Modifiedblue cross blue shield - louisianaPolicy AHS - G2042 - Pediatric Preventive Screening

G2042: Pediatric Preventive Screening

Defines coverage criteria for laboratory-based preventive screening tests for individuals newborn through age 18 (excluding newborn genetic disorder screening), specifying which screenings meet coverage and frequency limits, references to related policies, and applicable CPT/HCPCS codes.

Policy Summary

Payerblue cross blue shield - louisiana

PolicyG2042: Pediatric Preventive Screening

Policy CodePolicy AHS - G2042 - Pediatric Preventive Screening

Change TypeCoverage criteria modified (risk-based lead screening) + CPT code updates

Effective DateSep 1, 2025

Next Review Date

Key ActionProviders must document that the child meets the specified risk criteria (Note 1 for lead exposure, Note 2 for iron deficiency risk, Note 3 for TB risk, Note 4 for dyslipidemia risk) before billing for targeted screenings.

SourceLink

POLICY UPDATE CHANGES

CC5 edited to limit lead screening to children at increased risk, with defined frequencies (monthly at 6, 9, 12 months; yearly from 2 to 6 years).

Added CPT code 86481 to applicable procedure codes.

Removed CPT codes 86850, 87555, 87556, and 0257U from the applicable code list.

Updated background, guidelines, and evidence-based scientific references.

CC5 edited to limit lead screening to children at increased risk and specify frequencies: monthly at 6, 9, 12 months and annually from age 2 to 6.

CPT code 86481 added to the policy.

CPT codes 86850, 87555, 87556, 0257U removed.

HIV and Hepatitis B screening CPT codes removed and coverage moved to other policies (G2157, G2036, M2116).

CPT codes 83020 and 83021 added as correct codes for sickle cell testing.

CC8b.ii age specification changed to 'For individuals 17 years of age.'

Multiple CCs edited for clarity and high-risk situation lists moved into Notes 1-5.

9Explicit covered screening categories listed

newborn-18Age range covered (newborn to 18 years)

1Material coverage change (2025-09-01)

>=1CPT codes added

>=20CPT codes removed/updated across revisions

Covered Pediatric Preventive Screenings Overview

This policy covers laboratory-based preventive screening tests performed on individuals from newborn through age 18, excluding newborn screening for genetic disorders. It aligns with Bright Futures/AAP periodicity recommendations and other society guidelines (e.g., USPSTF, CDC) for pediatric preventive care. Newborn screening is addressed when it follows applicable federal and state law recommendations and RUSP guidance, noting that individual states determine required newborn screening panels and that federal/state regulations and Medicare/Medicaid policies take precedence where applicable.

Bright Futures and the American Academy of Pediatrics (AAP) periodicity schedule are primary references for recommended screenings and timing; the policy also references USPSTF and CDC recommendations and applicable state and federal regulations (including the Secretary of HHS/RUSP and CLIA/FDA/Laboratory-developed test considerations) to reflect variation in newborn screening panels and regulatory requirements.

Applicable CPT/HCPCS Codes

Covered/Applicable CPT/HCPCS codes referencedmixedCovered

80061	Lipid panel (Cholesterol total 82465, HDL 83718, Triglycerides 84478)
82247	Bilirubin; total
82248	Bilirubin; direct
82465	Cholesterol, serum or whole blood, total
83020	Hemoglobin fractionation and quantitation; electrophoresis
83021	Hemoglobin fractionation and quantitation; chromatography
83655	Lead
83718	Lipoprotein, direct measurement; HDL
84439	Thyroxine; free
84443	Thyroid stimulating hormone (TSH)

1–10 of 18

1/2

Removed codes (per revision history)CPTNot Covered

86850	Removed - previously listed
87555	Removed - previously listed
87556	Removed - previously listed
0257U	Removed - previously listed

CPT codes addedCPTCovered

86481	Added to policy (specific test not described in this part)
83020	Sickle cell testing (added per 03/10/2023 note)
83021	Sickle cell testing (added per 03/10/2023 note)

CPT codes removedCPTNot Covered

86850	Removed (per 09/01/2025 revision)
87555	Removed (per 09/01/2025 revision)
87556	Removed (per 09/01/2025 revision)
0257U	Removed (per 09/01/2025 revision)
86689	HIV code removed (moved to G2157)
86703	HIV code removed (moved to G2157)
87390	HIV code removed (moved to G2157)
87391	HIV code removed (moved to G2157)
87534	HIV code removed (moved to G2157)
87535	HIV code removed (moved to G2157)

1–10 of 38

1/4

Policy cross-references (screening moved)mixed

G2036	Policy referenced for Hepatitis B screening (all ages)
G2157	Policy referenced for diagnostic testing of common STIs and HIV screening (all ages)
M2116	Policy referenced for HIV screening (moved to M2116 per earlier note)
G2050	Policy referenced for dyslipidemia coverage in individuals 18+ (Cardiovascular Disease Risk Assessment)
AHS-G2006	Referenced for Hemoglobin A1c screening guidance (CC12 moved to note referencing this policy)

Billing, Documentation and Practice Impacts

Documentation Required

Apply risk assessment for lead, iron deficiency, TB and dyslipidemia

Providers must document that the child meets the specified risk criteria before billing for targeted screenings. The policy requires documentation that the patient meets risk definitions in Notes 1-4 for lead exposure, iron deficiency, tuberculosis, and dyslipidemia. This documentation supports billing only when the targeted screening criteria and specified frequencies apply.

Note 1: Lead exposure risk factors (CDC)
Note 2: Iron deficiency risk factors (AAP)
Note 3: TB risk factors (AAP)
Note 4: Dyslipidemia risk factors (AAP)

Billing Rule

Use appropriate CPT/HCPCS codes for covered screenings

Clinical and Policy Background

Evidence: The CDC estimated that newborn screening programs identify approximately 12,500 diagnoses per year (~1/4,000 live births) with about 5,000 severe disorders identified annually and an estimated program cost of approximately $30 per infant. These findings support newborn screening as an impactful public health intervention.

Background and revision rationale: Bright Futures/AAP recommendations and CDC guidance inform the policy's screening schedule. A literature review prompted the 09/01/2025 revision to limit routine lead testing to children at increased risk; the policy was edited (CC5) to specify that blood lead screening MEETS COVERAGE CRITERIA only for individuals at increased risk (see Note 1) with defined frequencies: one test per month at 6, 9, and 12 months and one test per year from 2 through 6 years of age. These changes align coverage with AAP, CDC, and USPSTF guidance emphasizing targeted lead testing based on risk assessment.

Alignment with guidelines: The policy explicitly references and aligns with Bright Futures/AAP periodicity recommendations for pediatric screening, CDC recommendations on lead testing and the blood lead reference value, and USPSTF statements where applicable (including recognized insufficiency of evidence for universal lead screening in asymptomatic 1–5 year olds). The policy therefore supports targeted, guideline-consistent screening practices and documents the evidence and rationale for the 2025 coverage update.

Lead screening thresholds and frequencies for at-risk children

Blood Lead Reference Value (BLRV)CDC updated BLRV to 3.5 µg/dL

Key Definitions

Adolescent: Defined per WHO as a person between the ages of 10 and 19 years.

Increased risk for lead exposure: As defined in Note 1 of the policy (CDC risk factors include living or spending time in a house or building built before 1978; low-income household; recent immigrant, refugee, or recently adopted from less developed countries; living or spending time with a person who works with lead or has lead-exposing hobbies). Note 1 is referenced here; the full note text is provided elsewhere in the policy.

Policy Revisions and Material Changes

2025-09-01material_changeLatest

09/01/2025 material revision: CC5 edited to limit blood lead screening to children at increased risk and to specify frequencies (one test per month at 6, 9, 12 months; one test per year from age 2 to 6). Background, guidelines, and references updated; CPT code 86481 added; CPT codes 86850, 87555, 87556, and 0257U removed.

2025-09-01coding_change

09/01/2025 coding updates noted in revision history: added CPT 86481 to the applicable procedure codes and removed CPTs 86850, 87555, 87556, 0257U.

2023-03-10coding_change

Policy Summary

Payerblue cross blue shield - louisiana

PolicyG2042: Pediatric Preventive Screening

Policy CodePolicy AHS - G2042 - Pediatric Preventive Screening

Change TypeCoverage criteria modified (risk-based lead screening) + CPT code updates

Effective DateSep 1, 2025

Next Review Date

SourceLink

On This Page

Report the applicable CPT/HCPCS codes listed in the policy when billing for covered pediatric preventive screening tests. Use the codes applicable to the service provided and the state/federal regulations that apply.

80061
83655
84443
85018
S3620

Prior Authorization

Benefit determination dependent on individual's coverage

Coverage and payable services depend on the member's benefits at the time of the request. Providers should verify individual member benefits and consult applicable Medicare and Medicaid rules or local coverage determinations prior to billing.

Documentation Required

Document increased risk for lead exposure

To meet the policy's coverage frequencies for lead screening, providers must identify and document that the child is at increased risk for lead exposure per Note 1. Documentation of lead risk factors (see Note 1) is required before billing for targeted lead screening at the specified intervals.

Billing Rule

Use updated CPT codes

Providers must bill using the updated CPT codes listed in the policy. The policy notes that CPT code 86481 was added and that multiple CPT codes were removed in the revision history; use current, active CPT codes when billing.

86481
83020
83021

Billing Rule

Do not bill removed CPT codes under this policy

Do not bill CPT codes that were removed from this policy for services covered under AHS-G2042. HIV and Hepatitis B screening CPT codes were moved to other policies as indicated in the revision history; providers should bill those services under the referenced policies.

86850
87555
87556
0257U
86689
86703
87390
87391
87534
87535
87536
87537
87538
87539
87806
S3645
86704
86705
86706
87320
87340
87341
87516
87517
85660

Lead screening — ages 6, 9, 12 months

One blood lead test per month at 6, 9, and 12 months for children at increased risk

Lead screening — ages 2 to 6 yearsOne blood lead test per year from age 2 to 6 for children at increased risk

ApplicabilityScreening meets coverage criteria only for children who are at increased risk for lead exposure (see Note 1)

Risk factors referenceRisk factors include living in pre-1978 housing, low-income household, recent immigrant/refugee/adopted, or household member with lead-related work/hobby

03/10/2023 coding enhancement: removed CPT 85660 (sickledex/solubility assays not reliable in newborns) and added CPTs 83020 and 83021 as the correct codes for sickle cell testing.

2023-09-01off_cycle_reorganization

Off-cycle reorganization (09/01/2023): HIV and Hepatitis B screening CPT codes and coverage were moved to other policies (Hep B to G2036, STIs to G2157, HIV to M2116); numerous HIV and Hep B CPT codes removed from this policy.