Modifiedblue cross blue shield - louisianaPolicy AHS - G2042

Pediatric Preventive Screening

Covers laboratory-based preventive screening tests for individuals newborn through age 18 (excluding newborn genetic disorder panels governed by state newborn screening mandates); establishes which pediatric screening tests meet coverage criteria and references related testing policies. Affects providers submitting claims to Blue Cross and Blue Shield of Louisiana.

Policy Summary

Payerblue cross blue shield - louisiana

PolicyPediatric Preventive Screening

Policy CodePolicy AHS - G2042

Change TypeMaterial edits to lead screening frequency and CPT code list

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionDocument patient age and lead exposure risk factors and follow the revised risk‑based lead screening frequency when ordering tests.

SourceLink

POLICY UPDATE CHANGES

CC5 edited to reflect that lead screening should be limited to children at an increased risk for lead exposure with specified testing frequencies.

Added CPT code 86481 to the policy's procedure code list.

Removed CPT codes 86850, 87555, 87556, 0257U (and others listed historically) from the policy.

newborn→18age range covered

1tests per month (6/9/12 mo) for at-risk

1tests per year (2-6 yrs) for at-risk

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36 core, 26 secondaryRUSP disorders listed

Coverage Criteria — Pediatric Preventive Laboratory Screening

Covered pediatric preventive laboratory screenings

Covered when ALL of the following age- and risk-based conditions are met as specified by the policy:

Newborn mandatory screenings: Newborn screening panel, hyperbilirubinemia, congenital hypothyroidism (serum T4 and/or TSH), and sickle cell disease meet coverage criteria for all newborns when following applicable federal/state law.

References RUSP and state mandates for newborn panels.

Lead screening - increased risk: For individuals at increased risk for lead exposure, blood lead screening meets coverage criteria: one test per month at 6, 9, and 12 months; one test per year from age 2 through 6 years.

See Note 1 for CDC-defined risk factors.

Anemia (Hgb/Hct): Screening for anemia with hemoglobin or hematocrit determination meets coverage criteria for: (a) all individuals at 12 months of age; (b) individuals 4 months and older who are at risk for iron deficiency.

See Note 2 for AAP-defined iron deficiency risk factors.

Tuberculosis screening: For individuals 1 month of age or older who are at increased risk of contracting tuberculosis, tuberculosis screening meets coverage criteria.

See Note 3 for AAP TB risk factors.

Dyslipidemia screening: Screening with fasting lipid profile or non-fasting non-HDL-C meets coverage criteria: (a) annually for children/adolescents at increased risk due to personal or family history; (b) once during ages 9-11 and once at age 17.

See Note 4 for dyslipidemia risk factors.

Lead screening and guideline alignment

Covered when criteria below are met (excerpted changes and references appear in this part of the document).

Lead screening for at-risk children

Infants 6-12 months: One test per month at six, nine, and twelve months.
Children 2-6 years: One test per year from two years of age to six years of age.

Guideline alignment: Policy references CDC, AAP, USPSTF recommendations: targeted lead testing, risk-based dyslipidemia and iron screening guidance, and newborn screening per RUSP/state panels.

Policy cites multiple guideline sources (see references).

Newborn genetic disorder screening is governed by state newborn screening mandates and the federal Recommended Uniform Screening Panel (RUSP). This policy excludes routine coverage determinations for state-mandated newborn genetic disorder panels — such panels and any associated testing requirements are implemented at the state level and follow applicable state law and public health programs. Providers should follow the applicable state newborn screening requirements when ordering or billing newborn metabolic/genetic panels.

The United States Preventive Services Task Force (USPSTF) has concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for elevated blood lead levels in asymptomatic children ages 1–5 years. Accordingly, the USPSTF does not recommend universal lead screening for this age group in children without increased risk; targeted, risk-based testing is indicated when risk factors are present.

The USPSTF finds the evidence insufficient to recommend routine dyslipidemia screening in children and adolescents aged ≤20 years. Similarly, the USPSTF deems the evidence insufficient to support universal screening for iron deficiency in children aged 6–24 months. The policy follows these USPSTF determinations and aligns coverage toward risk-based screening consistent with AAP recommendations.

For additional USPSTF context: the USPSTF assigned an insufficient evidence grade to dyslipidemia screening by fasting lipid panel in children and adolescents and to iron deficiency screening by complete blood count in young children. Where USPSTF evidence is insufficient, the American Academy of Pediatrics (AAP) risk-based recommendations (for example, screening at 12 months for iron deficiency and targeted dyslipidemia assessments) are used to guide coverage decisions.

Procedure Codes and Reference Values

Covered CPT CodesCPTCovered

80061	Lipid panel This panel must include Cholesterol total, HDL, Triglycerides (components listed)
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 cholesterol
84439	Thyroxine; free
84443	Thyroid stimulating hormone (TSH)

1–10 of 18

1/2

CDC Blood Lead Reference Value (BLRV)

CDC BLRV (numeric)3.5 µg/dL

BLRV purposeMetric to identify children with blood lead levels higher than most (97.5th percentile)

CDC BLRV update dateUpdated May 14, 2021 (from 5 µg/dL to 3.5 µg/dL)

Blood Lead Reference Value (BLRV)

Blood Lead Reference Value (BLRV)3.5 µg/dL

Used to identify children above the 97.5th percentile for blood leadIndicates children with blood lead levels higher than most other children

Source references

Provider Actions, Documentation, and Billing Notes

Denial Risk

Benefit verification required

Coverage is dependent on the member's benefit at the time of the request. Providers must verify the individual's coverage, benefit limitations, and any applicable member cost-share before ordering or performing testing. Tests that do not follow the member's benefit rules or that are not covered under the member's plan may be denied.

Benefit verification required: confirm individual benefits, limitations, and applicable member cost-share prior to testing.
Tests inconsistent with benefit rules may be denied.

Documentation Required

Clinical documentation of indication

Document the clinical indication for testing in the medical record. At a minimum include: patient age, specific risk factors or exposures (e.g., lead exposure risk, tuberculosis risk, family history for dyslipidemia), relevant symptoms or findings, and reference to applicable guideline-based recommendations (e.g., AAP/Bright Futures, USPSTF) used to justify testing.

Background and Purpose

Preventive screening across the newborn, child, and adolescent population aims to detect disease early and promote health across developmental stages. National guidance such as Bright Futures (AAP/HRSA) provides age-based periodicity schedules that specify which laboratory screenings are recommended at well-child visits. Newborn screening programs, guided by state mandates and the federal RUSP, identify conditions (for example, metabolic disorders, congenital hypothyroidism, and hemoglobinopathies) using validated laboratory methods to enable early intervention and improved outcomes.

Definitions and Abbreviations

Adolescent definition

Adolescent (WHO)Any person between the age of 10 and 19 years

Context of use in policyDefines age group for pediatric preventive screening guidance (newborn through 18 years referenced elsewhere)

SourceWorld Health Organization definition cited in policy

RUSP

RUSPRecommended Uniform Screening Panel — federal list of conditions recommended for newborn screening

Policy usageReferences RUSP when describing newborn screening mandates and covered newborn tests

Abbreviation listed in terminology table

Policy Summary

Payerblue cross blue shield - louisiana

PolicyPediatric Preventive Screening

Policy CodePolicy AHS - G2042

Change TypeMaterial edits to lead screening frequency and CPT code list

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionDocument patient age and lead exposure risk factors and follow the revised risk‑based lead screening frequency when ordering tests.

SourceLink

On This Page

CDC Blood Lead Reference Value (updated March 7, 2025) and CDC guidance

Record patient age and relevant risk factors or exposures.
Cite the guideline or recommendation supporting the test (for example, AAP/Bright Futures or USPSTF).
Include prior risk assessments or screening results when applicable (e.g., lead risk assessment).

Prior Authorization

Prior authorization

No explicit prior authorization requirement is stated in this policy. Coverage of tests is governed by the member's benefit terms and applicable federal/state rules; when government policy (Medicare/Medicaid) conflicts with this policy for a particular member, the government policy prevails.

No prior authorization required by this policy; verify member-specific requirements.
Government policies (LCD/NCD or state Medicaid) supersede this policy when applicable.

Step Therapy

Step therapy

No step therapy requirements are specified in this policy for the listed screens.

Billing Rule

Coding documentation

Providers should document the specific tests performed (test name and method) and the clinical indication supporting each test. The listed CPT/HCPCS codes are provided for general reference only and may not be all-inclusive; bill using the code that accurately describes the service provided.

Procedure codes in the policy are for reference and may not be comprehensive.
Document the test method (e.g., serum TSH, transcutaneous bilirubin) and clinical rationale when submitting claims.

Note

Include a provider-action placeholder for any additional provider steps required by source text or local practice; populate this if applicable.

RUSP defined in Table of Terminology

BLRV

BLRV (term)Blood Lead Reference Value — metric to identify children with elevated blood lead levels (97.5th percentile)

Clinical implicationUsed to identify children at increased blood lead exposure for targeted testing

Policy referenceCDC BLRV referenced as basis for lead screening recommendations in policy

S3620

S3620 descriptionNewborn metabolic screening panel, includes test kit, postage and the laboratory tests specified by the state for inclusion in this panel

IncludesState-specified tests such as galactose, hemoglobin electrophoresis, hydroxyprogesterone (17-OH), phenylalanine (PKU), and total thyroxine

Use in policyListed among applicable CPT/HCPCS codes for newborn screening panels