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L.2.01.410
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. Created in 1984, the U.S. Preventive Services Task Force (USPSTF or Task Force) is an independent group of national experts in prevention and evidence-based medicine. Members represent disciplines of primary care including family medicine, internal medicine, nursing, obstetrics/gynecology, pediatrics, and behavioral medicine. The Task Force works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as:
screenings
counseling services
preventive medications.
Findings and recommendations from the USPSTF are routinely used in a variety of settings to improve the preventive care that patients receive.
These recommendations apply only to people who have no signs or symptoms of the specific disease or condition that the screening, counseling, or preventive medication targets. Recommendations address only services offered in the primary care setting or services referred by a primary care clinician. The Task Force makes recommendations to help primary care clinicians and patients decide together whether a preventive service is right for a patient’s needs.
Since 1998, through acts of the U.S. Congress, the Agency for Healthcare Research and Quality (AHRQ) has been authorized to convene the Task Force and to provide ongoing scientific, administrative, and dissemination support to the Task Force. While AHRQ provides support to the Task Force, it is important to note that the USPSTF is an independent entity.
The letter grade linked to each recommendation reflects the magnitude of net benefit and the strength and certainty of the evidence supporting the provision of a specific preventive service. These grades translate to practice guidance for clinicians:
“A” | Strongly Recommended | The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. | The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms. |
“B” | Recommended | The USPSTF recommends that clinicians provide [the service] to eligible patients. | The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms. |
“C” | No Recommendation | The USPSTF makes no recommendation for or against routine provision of [the service]. | The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation. |
“D” | Not Recommended | The USPSTF recommends against routinely providing [the service] to asymptomatic patients. | The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits. |
“I” | Insufficient Evidence to Make a Recommendation | The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. | Evidence that the [service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined. |
Medically Necessary Screening
Only services/procedures (screenings, counseling services, and preventive medications) with "A" or "B" USPSTF recommendations are considered medically necessary under this policy. The following are considered medically necessary based on grade “A” or grade “B” by the USPSTF if criteria outlined in the noted Coverage Guidelines/Policy are met:
# | Service/Procedure | USPSTF Recommendation | Coverage Guidelines/Policy |
1 | Abdominal Aortic Aneurysm: Screening: Men aged 65 to 75 years who have ever smoked | The USPSTF recommends 1-time screening for abdominal aortic aneurysm (AAA) with ultrasonography in men aged 65 to 75 years who have ever smoked. | |
2 | 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. | ||
3 | Asymptomatic Bacteriuria in Adults: Screening: Pregnant persons | The USPSTF recommends screening for asymptomatic bacteriuria using urine culture in pregnant persons. | |
4 | 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. | ||
5 | 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. | ||
6 | The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. † | ||
7 | Breastfeeding: Primary Care Interventions: Pregnant women, new mothers, and their children | The USPSTF recommends providing interventions during pregnancy and after birth to support breastfeeding. | |
8 | 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). | ||
9 | Chlamydia: Screening: sexually active women, including pregnant persons | The USPSTF recommends screening for chlamydia in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection. | |
10 | Gonorrhea: Screening: sexually active women, including pregnant persons | The USPSTF recommends screening for gonorrhea in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection. | |
11 | The USPSTF recommends screening for colorectal cancer in adults aged 45 to 49 years. | ||
12 | The USPSTF recommends screening for colorectal cancer in all adults aged 50 to 75 years. | ||
13 | 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. | |
14 | 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. | |
15 | The USPSTF recommends that all women who are planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid. | ||
16 | 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. | |
17 | The USPSTF recommends offering or referring adults with cardiovascular disease risk factors to behavioral counseling interventions to promote a healthy diet and physical activity. | ||
18 | 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. | |
19 | The USPSTF recommends screening for hepatitis B virus (HBV) infection in adolescents and adults at increased risk for infection. | ||
20 | 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 | |
21 | 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. | |
22 | 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. | |
23 | 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. | |
24 | 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. | |
25 | 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. | ||
26 | The USPSTF recommends screening for LTBI in populations at increased risk. | ||
27 | 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. | ||
28 | 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. | |
29 | Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum: Preventive Medication: Newborns | The USPSTF recommends prophylactic ocular topical medication for all newborns to prevent gonococcal ophthalmia neonatorum. | |
30 | 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. | ||
31 | 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. | |
32 | 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. | |
33 | 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. | ||
34 | The USPSTF recommends screening for preeclampsia in pregnant women with blood pressure measurements throughout pregnancy. | ||
35 | 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. | ||
36 | 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. | ||
37 | The USPSTF recommends that clinicians offer preexposure prophylaxis (PrEP) with effective antiretroviral therapy to persons who are at high risk of HIV acquisition. | ||
38 | 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. | |
39 | 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. | |
40 | The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. | ||
41 | 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. | ||
42 | 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. | ||
43 | 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. | ||
44 | The USPSTF recommends screening for syphilis infection in persons who are at increased risk for infection. | ||
45 | Syphilis Infection in Pregnant Women: Screening: Pregnant women | The USPSTF recommends early screening for syphilis infection in all pregnant women. | |
46 | Tobacco Smoking Cessation in Adults, Including Pregnant Persons: Interventions: Nonpregnant adults | The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and US Food and Drug Administration (FDA)--approved pharmacotherapy for cessation to nonpregnant adults who use tobacco. | |
47 | Tobacco Smoking Cessation in Adults, Including Pregnant Persons: Interventions: Pregnant persons | The USPSTF recommends that clinicians ask all pregnant persons about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant persons who use tobacco. | |
48 | 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. | ||
49 | 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. | ||
50 | 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.) | ||
51 | Vision in Children Ages 6 Months to 5 Years: Screening: Children aged 3 to 5 years | The USPSTF recommends vision screening at least once in all children aged 3 to 5 years to detect amblyopia or its risk factors. | |
52 | 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. |
NOT MEDICALLY NECESSARY SCREENING
ALL other services/procedures performed for screening purposes are considered not medically necessary, including, but not limited to:
Basic and comprehensive metabolic panel
Female and male sex hormone tests
Antigen leukocyte cellular antibody (ALCAT) testing
Thyroid testing
Stress hormone tests (including DHEA and cortisol)
Vitamin B12 testing
Vitamin D testing
Allergy testing
Heavy metal testing
Saliva testing
Molecular Diagnostic and Genetic testing
All nutritional deficiencies testing/ micronutrient testing (including vitamins, minerals, amino acids, antioxidants, carbohydrate metabolism, fatty acids and metabolites)
Calcium; total testing
Enzyme testing
Cardiac screening tests
Homocysteine testing
High-sensitivity C-reactive protein (hs-CRP)
Novel lipid risk factors (i.e., apolipoprotein B, apolipoprotein A-I, apolipoprotein E, LDL subclass, HDL subclass, lipoprotein[a])
Nephelometry
Immune cell function assays
Stress cardiac imaging or coronary angiography
Radiologic examinations, including chest x-rays
Electrocardiogram [ECG] [EKG] services
Ultrasounds
Computed Tomography (CT) and Computed Tomography Angiography (CTA)
Magnetic Resonance Imaging (MRI)
Surveillance testing or imaging for cancer
None
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
12/01/2012: New policy added.
08/20/2013: Policy statement revised to add Calcium; total testing as not medically necessary for screening purposes.
07/23/2015: Code Reference section updated for ICD-10.
06/06/2016: Policy number L.2.01.410 added. Policy Guidelines updated to add medically necessary definition.
05/31/2018: Updated links in Policy and Sources sections.
11/16/2018: Policy section updated with current USPSTF recommendations. Removed fecal testing from the list of services/procedures considered not medically necessary.
05/15/2023: Policy description updated regarding the U.S. Preventive Services Task Force. Policy section updated to list current Task Force recommendations regarding medically necessary screenings. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity." Sources updated.
02/15/2024: Policy reviewed; no changes.
03/26/2025: Policy reviewed; no changes.
U.S. Preventive Services Task Force. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
This may not be a comprehensive list of procedure codes applicable to this policy.
All procedure codes filed for screening purposes that are not listed as grade a “A” or grade “B” recommendation by the USPSTF in the "Policy" section above are considered not medically necessary and not eligible for coverage.
Code Number | Description |
CPT-4 | |
Any procedure code filed for screening purposes that is not listed as a grade "A" or grade "B" recommendation by the USPSTF | |
HCPCS | |
ICD-10 Procedure | |
ICD-10 Diagnosis |
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