Baylor Scott & White ACA Preventive Coverage Update

Colorectal Stool-Based Testing Coverage Stance

Stance on stool-based colorectal screening tests:

Stool-based tests: Fecal immunochemical tests (FIT) and guaiac-based FOBT are available and covered; multi-target stool DNA testing (FIT-DNA, e.g., Cologuard; CPT 81528) is considered not medically necessary in general because alternatives are equally effective, less costly, and associated with fewer false positives (note: FIT-DNA is available to some Medicare-related plans and TX mandate covers 81528 for commercial since 1/1/22)

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Breastfeeding Pump and Lactation Support

Durable medical equipment and lactation support coverage when criteria met:

Electric breast pump coverage: One personal-use electric breast pump (HCPCS E0603/E0602 as listed) is available through contracted DME providers with a script from a network provider; limited to one pump per completed pregnancy and no more than one pump in a calendar year; in multiple births only one pump provided; purchase includes necessary supplies; additional supplies may be provided once per calendar year; hospital-grade pump rental (E0604) is considered medically necessary while newborn is detained in hospital, up to six monthsone pump per completed pregnancy; <=1 per calendar year; rental up to 6 months

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Excluded pump items: Manual pumps and related equipment, batteries/travel adapters, non-specific bottles, travel bags, cleaning supplies, garments for hands-free operation, storage bags, certain nursing accessories, creams/ointments, baby weight scales and similar items are excluded from the benefit

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Lactation consultant visits: Up to six visits with a network lactation consultant during the six months following delivery are covered for members needing lactation support; claims require the specified diagnosis code per policyup to 6 visits within 6 months postpartum

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Abdominal Aortic Aneurysm Screening

Covered when ALL of the following are met:

AAA screening criteria: One-time abdominal aortic aneurysm screening by ultrasonography for men aged 65–75 years who have ever smoked (USPSTF Grade B); CPT 76706 appliesMale age 65–75; history of ever smoked

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Unhealthy Alcohol Use Screening and Counseling

Covered when performed in primary care settings for adults:

Alcohol screening criteria: Screen adults age 18 years or older for unhealthy alcohol use and provide brief behavioral counseling interventions to persons engaged in risky or hazardous drinking (USPSTF Grade B); CPTs 99408 and 99409 identifiedage >=18

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Breast Cancer Screening and Preventive Counseling

Covered services include screening mammography and risk-reducing medication counseling:

Mammography screening: Biennial screening mammography for women aged 50 to 74 years (USPSTF Grade B); includes digital breast tomosynthesis (CPTs 77063, 77067); Texas mandates and plan variations noted may alter age/frequencywomen 50–74 years (biennial)

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Risk-reducing medication counseling: Offer and, when appropriate, prescribe risk-reducing medications (e.g., tamoxifen, raloxifene) to women at increased risk for breast cancer and low risk for adverse effects; SWHP requirement: no prior diagnosis of breast cancer; covered under drug benefit as applicable (not a Medicare preventive benefit)female; risk assessment documented

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Breastfeeding Support and Breast Pump Benefit

Covered lactation support and breast pump equipment with limits:

Lactation consultant visits: Interventions during pregnancy and after birth to promote and support breastfeeding; up to six lactation consultant visits are covered; claims require diagnosis code 239.1up to 6 visits

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Breast pump coverage: One electric breast pump per completed pregnancy (HCPCS E0602/E0603), no more than one pump in a calendar year; additional supplies may be provided once per calendar year; hospital-grade pump rental (E0604) subject to policy limitationsone pump per pregnancy; <=1 per year

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Cervical and Chlamydia Screening

Covered screening per USPSTF recommendations:

Cervical cancer screening: Pap smear every 3 years for women aged 21–29; for women 30–65 years: cytology every 3 years OR hrHPV testing alone every 5 years OR cotesting every 5 years; Texas mandates may alter age/interval and some Medicare codes/diagnoses applywomen 21–65 years per modality

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Chlamydia screening: Screen sexually active women age 24 years or younger and women 25+ who are at increased risk for infection; CPTs 86631/86632 listed; required diagnosis codes referenced in policyage <=24 or older if increased risk

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Cholesterol Screening

Covered lipid screening and risk-based recommendations:

Cholesterol screening criteria: USPSTF recommends routine lipid screening: men >=35 years; younger men (20–35) and women at increased risk should be screened earlier; universal lipid screening for adults 40–75 to support statin primary prevention decisions (CPTs 80061, 82465 etc.)men >=35; adults 40–75 for risk calculation

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Colorectal Cancer Screening (Non-Medicare and Medicare-specific)

Covered screening options with differing ages/frequencies for Medicare vs non-Medicare:

Non-Medicare colorectal screening: USPSTF: start screening at age 45 through 75; options include annual FOBT/FIT, FIT-DNA every 3 years, sigmoidoscopy every 5 years, colonoscopy every 10 years, CT colonography every 5 years, DCBE every 5 years; TX mandate notes coverage of Cologuard (81528) for commercial plans since 1/1/22age 45–75

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Medicare colorectal screening: Medicare covers tests with age- and frequency-specific rules (e.g., FIT annually for 50+; FIT-DNA (81528) once every 3 years for 50–85 under Medicare rules; colonoscopy and sigmoidoscopy frequencies per Medicare guidance; specific ICD-10 requirements apply for some CPTsMedicare age/frequency rules (50+ and intervals)

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Colorectal Cancer Screening (Medicare high-risk)

Colorectal cancer screening — Medicare high-risk rules and frequencies

High-risk definition: High risk individuals include those with a close relative (sibling, parent, or child) with colorectal cancer or an adenomatous polyp; family history of familial adenomatous polyposis; family history of hereditary nonpolyposis colorectal cancer; or personal history of adenomatous polyps

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FIT-DNA (81528) Medicare guidance: FIT-DNA (CPT 81528) under Medicare guidance is recommended once every 3 years for ages 50–85 with specific ICD coding and is accompanied by marker/anesthesia codes (e.g., G0327, 00812) when relevantq3y for Medicare ages 50–85

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Colonoscopy/sigmoidoscopy frequency for high risk: Colonoscopy for high-risk Medicare beneficiaries (G0105/GO105) may be covered at intervals of once every 24–48 months depending on prior testing and clinical details; flexible sigmoidoscopy frequencies and other intervals per Medicare rules

Depression & Dental Caries Prevention

Depression screening and dental fluoride

Adolescent depression screening: Screen adolescents aged 12–18 for major depressive disorder with systems in place for accurate diagnosis, treatment and follow-up; include diagnosis code Z13.89 and CPTs such as 96127 and 60444 as listedages 11–18 as table lists

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Adult depression screening: Screen adults, including pregnant and postpartum persons, for depression with appropriate systems for follow-up; Medicare covers annual assessment; include CPTs 96127 and 60444annual for Medicare; per USPSTF for adults

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Dental caries prevention: For infants and children age ~6 months to <5 years, recommend fluoride supplementation when water supply is deficient and application of fluoride varnish starting at primary tooth eruption (CPT 99188)

Diabetes Screening and Prevention Programs

Diabetes screening, DSMT, and MDPP

Diabetes screening (commercial): Screen adults aged 35–70 with overweight or obesity for prediabetes and type 2 diabetes (CPT lab codes include 82947, 82948, 82950, 82951, 82952, 83036); required commercial diagnosis codes referenced in policyage 35–70 with overweight/obesity

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Medicare diabetes screening: Medicare covers screening for Part B beneficiaries with specified risk factors; frequency q6–12 months depending on prediabetes status and requires diagnosis code Z13.1q6mo for prediabetes; q12mo otherwise

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DSMT coverage: Medicare DSMT requires a diagnosis of diabetes and an order from a physician or qualified practitioner; first year up to 10 hours within 12 months, subsequent years up to 2 hours per year

Falls Prevention and CVD Behavioral Counseling

Falls prevention and behavioral counseling for cardiovascular risk

Falls prevention: Offer exercise or physical therapy interventions to prevent falls in community-dwelling older adults (age 65+); CPTs include 97161, 97110 and related codes; note: falls prevention exercise interventions are not classified as a Medicare preventive benefit in some cases and G0159 may have copay/cost-shareage >=65

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Healthy diet/physical activity counseling: Offer or refer adults with cardiovascular risk factors to behavioral counseling for healthy diet and physical activity; CPTs include 97802–97804, G0270, G0271, S9449, S9470; nutrition therapy coverage limits and diagnosis requirements applycoverage caps and diagnosis requirements per policy

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Medicare annual CVD counseling: Medicare covers one face-to-face CVD risk reduction visit per year (G0447) for eligible beneficiaries; Intensive Behavioral Therapy for obesity (G0446/G0473) has BMI and diagnosis requirements

HBV, HCV, and HIV Screening / PrEP

Infectious disease screenings and PrEP

Hepatitis B screening: Screen adolescents and adults at increased risk for HBV infection; CPTs 87340/87341 and related codes apply; Medicare provides a single screening for HBV as notedrisk-based

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Hepatitis C screening: Screen adults aged 18–79 for HCV infection once in a lifetime (CPT 86803 referenced)once in lifetime; age 18–79

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HIV screening and PrEP: Screen adolescents and adults for HIV per USPSTF; Medicare covers up to 8 HIV screening tests every 12 months; offer PrEP to individuals at high risk and cover under the drug benefit (J-codes listed)Medicare: up to 8 tests/12 months; PrEP as indicated

Hypertension Screening

Hypertension screening

Hypertension screening recommendation: Screen adults age 18 years or older for high blood pressure using office blood pressure measurement; obtain out-of-office measurements for diagnostic confirmation before initiating treatment (USPSTF Grade A)age >=18

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Obesity (Adults) — Covered when ALL of the following are met

Covered when ALL of the following are met

Adult obesity behavioral interventions: Offer or refer adults with BMI >=30.0 to intensive, multicomponent behavioral interventions per USPSTF; required diagnosis codes for BMI 30+ should be documentedBMI >=30.0

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Obesity (Children) — Covered when ALL of the following are met

Covered when ALL of the following are met

Child obesity screening and counseling: Screen children aged 6–21 years for obesity and offer or refer to comprehensive, intensive behavioral interventions (Bright Futures/AP recommendations); service is included in preventive wellness visits and required diagnosis codes applyAge 6–21 years

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Lung Cancer Screening — Covered when ALL of the following are met

Covered when ALL of the following are met

LDCT lung cancer screening eligibility: Adults aged 50–80 years with a >=20 pack-year smoking history who currently smoke or have quit within the past 15 years are eligible for annual low-dose CT (LDCT) lung cancer screening; Medicare includes an eligibility counseling/shared decision-making visit (G0296)Age 50–80; >=20 pack-years; current smoker or quit <=15 years

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Pregnancy-related screenings — Covered as indicated

Covered when pregnancy-related diagnosis codes present and timing met

HIV in pregnancy: Screen all pregnant persons for HIV, including those presenting in labor with unknown status; follow required pregnancy diagnosis coding as listedpregnant; at initiation of prenatal care or labor if unknown

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Bacteriuria in pregnancy: Screen asymptomatic pregnant persons for bacteriuria with urine culture per USPSTF recommendations; document pregnancy diagnosis codespregnant

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Gestational diabetes: Screen asymptomatic pregnant persons for gestational diabetes at 24 weeks gestation or later using recommended lab tests (CPTs 82947/82950 etc.); required pregnancy diagnosis codes apply>=24 weeks gestation

Statin preventive medication — Covered when ALL of the following are met

Covered when ALL of the following are met

Statin primary prevention: Adults aged 40–75 years with one or more cardiovascular disease (CVD) risk factors (dyslipidemia, diabetes, hypertension, or smoking) AND an estimated 10-year CVD risk >=10% are recommended for statin preventive medication; coverage is under the drug benefit as applicableAge 40–75; estimated 10-year CVD risk >=10%

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Tobacco cessation and counseling — Coverage conditions

Covered as recommended by USPSTF

Tobacco cessation (pregnant and non-pregnant): Provide behavioral interventions and FDA‑approved pharmacotherapy to nonpregnant adults who use tobacco; provide behavioral interventions to pregnant women; Medicare limits apply (two cessation attempts/year; each attempt up to 4 sessions, up to 8 sessions annually)per USPSTF and Medicare limits where applicable

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Statin preventive medication

Covered when ALL of the following are met

Statin primary prevention (duplicate): Adults aged 40–75 years with >=1 CVD risk factor and estimated 10-year CVD risk >=10% are indicated for statin preventive medication; covered under the drug benefit as applicableAge 40–75; 10-year risk >=10%

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Syphilis screening (increased risk)

Covered for persons at increased risk

Syphilis screening criteria: Screen persons at increased risk for syphilis infection per USPSTF; CPTs 86592/86593 listed and required diagnosis coding appliesincreased risk as clinically indicated

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Tobacco smoking cessation (non-pregnant adults)

Covered service

Tobacco cessation services (non-pregnant adults): Ask all adults about tobacco use, advise to stop, and provide behavioral interventions and FDA‑approved pharmacotherapy for cessation to nonpregnant adults who use tobacco; CPTs 99406 and 99407 apply; Medicare benefit limits describedper Medicare: up to two attempts/year; up to 8 sessions total

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Tuberculosis screening (increased risk)

Covered for populations at increased risk

TB screening criteria: Screen for latent tuberculosis infection in populations at increased risk (risk assessment included in preventive wellness exam); CPT 86580 and diagnosis code Z11.1 referencedincreased risk per assessment

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Unhealthy drug use screening

Covered when follow-up services available

Unhealthy drug use screening criteria: Screen adults age 18 years or older by asking validated questions about unhealthy drug use when services for accurate diagnosis and effective treatment or referral are available; screening refers to questions rather than biologic testingage >=18

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Pediatric Bright Futures screenings

Included as part of Bright Futures pediatric preventive care

Vision screening for all children at least once between ages 3 and 5 to detect amblyopia or risk factors; Bright Futures periodicity applies and CPTs 99173/99174/99177 notedat least once between ages 3–5

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Hearing screening per Bright Futures with recommended age-based periodicity (audiometry once between 11–14 and again at 15+ as indicated); required diagnosis codes and CPTs applyage ranges per Bright Futures

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Women's preventive services (selected)

Covered women's preventive services per WPSI (selected items):

Anxiety screening: Screen adolescent and adult women (including pregnant/postpartum) for anxiety using recommended tools; CPT 96127 referencedfemale

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Contraceptive services: Access to the full range of contraceptive services is covered (sterilization, implants, IUDs, injectables, oral contraceptives, patches, rings, barrier methods, emergency contraception); counseling and provision included with applicable CPT/HCPCS codes listedfemale; reproductive capacity as appropriate

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Diabetes screening after pregnancy: Women with a history of gestational diabetes mellitus who are not currently pregnant and not previously diagnosed with type 2 diabetes should be screened within the first year postpartum (as early as 4–6 weeks) using lab CPTs listed

Contraceptive products that do not require a prescription — for example, condoms, contraceptive sponges, spermicides, and non-prescription "morning after" pills — are explicitly listed as not covered under this preventive services policy. Male contraception methods are likewise excluded from coverage. Providers should bill only for covered contraceptive services and devices enumerated in the policy's CPT/HCPCS lists; non-prescription barrier or over-the-counter methods are not reimbursable through the preventive benefit.

The policy clarifies that breast cancer preventive counseling medications (e.g., tamoxifen, raloxifene) are covered as applicable under the drug benefit for eligible commercial members, but are not considered a Medicare preventive benefit. Similarly, BRCA genetic testing and related testing/counseling require prior authorization where testing criteria are met and may not be covered as Medicare preventive services in the same manner as commercial plans. Providers serving Medicare beneficiaries should follow Medicare-specific guidance and prior authorization requirements referenced in the policy.

Falls-prevention exercise and physical therapy interventions are recommended by USPSTF for community-dwelling older adults, but the policy notes that these services are not classified as a Medicare preventive benefit in some cases. For Medicare beneficiaries, certain codes used for falls prevention (for example, G0159) may be subject to co-pay or cost-sharing. Providers should verify the member's plan type and Medicare rules before assuming no member cost-share for falls-prevention services.

Texas-specific mandate: the policy includes coverage for ovarian cancer screening in women age 18 years and older under state requirements. Covered screening includes an annual CA-125 blood test plus a conventional Pap smear. This coverage is conditioned on the absence of certain ovarian cancer diagnosis codes — see the exclusions for when the screening is not appropriate.

Certain screenings in the policy apply only to persons identified as being at increased risk. Examples include syphilis screening (CPT 86592/86593) and tuberculosis screening (CPT 86580)

This policy differentiates preventive services for commercial members from those covered under Medicare. Medicare has its own list of covered preventive items and specific frequency, coding, and benefit limits; some services covered for commercial members may be subject to Medicare rules or not be Medicare preventive benefits. Providers should confirm the member's coverage type (commercial vs. Medicare) and apply the Medicare-specific coding, frequency, and documentation rules referenced in the policy when treating Medicare beneficiaries.

Multi-target stool DNA testing (FIT-DNA, e.g., Cologuard; CPT 81528) is addressed explicitly: after literature review the plan determined that FIT‑DNA is NOT medically necessary for colorectal cancer screening because alternatives such as FITs are considered equally effective and less costly with fewer false positives. Note, however, that the policy also documents Medicare-related provisions for FIT‑DNA in Medicare plans; commercial billing should follow the not-medically-necessary stance for FIT‑DNA unless other plan-specific exceptions apply.

Ovarian cancer screening is covered under the Texas mandate for women aged 18 and older (annual CA‑125 and Pap), but the policy excludes screening when specific ovarian cancer diagnosis codes are present. Screening is not appropriate — and therefore not covered as preventive — when codes for ovarian malignancy such as C56.1, C56.2, or C56.9 are recorded, consistent with the policy's exclusion language.

CPT / HCPCS / ICD-10 Codes and Related Notes

Covered CPT/HCPCS Codes (wellness visits, breast pump)mixedCovered

99381	Wellness visit for young children (CPT) — preventive medicine evaluation and management
99382	Wellness visit for young children (CPT)
99391	Wellness visit for young children (CPT)
99392	Wellness visit for young children (CPT)
99383	Wellness visit beyond age 5 (CPT)
99384	Wellness visit beyond age 5 (CPT)
99385	Wellness visit beyond age 5 (CPT)
99386	Wellness visit beyond age 5 (CPT)
99387	Wellness visit beyond age 5 (CPT)
99393	Wellness visit beyond age 5 (CPT)

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USPSTF A/B sample service codesCPTCovered

76706

Abdominal aortic aneurysm screening by ultrasound (CPT)

Diagnosis codes referenced for screening/behavioral interventionsICD-10

F17.210	Nicotine dependence, cigarettes, uncomplicated (ICD-10)
F17.211	Nicotine dependence, cigarettes, in remission (ICD-10)
F17.213	Nicotine dependence, cigarettes, with other nicotine-induced disorders (ICD-10)
F17.218	Other nicotine dependence (ICD-10)
F17.219	Nicotine dependence, unspecified (ICD-10)
287.891	Code listed in policy (documented) — original text includes this code
Z71.41	Alcohol use counseling (ICD-10)

Vaccine administration codesCPTCovered

90471	Vaccine administration (CPT)
90472	Vaccine administration (CPT)
90473	Vaccine administration (CPT)
90474	Vaccine administration (CPT)

Abdominal aortic aneurysm screening CPTCPTCovered

76706

Abdominal aortic aneurysm ultrasonography (CPT)

Unhealthy alcohol use screening CPTCPTCovered

99408	Unhealthy alcohol use screening/brief intervention (CPT)
99409	Unhealthy alcohol use screening/brief intervention (CPT)

Breast cancer screening mammography CPTCPTCovered

77063	Screening digital breast tomosynthesis (CPT)
77067	Screening mammography, bilateral (CPT)

Breastfeeding and breast pump codesmixedCovered

S9443	Breastfeeding support services (HCPCS/CPT)
E0602	Personal-use electric breast pump, DC (E0602)
E0603	Breast pump accessory (E0603)
E0604	Hospital-grade breast pump rental (E0604)
A4281	Breast pump supply (A4281)

Cervical cancer screening CPT/HCPCS groupsmixedCovered

G0124	Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to lab (Medicare)
G0143	Screening cytopathology, direct smears
P3000	Cytology procedure code listed in policy group

Chlamydia screening CPTCPTCovered

86631	Chlamydia trachomatis antigen detection (CPT)
86632	Chlamydia trachomatis testing (CPT)

Cholesterol screening CPTCPTCovered

80061	Lipid panel (CPT)
82465	Apolipoprotein B test (CPT)

Colorectal cancer screening CPT/HCPCSmixedCovered

G0121	Colorectal cancer screening; colonoscopy for colorectal cancer screening with or without collection of specimen(s) (HCPCS)
G0105	Colorectal cancer screening; colonoscopy for high risk patients (Medicare)
45378	Diagnostic colonoscopy (CPT)
G0328	Fecal immunochemical test (FIT) (HCPCS)
81528	Stool-based DNA (Cologuard) (CPT)
74263	CT colonography (CPT)
G0104	Screening flexible sigmoidoscopy (Medicare)

Colorectal screening markers/anesthesiaHCPCS | CPT

G0327	Marker — colorectal screening (Medicare)
00812	Anesthesia (noted with colonoscopy)

Dental caries preventionCPTCovered

99188

Application of fluoride varnish to primary teeth

Depression screening CPTsCPTCovered

96127	Brief emotional/behavioral assessment for depression screening
60444	Depression screening (documented in table)

Diabetes screening labsCPTCovered

82947	Glucose; quantitative, blood (e.g., for diabetes screening)
82950	Glucose tolerance test, 3 specimens (alternate diabetes screening)
83036	Hemoglobin; glycosylated (A1c)

MDPP CPT/HCPCS groupmixedCovered

G9880

MDPP code (listed among MDPP codes)

Falls prevention / therapy codesCPT | HCPCSCovered

97161	Physical therapy evaluation
97110	Therapeutic exercises
S9131	Non-face-to-face falls prevention (listed)
G0159	Therapeutic procedure; may have cost-share for Medicare

Medicare behavioral therapy codesHCPCSCovered

G0447	One face-to-face per year CVD risk reduction visit (Medicare)
G0473	Intensive Behavioral Therapy for obesity (Medicare)

HIV preexposure prophylaxis J-codesCPTCovered

J0739	PrEP medication (listed among J-codes)
J0750	PrEP medication

HIV screening codesCPT | HCPCSCovered

86689	HIV antibody test
G0432	HIV screening, counseling and referral (Medicare)

Hepatitis C screeningCPTCovered

86803

Hepatitis C virus infection screening

Medicare-specific CPT/HCPCSHCPCS

G0446

Intensive Behavioral Therapy for Cardiovascular Disease (Medicare)

Screening and counseling CPT/HCPCSmixed

G0296	Counseling visit to discuss need for cancer screening using low dose CT (Medicare)
60297	Lung cancer screening CPT listed
71271	LDCT for lung cancer screening
G0270	Obesity: Behavioral (HCPCS listed)
G0271	Obesity: Behavioral (HCPCS listed)
S9449	Obesity counseling
S9470	Obesity counseling

Newborn screening CPTCPTCovered

S3620	Newborn metabolic screening panel
84436	Thyroid stimulating hormone (TSH)
84437	Thyroxine (T4)
84443	Phenylalanine
83020	Hemoglobin electrophoresis
83030	Hemoglobin; quantitation
83033	Hemoglobin variant
83051	Sickle cell testing

Pregnancy-related screening CPT/HCPCSmixedCovered

80081	Pregnancy screening panel (HIV included)
86689	HIV test
86701	HIV-1 antigen
86702	HIV-2 antibody
86703	HIV-1/2 combined
87389	HIV test
87390	HIV test
87391	HIV test
87806	HIV rapid test
G0475	HIV screening in pregnancy (Medicare)

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Osteoporosis screening CPTCPTCovered

76977	Ultrasound (bone density)
77078	DXA bone density
77080	DXA bone density
77081	Bone density
77085	Bone densitometry
0557T	Bone density
0558T	Bone density

Cancer screening and counseling CPT/HCPCS and counseling codesmixed

84152	PSA test
84153	PSA test
84154	PSA test
G0102	Prostate digital exam
G0103	PSA test (Medicare)
G0445	STD/HIV intensive behavioral counseling
99401	Preventive counseling
99402	Preventive counseling
99403	Preventive counseling
99404	Preventive counseling

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Nutrition/medical nutrition therapy codesCPT

97802	Medical nutrition therapy; initial assessment and intervention
97803	Medical nutrition therapy; re-assessment
97804	Medical nutrition therapy; group
G0270	Obesity counseling HCPCS
G0271	Obesity counseling HCPCS

Statin preventive medication coding notemixed

CPT	Covered as applicable under drug benefit (statin preventive medication) — no specific CPT listed

Syphilis screening CPT codesCPTCovered

86592	Syphilis screening (treponemal/non-treponemal codes listed)
86593	Syphilis screening

Tobacco cessation CPT codesCPTCovered

99406	Tobacco cessation counseling (intermediate)
99407	Tobacco cessation counseling (intensive)

Tuberculosis screening CPTCPTCovered

86580

Tuberculosis screening (tuberculin test)

Pediatric visual acuity screening CPT codesCPTCovered

99173	Vision screening, instrumental
99174	Vision screening, automated
99177	Vision screening, other

Venipuncture/blood draw codesmixedCovered

36415	Venipuncture
36416	Collection of capillary blood specimen
99000	Handling and/or conveyance of specimen
99001	Services related to testing (facility-specific)
99002	Shipment/handling of lab specimens
P9603	Venipuncture related HCPCS
P9604	Venipuncture related HCPCS
P9612	Venipuncture related HCPCS
P9615	Venipuncture related HCPCS

Pediatric screening lab/assessment codesCPTCovered

85013	CBC automated count — pediatric anemia screening listed
96110	Developmental screening
80061	Lipid panel component (cholesterol/dyslipidemia screening)
92465	Note: document lists multiple lab CPTs (82465,83718,83719,83721,84478) for pediatric lipid screening
83655	Lead screening

Women's health screening CPT codesCPTCovered

96127

Brief emotional/behavioral assessment (anxiety screening)

Contraceptive method CPT/HCPCSmixedCovered

58565	Tubal ligation
58600	Laparoscopic tubal ligation
58605	Sterilization procedure
J7304	IUD device HCPCS
J7307	IUD (levonorgestrel) HCPCS
J1050	Contraceptive injection (Depo-Provera) HCPCS
11982	Insertion of contraceptive implant
11983	Removal of contraceptive implant

HIV screening codesmixedCovered

80081	HIV testing (grouped code listed among HIV screening codes)
86689	HIV antibody
87389	HIV antigen/antibody

Pregnancy diagnosis code listICD-10

ICD-9/ICD-10 pregnancy list

Extensive list of pregnancy diagnosis codes included in policy (chunks 87-91)

Representative diagnosis codes (partial list as presented)ICD-10

041.1225
041.1229
041.1230
041.1231
041.1232
041.1233
041.1234
041.1235
041.1239
041.1290

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Medicare required ICD-10 examples for G0105, G0120ICD-10

K50.011	Crohn's disease of small intestine with rectal bleeding
K50.012	Crohn's disease of small intestine with intestinal obstruction
K50.013	Crohn's disease of small intestine with fistula
K50.014	Crohn's disease of small intestine with abscess
K50.018	Crohn's disease of small intestine with other complication
K50.019	Crohn's disease of small intestine with unspecified complications
K50.10	Crohn's disease of large intestine without complications
K50.111	Crohn's disease of large intestine with rectal bleeding
K50.112	Crohn's disease of large intestine with intestinal obstruction
K50.113	Crohn's disease of large intestine with fistula

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Procedure/HCPCS/CPT placeholdersmixed

CPT	Not enumerated in this part; section indicates CPT codes may apply
HCPCS	Not enumerated in this part; section indicates HCPCS codes may apply
ICD-10	Not enumerated in this part; section indicates ICD-10 codes may apply

inv-85: AAA screening age and history — one-time screening for men 65-75 who have ever smoked

Screening indicationOne-time abdominal aortic aneurysm (AAA) screening by ultrasonography for men who have ever smoked

Age range65–75 years (male)

FrequencyOnce in a lifetime (one-time)

Relevant CPT76706 (abdominal aortic aneurysm ultrasound)

USPSTF gradeGrade B

inv-86: AAA screening age — Male 65-75 years

Applicable sexMale

Age range65–75 years

FrequencyOne-time screening

Coding noteCPT 76706 listed for AAA ultrasonography

inv-87: Colorectal screening age (non-Medicare) — 45-75 years

Age range (non‑Medicare)45–75 years

Screening optionsAnnual FOBT/FIT, FIT‑DNA every 3 years, sigmoidoscopy q5y, colonoscopy q10y, CT colonography q5y

Frequency summaryDepends on modality (see screening options)

Coding noteFIT‑DNA (81528) commercially covered per TX mandate (effective 1/1/22)

inv-88: Mammography age (USPSTF) — 50-74 years (biennial)

PopulationWomen

Age range50–74 years

IntervalBiennial (every 2 years)

Included modalitiesScreening mammography including digital breast tomosynthesis (CPT 77063, 77067)

USPSTF gradeGrade B

inv-89: MDPP weight loss goal — at least 5% weight loss

ProgramMedicare Diabetes Prevention Program (MDPP)

Weight‑loss goalAt least 5% weight loss

Service frequencyEach MDPP code once per lifetime (Medicare guidance)

Provider requirementOnly available through Medicare‑enrolled and CDC‑recognized providers

inv-90: MDPP BMI eligibility — BMI >=25 (>=23 if Asian)

BMI thresholdBMI ≥ 25 kg/m2 (≥ 23 kg/m2 if self‑identifies as Asian)

ExclusionsNo history of type 1 or type 2 diabetes (except gestational diabetes); no ESRD

DocumentationBMI and qualifying labs must be documented; provider enrollment required for MDPP codes

inv-91: MDPP qualifying lab ranges — A1c 5.7-6.4%; fasting plasma glucose 110-125 mg/dL; OGTT 140-199 mg/dL

A1c rangeHemoglobin A1c 5.7%–6.4%

Fasting plasma glucose110–125 mg/dL

Oral glucose tolerance test (OGTT)140–199 mg/dL

TimingQualifying test results must be within 12 months before MDPP start

inv-92: Obesity BMI threshold — BMI >= 30.0 (required diagnosis codes listed for BMI of 30+)

DefinitionAdult obesity defined as BMI ≥ 30.0 kg/m2

Coverage triggerReferral or offer of intensive multicomponent behavioral interventions per USPSTF for adults with BMI ≥30

Coding noteRequired diagnosis codes listed for BMI of 30+ (policy references specific ICD codes)

inv-93: Statin 10-year CVD risk threshold — Estimated 10-year CVD risk >= 10%

RecommendationPrescribe statin for primary prevention in adults meeting criteria

Age range40–75 years

Risk requirementHas ≥1 CVD risk factor (dyslipidemia, diabetes, hypertension, or smoking)

10‑year risk thresholdEstimated 10‑year CVD risk ≥ 10%

inv-94: Lung cancer screening age/pack-year criteria — Age 50–80 with 20 pack-year history and current smoker or quit within 15 years

Age range50–80 years

Smoking history≥20 pack‑year history

Current/former statusCurrent smoker OR quit within past 15 years

Screening modalityAnnual low‑dose CT (LDCT); Medicare counseling code G0296 applies for shared decision making

inv-95: Estimated 10-year cardiovascular risk — >= 10%

MetricEstimated 10‑year cardiovascular (CVD) risk

Threshold>= 10%

Use caseUsed to determine eligibility for statin primary prevention in adults aged 40–75 with ≥1 CVD risk factor

Billing, Authorization, and Documentation Requirements

Documentation Required
Network provider requirement
Services must be obtained from Plan network providers to be eligible for no-member-cost preventive coverage under this policy. If services are rendered by non-network providers (except as allowed by the member's benefit plan for emergency care or approved referrals), member cost-sharing may apply.
Obtain preventive services from in-network providers to avoid member cost share.
Non-network services may be subject to member cost sharing unless plan terms or emergency/approved referrals apply.

Prior Authorization
BRCA testing prior authorization
BRCA genetic testing requires prior authorization when testing criteria are met. BRCA testing is not a Medicare preventive benefit and must follow the Plan's prior authorization process.
Testing requires prior authorization when clinical criteria are met.
Not covered as a Medicare preventive benefit.

Documentation Required
MDPP provider enrollment required
Only MDPP services delivered by providers enrolled in Medicare and recognized through the CDC Diabetes Prevention Recognition Program are covered under the Medicare MDPP benefit. Documentation of qualifying lab/diagnostic evidence is required within 12 months before MDPP start.
Provider enrollment: MDPP available only through providers enrolled in Medicare and recognized by the CDC/Diabetes Prevention Recognition Program.
Eligibility labs within 12 months: A1c 5.7-6.4%, fasting plasma glucose 110-125 mg/dL, or 2‑hour OGTT 140-199 mg/dL.
BMI requirement: BMI ≥25 (≥23 if self-identified Asian).
No prior diagnosis of type 1 or type 2 diabetes (except history of gestational diabetes); no ESRD.
Each MDPP code is limited to once per lifetime.

Billing Rule
Immunization formulary management
Formulary or other medical management rules may limit vaccine coverage to the most appropriate FDA‑approved form for the intended recipient. When CPT 90471-90474 are billed on the same claim as the immunization, no cost‑sharing is allocated to vaccine administration under this policy.
Vaccines must be CDC/ACIP recommended and FDA‑approved for the recipient to be covered without member cost share.
Formulary or medical management rules may determine which vaccine presentation is covered.
When vaccine administration is billed with CPT 90471-90474 on the same claim as the immunization, administration is not subject to cost sharing.

Billing Rule
Statin coverage (drug benefit)
Statin preventive medication is covered as applicable under the drug benefit. Authorization and utilization follow the Plan's drug benefit rules (formulary, prior authorization, step therapy if applicable).
Statin preventive medication coverage is managed under the drug benefit, not this medical preventive policy.
Follow drug benefit rules for prior authorization, formulary, and any step therapy requirements.

Billing Rule
Contraceptive methods — billing codes
Billing for contraceptive services should use the listed procedure and supply codes. Some methods and procedures require specific diagnosis codes to support claims (for example, certain sterilization procedures require sterilization diagnosis codes).
Common procedure/device codes include: tubal ligation 58565, 58600, 58605, 58611, 58615, 58670, 58671; implantable devices J7304, J7307; insertion codes 11982, 11983; injection J1050; IUD/implant supply HCPCS A4261–A4266.
No diagnosis is necessary for many contraceptive supply codes (A4261–A4266, J7300, J7301, J7303, 17297, 57170, 96372).
Tubal ligation procedures must include sterilization diagnosis codes (examples listed in policy).

Documentation Required
Tobacco cessation Medicare benefit limits
Medicare tobacco cessation benefit limits must be followed: Medicare covers up to two cessation attempts per year; each attempt may include up to four intermediate or intensive counseling sessions, with a total of up to eight sessions per year.
Required diagnosis codes for tobacco cessation services include F17.* and relevant T65.* codes as listed in the policy.
Medicare benefit: up to 2 quit attempts/year; each attempt may include up to 4 sessions; total up to 8 sessions/year.

Billing Rule
Colorectal screening coding notes
Colorectal screening coding varies by test. Some CPTs have no diagnosis code requirement; other tests (and some Medicare-specific screening codes) require specific ICD‑10 diagnosis codes listed in the policy. CT colonography and certain Medicare screening codes have additional requirements.
Stool‑based DNA (FIT‑DNA, e.g., 81528 Cologuard) is covered per state mandate with its applicable coding and frequency.
Some codes (listed in policy) require diagnosis codes such as Z00.00, Z00.01, Z12.10, Z12.11, etc.; CT colonography (74263) and G0106/G0120 have specific ICD‑10 requirements.
Copay/coinsurance may apply to G0106 and G0120 when required ICD‑10 codes are not present.

Documentation Required
DSMT documentation
Diabetes Self‑Management Training (DSMT) requires a documented diagnosis of diabetes and an order from the physician or qualified practitioner treating the patient's diabetes. Medicare limits apply to initial and follow‑up training hours.
Required documentation: diagnosis of diabetes and a signed DSMT order from the treating physician or qualified practitioner.
Medicare limits: First year up to 10 hours initial training within a continuous 12‑month period; subsequent years up to 2 hours follow‑up training per calendar year.

Billing Rule
Pregnancy coding
Pregnancy‑related preventive screenings require the appropriate pregnancy diagnosis codes to be present on the claim. Many pregnancy screenings (HIV, bacteriuria, hepatitis B, gestational diabetes screening, Rh incompatibility, preeclampsia screening, etc.) are coded as 'Pregnant' and must reference the pregnancy diagnosis list in the policy.
Use the pregnancy diagnosis codes listed in the policy when billing pregnancy screenings to ensure preventive (no cost‑share) coverage.
Services applicable to pregnancy are to be billed with the pregnancy-specific CPTs and required diagnosis codes as listed (e.g., HIV screening codes and corresponding pregnancy diagnosis).

Documentation Required
Osteoporosis supporting diagnoses
Osteoporosis screening for women 65+ and high‑risk postmenopausal women under 65 requires bone measurement testing codes and supporting diagnosis codes for coverage without cost share. The policy lists required ICD‑10 codes and additional supporting diagnoses for women under 65.
Covered CPTs include 76977, 77078, 77080, 77081, 77085, 0557T, 0558T.
Required diagnosis codes include Z00.00, Z00.01, Z13.820 and listed supporting codes for women under 65 (e.g., Z78.0, E21.0, M85.8xx, M85.9, etc.).
Texas mandates coverage in specified clinical situations (postmenopausal not on estrogen, vertebral abnormalities, primary hyperparathyroidism, history of fractures, long‑term glucocorticoid therapy, or monitoring osteoporosis therapy).

Denial Risk
Coding and documentation note
When a code is listed in the policy it does not guarantee reimbursement — the patient must meet the coverage criteria and plan medical management and network requirements must be met.
Inclusion of a code in the policy is informational; eligibility and reimbursement depend on meeting clinical criteria and plan terms.
Failure to meet plan medical management and network requirements may result in member cost sharing or claim denial.

OpenPayer

Preventive Care — Affordable Care Act (No Cost-Sharing)

Preventive Services Covered Without Member Cost-Sharing

CPT / HCPCS / ICD-10 Codes and Related Notes

Billing, Authorization, and Documentation Requirements

Key Definitions and Eligibility Criteria

Policy Purpose and Scope

Policy Dates and Revision Notes