	86701 86702 86703	V70.0 (for sexually active women) V72.31 (for sexually active women) V01.6 V01.79 V01.89 V01.9 V15.85 V15.89 V65.45 V69.2 V73.89 V73.99 V74.5
12. Iron Supplementation The USPSTF recommends routine iron supplementation for asymptomatic children aged 6 to 12 months who are at increased risk for iron deficiency anemia	6 – 12 months	N/A	Prescription strength iron supplements will be covered for children 6-12 months that are at increased risk of iron deficiency anemia. Prescription is required.	Prescriptions will be required at the pharmacy to obtain iron supplements. The healthcare provider must document anemia risk in the medical record.	N/A	N/A
13. Fluoride Supplementation USPSTF Recommendation: Recommends that primary care clinicians prescribe oral fluoride supplementation at currently recommended doses to preschool children older than 6 months of age whose primary water source is deficient in fluoride	0 – 6 years	N/A	Prescription strength fluoride supplements will be covered for children 6 months and older that have a primary source of water that is deficient in fluoride. Prescription is required.	Prescriptions will be required at the pharmacy to obtain fluoride supplements. The healthcare provider must document in the medical record that the child’s primary source of water is deficient in fluoride.	N/A	N/A
14. Immunizations CDC Recommendation: Recommends that immunizations & codes be applied as with Healthy You!	N/A	N/A	Covered under Healthy You! preventive wellness benefits	N/A	N/A	N/A

D.	Coverage of Preventive Health Services for Women 21 Years and Older
Service	Age/Sex	Interval/Limits	Policy	Risk Factors	Procedure Code(s)	Diagnosis Code(s)
1. Chlamydia Screening USPSTF Recommendation: Recommends screening for chlamydial infection for all sexually active non-pregnant young women aged 24 and younger and for older non-pregnant women who are at increased risk.	Sexually active non-pregnant young women aged 24 and younger	1 screening per calendar year	Chlamydia screening will be covered for all sexually active non-pregnant women ages 24 and younger.	All sexually active women 24 years of age or younger, including adolescents, are at increased risk for chlamydial infection. In addition to sexual activity and age, other risk factors for chlamydial infection include - a history of chlamydial or other sexually transmitted infection new or multiple sexual partners inconsistent condom use exchanging sex for money or drugs	87110 87270 87320 87490 87491 87492 87810	V01.6 V01.79 V01.89 V01.9 V15.85 V15.89 V65.45 V69.2 V72.31 V72.41 V72.62 V72.69 V73.88 V73.89 V73.98 V73.99 V74.5 V75.9
	Women 25 and older who are at increased risk	1 screening per calendar	Chlamydia screening may be conducted once per calendar year for women ages 25 and older with documented risk factors by the healthcare provider.	In addition to sexual activity and age, other risk factors for chlamydial infection include - a history of chlamydial or other sexually transmitted infection new or multiple sexual partners inconsistent condom use exchanging sex for money or drugs	87110 87270 87320 87490 87491 87492 87810	V69.2
2. Syphilis Screening USPSTF Recommendation: Recommends that clinicians screen persons at increased risk for syphilis infection.	Men and women at increased risk	1 screening per calendar year	Syphilis screening will be covered for adolescents & adults at increased risk for syphilis infection. The screening may be conducted once per calendar year with documented risk factors by the healthcare provider.	Syphilis screening will be covered for adolescents & adults at increased risk for syphilis infection. Populations at increased risk for syphilis infection (as determined by incident rates) include - men who have sex with men and engage in high-risk sexual behavior commercial sex workers persons who exchange sex for drugs those in adult correctional facilities	86592 86593	V01.6 V01.79 V01.89 V01.9 V15.85 V15.89 V65.45 V69.2 V72.31 V72.62 V72.69 V73.89 V73.99 V74.5 V75.9 V82.89
3. Gonorrhea Screening USPSTF Recommendation: Recommends that clinicians screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection (that is, if they are young or have other individual or population risk factors	Sexually active women at increased risk	1 screening per calendar year	Gonorrhea screening will be covered for females at increased risk for gonorrhea infection. The screening may be conducted once per calendar year with documented risk factors by the healthcare provider.	Risk factors for gonorrhea include – a history of previous gonorrhea infection other sexually transmitted infections new or multiple sexual partners inconsistent condom use sex work drug use	87590 87591 87592 87850	V01.6 V01.79 V01.89 V01.9 V15.85 V15.89 V65.45 V69.2 V72.62 V73.89 V72.31 V72.41 V72.69 V73.99 V74.5 V75.9
4. HIV Screening and Counseling (as described in F.6 below) USPSTF Recommendation: Recommends that clinicians screen for human immunodeficiency virus (HIV) all adolescents and adults at increased risk for HIV infection.	All sexually active women	1 screening per calendar year	HIV screening will be covered for all sexually active women.	None	86701 86702 86703	V70.0 V72.31 V73.89
5. Human papillomavirus (HPV) DNA Testing	Women ages 30-65	1 test every 5 years	HPV DNA testing will be covered at an interval of every 5 years for women ages 30-65.	None	87620 87621 86722	V70.0 V72.31 V73.81 V76.2
6. BRCA Counseling and Evaluation USPSTF Recommendation: Recommends that women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes be referred for genetic counseling and evaluation for BRCA testing.	Women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes	1 genetic counseling and evaluation for BRCA testing per lifetime	Covered as part of the Healthy You! preventive wellness visit where warranted BRCA counseling and evaluation will be covered for women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes. Coverage guidelines for BRCA1 and BRCA2 genetic testing is outlined in the Genetic Testing for Hereditary Breast and/or Ovarian Cancer medical policy.	In identifying families with a high risk of mutation in the BRCA1 or BRCA 2 gene, both maternal and paternal family histories are important and each lineage must be considered separately. Any of the following scenarios indicates a high risk of BRCA1 or BRCA2 mutation. In assessing risk of a mutation for those affected with cancer, the overall family history (one lineage) including the affected person is considered. For non-Ashkenazi Jewish women, high-risk includes the following: Three or more first or second degree relatives with breast cancer regardless of age at diagnosis; or Two first-degree relatives with breast cancer, one of whom was diagnosed at age 50 years or younger; or Combination of both breast and ovarian or fallopian tube or primary peritoneal cancer among first- and second degree relatives; or First degree relative with bilateral breast cancer; or A combination of two or more first or second degree relatives with ovarian or fallopian tube or primary peritoneal cancer regardless of age at diagnosis; or A first or second degree relative with both breast and ovarian or fallopian tube or primary peritoneal cancer at any age; or A history of breast cancer in a male relative.		V16.3
7. Preventive Aspirin Therapy USPSTF Recommendation: Recommends the use of aspirin for women age 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage.	Women age 55 to 79 years	N/A	Covered as part of the Healthy You! preventive wellness visit where warranted	N/A	N/A	N/A
8. Folic Acid Supplementation USPSTF Recommendation: Recommends that all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid.	Women planning or capable of pregnancy	1 tablet per day by prescription	Folic acid supplementation may be covered at least 1 month before conception and may continue up to 3 months of pregnancy. Prescription is required.	Prescriptions will be required at the pharmacy to obtain folic acid supplements.	N/A	N/A
9. Depression Screening USPSTF Recommendation: Recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up.	N/A	N/A	Covered as part of the Healthy You! preventive wellness visit	N/A	N/A	N/A

E.	Coverage of Preventive Health Services for High Risk Population Ages 21 Years and Older
Service	Age/Sex	Intervals/Limits	Policy	Risk Factors	Procedure Code(s)	Diagnosis Code(s)
1. Screening for Abdominal Aortic Aneurysm USPSTF Recommendation: Recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65 to 75 who have ever smoked.	Men aged 65 to 75 who have ever smoked	1 screening per lifetime	Abdominal Aortic Aneurysm screening will be covered for men at increased risk, defined as 65 and greater with a history of smoking	Men who have smoked at least 100 cigarettes in their lifetime.	G0389 76705 76770 76775 76700	V15.82 V81.2
2. Syphilis Screening USPSTF Recommendation: Recommends that clinicians screen persons at increased risk for syphilis infection.	Men and women at increased risk	1 screening per calendar year	Syphilis screening will be covered for adolescents & adults at increased risk for syphilis infection. The screening may be conducted once per calendar year with documented risk factors by the healthcare provider.	Populations at increased risk for syphilis infection (as determined by incident rates) include – men who have sex with men and engage in high-risk sexual behavior commercial sex workers persons who exchange sex for drugs those in adult correctional facilities	86592 86593	V01.6 V01.79 V01.89 V01.9 V15.85 V15.89 V65.45 V69.2 V72.31 V72.62 V72.69 V73.89 V73.99 V74.5 V75.9 V82.89
3. HIV Screening USPSTF Recommendation: Recommends that clinicians screen for human immunodeficiency virus (HIV) all adolescents and adults at increased risk for HIV infection.	All sexually active women Men at increased risk for HIV infection	1 screening per calendar year	HIV screening will be covered for all sexually active women. HIV screening will be covered for men at increased risk HIV infection. The screening may be conducted once per calendar year with documented risk factors by the healthcare provider.	Risk factors for HIV include - Men having sex with men (MSM) Unprotected sex with multiple partners Injection drug user Sex worker History of sex partners who are HIV+, bisexual, or injection drug users History of STDs Transfusion between 1978-85 Patient requests an HIV test	86701 86702 86703	V70.0 (for sexually active women) V72.31 (for sexually active women) V01.6 V01.79 V01.89 V01.9 V15.89 V15.85 V65.44 V65.45 V69.2 V73.89 V73.99 V74.5 V75.9
4. Preventive Aspirin Therapy USPSTF Recommendation: Recommends the use of aspirin for men age 45 to 79 years when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage.	Men age 45 to 79 years	N/A	Covered as part of the Healthy You! preventive wellness visit where warranted	N/A	N/A	N/A
5. Depression Screening USPSTF Recommendation: Recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up.	N/A	N/A	Covered as part of the Healthy You! preventive wellness visit	N/A	N/A	N/A
6. Immunizations CDC Recommendation: Recommends that immunizations & codes be applied as with Healthy You!	N/A	N/A	Covered under Healthy You! preventive wellness benefits	N/A	N/A	N/A

F.	Other Preventive Health Services
Service	Age/Sex	Interval/Limits	Policy	Risk Factors	Procedure Code(s)	Diagnosis Code(s)
1. Tobacco cessation counseling- Pregnancy USPSTF Recommendation: Recommends clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke.	All pregnant women	N/A	Covered as part of the be smoke-free program	N/A	N/A	N/A
2. Tobacco cessation counseling- Adults 21+ USPSTF Recommendation: Recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products	21 and older	N/A	Covered as part of the be smoke-free program	N/A	N/A	N/A
3. Alcohol misuse counseling- Pregnancy, Adults 21+ USPSTF Recommendation: Recommends screening and behavioral counseling interventions to reduce alcohol misuse (go to Clinical Considerations) by adults, including pregnant women, in primary care settings.	All pregnant women and adults 21 and older	N/A	Covered as part of the Healthy You! preventive wellness visit	N/A	N/A	N/A
4. Obesity Counseling-Children 0-18 USPSTF Recommendation: Recommends that clinicians screen children aged 6 years and older for obesity and offer them or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status.	0 – 18 years	N/A	Initial counseling covered as part of the Healthy You! wellness visit. Additional counseling requires enrollment in Care Management obesity management program.	N/A	N/A	N/A
5. Obesity Counseling- Adults 19+ USPSTF Recommendation: Recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults.	19 and older	N/A	Initial counseling covered as part of the Healthy You! wellness visit. Additional counseling requires enrollment in Care Management obesity management program.	N/A	N/A	N/A
6. Sexually Transmitted Infection Counseling USPSTF Recommendation: Recommends high-intensity behavioral counseling to prevent sexually transmitted infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs.	All sexually active women All sexually active adolescents and adults at increased risk for STIs	N/A	Covered as part of the Healthy You! preventive wellness visit	N/A	N/A	N/A
7. Healthy Diet Counseling USPSTF Recommendation: Recommends intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitian.	Adults with hyperlipidemia and other known risk factors for cardio-vascular and diet-related chronic disease.	N/A	Covered as part of the Healthy You! preventive wellness visit	N/A	N/A	N/A
8. Screening and counseling for domestic violence	All women	N/A	Covered as part of the Healthy You! preventive wellness visit	N/A	N/A	N/A

G.	Contraception Counseling and Coverage
Service	Age/Sex	Interval/Limits	Policy	Risk Factors	Procedure Code(s)	Diagnosis Code(s)
1. Patient education and counseling of contraceptive methods	All women with reproductive capacity	N/A	Covered as part of the Healthy You! preventive wellness benefits	N/A	N/A	N/A
2. Prescription Drug Contraception	All women with reproductive capacity	As prescribed	Prescription will be required at the pharmacy to obtain contraception.	N/A	N/A	N/A
3. Other Food and Drug Administration (FDA) approved contraceptive methods	All women with reproductive capacity	FDA-approved birth control as prescribed/ordered by the healthcare provider	Must be prescribed/ ordered by healthcare provider Over-the-counter items are not covered under this policy.	N/A	96372 J1055 J7303 J7304 J7306 J7307	V25.02 V25.49
4. Intrauterine Devices (IUDs)	All women with reproductive capacity	1 device and insertion at an interval of every 5 years	N/A	N/A	58300 J7300 J7302 S4989	V25.10 V25.11 V25.13
5. Inpatient tubal ligation with c-section delivery	Postpartum women post c-section delivery	1 per lifetime	N/A	N/A	58600 58605 58611 00851	V25.2
6. Inpatient tubal ligation post vaginal delivery	Postpartum women post vaginal delivery	1 per lifetime	N/A	N/A	58600 58605 58615 00851	V25.2
7. Outpatient tubal ligation	All women with reproductive capacity	1 per lifetime	N/A	N/A	58600 58605 58615 00851	V25.2

POLICY EXCEPTIONS

Federal Employee Program (FEP)

State Health Plan (State and School Employees)

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

POLICY HISTORY

12/01/2010: Policy added.

08/01/2012: Policy revised to add coverage and coding guidelines for the following women's preventive health services: breast feeding equipment, gestational diabetes screening, HIV screening and counseling, human papillomavirus (HPV) DNA testing, screening and counseling for domestic violence, and contraception coverage and counseling. Note: This policy revision will become effective for underwritten groups on January 1, 2013. For self-funded groups, coverage will become effective on the group's first renewal date on or after 08/01/2012. Please review the patient's benefits and eligibility prior to rendering services.

SOURCE(S)

Federal Register / Vol. 75, No. 137 / Monday, July 19, 2010 / Rules and Regulations
USPSTF Preventive Services Database - http://epss.ahrq.gov/ePSS/search.jsp

CODE REFERENCE

Covered Codes

See table in "Policy" section above.

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