CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPOO6

Preventive Services Policy

Governs coverage, coding, and reimbursement rules for preventive services (USPSTF, ACIP, HRSA, Bright Futures) for BCBSNM members and providers submitting claims.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPreventive Services Policy

Policy CodePolicy CPCPOO6

Change TypeNo material changes

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionVerify member benefits and prior authorization requirements (including use of Modifier 33/PT) before submitting preventive service claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

No cost-shareNo cost-share

ManyProcedure codes

PA/Modifier 33Modifiers/PA noted

Non-grandfatheredApplies to plans

30+USPSTF topics

Preventive Coverage Criteria

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Preventive coverage criteria

Covered when ALL of the following are met:

Service aligns with a USPSTF Grade A or B recommendation, ACIP, HRSA, or Bright Futures guidance

See referenced agency recommendations for specific services.

Service is furnished by an in-network provider (non-grandfathered plans) to qualify for no member cost-share

Preventive services obtained out-of-network are subject to copay, deductible, and coinsurance.

Claim includes an appropriate preventive diagnosis code and preventive procedure code

Claims must meet medical policy review criteria and use valid HIPAA-approved code sets.

Service falls within applicable plan guidelines and medical policy criteria

Coverage and application determined by BCBSNM; providers should exercise clinical judgment.

Exceptions and special reimbursement rules

Some services have additional reimbursement rules or prior authorization requirements:

ONE of

Certain colorectal cancer screening services may be subject to medical policy criteria and may require prior authorization
Modifier 33 or PT may be payable with a Diagnosis List 1 code; polypectomy during preventive colonoscopy and related services may be reimbursable at preventive level when billed appropriately.
Sedation procedure codes for colonoscopy will process at the preventive level only when billed with Z12.11 or Z12.12
See colorectal screening guidance for applicable sedation codes and billing.

BRCA-related genetic counseling and testing services are subject to medical policy and may require prior authorization

Genetic testing and counseling services follow Medical Policy prior authorization processes.

Procedure 96127 is reimbursable at the preventive level only when billed with specified preventive diagnosis codes (e.g., Z00.129 and others listed)

Reference the document’s diagnosis list for allowable preventive diagnosis codes.

Selected preventive services coverage criteria

Coverage guidance for selected USPSTF/HRSA/ACIP recommendations (procedure codes and billing notes):

Gestational diabetes screening: screen at 24 weeks or aftercodes: 82947, 82948, 82950, 82951, 82952, 83036

Payable with a pregnancy diagnosis.

Hepatitis B screening in pregnancy: screen at first prenatal visitcodes: 86705, 86706, 86707, 87340, 87341, 80074, 80076

Payable with a pregnancy diagnosis or Diagnosis List 1 as specified.

Hepatitis C screening: adults age 18–79codes: 86803, 86804, 87520, 87521, G0567

Payable with pregnancy diagnosis or Diagnosis List 1 where specified.

Preventive service coverage criteria

Preventive services are reimbursable when aligned with USPSTF/HRSA/ACIP recommendations and billed with appropriate procedure and diagnosis codes:

Vision screening for children aged 3–5: at least once to detect amblyopia or risk factorscodes: 99172, 99173, 0333T

Payable when billed per guidance and with Diagnosis List 1 codes as specified.

Cervical cancer screening for average‑risk women 21–65: cytology alone or cotesting per age rangescodes: 87624, 88141–88167 (examples)

Payable with appropriate diagnosis codes from Diagnosis List 1.

Well‑woman visits: at least one preventive visit per year across the lifespancodes: 99384–99387, 99394–99397 and related preventive CPTs

Labs for normal pregnancy reimbursable at preventive level when billed with pregnancy diagnosis.

Preventive services coverage conditions

Reimbursement is provided for specified preventive services and equipment when billed with the appropriate procedure and diagnosis codes (Diagnosis List 1 where specified):

Urinary incontinence screening: recommended annually and reimbursable as part of the preventive office visit

There are no service‑specific procedure codes; payable with a Diagnosis List 1 code.

Well‑woman visits: at least one preventive visit per year and associated preventive CPTs listed

Labs administered as part of a normal pregnancy are reimbursable at the preventive level when billed with a pregnancy diagnosis.

Vaccines and administration: ACIP‑recommended vaccines and listed administration codes are payable at the preventive level

Some vaccines may require a Diagnosis List 1 code for preventive reimbursement; see vaccine code listing.

Screening assessments (Bright Futures): developmental, behavioral, anemia, lead, hearing, vision, maternal depression, STI/HIV, newborn screenings and related labs are payable when billed with Diagnosis List 1 codes

Procedure, Vaccine, and Supply Codes

Abdominal aortic aneurysm screeningCPTCovered

76706

Abdominal aortic aneurysm screening, ultrasound

Behavioral and screening codesCPTCovered

99408	Alcohol and/or substance abuse structured screening and brief intervention
96127	Brief emotional/behavioral assessment

Colorectal screening codesCPTCovered

45378	Diagnostic colonoscopy
74263	Imaging related to colorectal screening (procedure 74263)

Diabetes/pregnancy screening labsmixedCovered

82947, 82948, 82950, 82951, 82952, 83036

Glucose and related laboratory codes for gestational diabetes and diabetes screening

HIV PrEP medication code exampleHCPCS | mixedCovered

J0739

HIV PrEP injectable (cabotegravir) listed among PrEP-related items

Cancer and lab screening codesmixedCovered

71271	Low-dose chest CT for lung cancer screening
80055, 80081	Syphilis and other serology/laboratory panel codes referenced for screening

Breastfeeding equipment and servicesHCPCSCovered

E0602	Electric/manual breast pump (manual E0602 listed)
S9443	Breastfeeding/lactation counseling

Cervical cancer screening codesCPTCovered

87624	HPV testing (example code listed)
88141	Cytopathology code (Pap test)

Well-woman visit codesCPTCovered

99395

Periodic comprehensive preventive medicine reevaluation and management

Well-woman / preventive visit codesCPTCovered

99384-99387, 99394-99397, 99381-99383, 99391-99395	Preventive medicine service CPT codes for new and established patients / well-woman visits
99401-99404, 99411-99412	Preventive counseling codes referenced for well-woman and prenatal visits

Vaccines and administrationCPT | HCPCSCovered

90632-91322 (various vaccine CPT/HCPCS)	Vaccine product codes listed for preventive reimbursement (COVID-19, DTaP, HepA, HepB, Hib, HPV, Influenza, etc.)
90460-90474, 96380-96381	Immunization administration codes

Screening codesmixedCovered

96110, 96127, 99408-99409	Screening and assessment codes (developmental/autism, brief behavioral/depression, substance use)
85014, 85018, 80061	Laboratory screening codes (anemia, hemoglobin/hematocrit, lipid panel)

Breastfeeding equipmentHCPCSCovered

E0602, E0603, E0604, A4281-A4286

Breast pump and supply HCPCS codes (manual, electric, hospital-grade pumps and replacement supplies)

Preventive-level reimbursement for procedure code 96127

Procedure code96127 (Brief emotional/behavioral assessment)

Preventive-level condition96127 is reimbursable at the preventive level ONLY when billed with an appropriate preventive diagnosis (e.g., Z00.129 and other Diagnosis List 1 codes)

Associated recommendationsUsed for USPSTF-recommended behavioral health screenings (anxiety, substance use, etc.) when preventive criteria are met

Lung cancer screening eligibility

Age rangeAdults aged 50–80 years

Smoking historyAt least a 20 pack-year smoking history and currently smoke or have quit within the past 15 years

Discontinuation rulesScreening should be discontinued after 15 years of smoking cessation or if the person develops a comorbidity that makes them unable to undergo curative lung surgery

Electric breast pumps per benefit

Benefit limitElectric breast pumps (E0603) are limited to one per benefit period

Service contextCovered as part of comprehensive lactation support per the Women's Preventive Services Initiative

Supply codesReplacement supplies (A4281–A4286) reimbursable at preventive level

Hospital-grade pump coverage

Coverage typeHospital-grade breast pumps are covered as rental-only equipment

Billing codesG0513 and G0514 are payable when billed with a diagnosis from Diagnosis List 1

Provider requirementRental must be In-Network or from an In-Network durable medical equipment supplier for preventive-level coverage

Hospital-grade breast pump purchase cap

Purchase cap / rental limitHospital-grade breast pump coverage is up to the purchase price of $1,000 or up to 12 months of rental, whichever comes first

Return requirementAt the end of coverage the unit must be returned to the durable medical equipment supplier

Benefit frequencyMembers are allowed one breast pump per benefit period

Prior Authorization, Billing Guidance, and Provider Responsibilities

Prior Authorization

Prior authorization and modifier notes for colorectal screening — may require PA

Certain colorectal cancer screening services may require prior authorization and specific billing modifiers. When applicable, use Modifier 33 or PT and bill with a diagnosis from Diagnosis List 1 to receive preventive-level reimbursement. If a polyp is removed during a preventive colonoscopy, the colonoscopy, polypectomy, and related labs/services are reimbursable at the preventive level. Sedation codes (99152, 99153, 99156, 99157, G0500) and procedure 74263 may process at the preventive level when billed with the listed preventive diagnosis codes.

Affected codes: 45378, 45380, 45381, 45384, 45385, 45388, 74263, 88304, 88305, G0104, S0285
Modifiers: Modifier 33 or PT may be required
Action: Verify medical policy and obtain prior authorization when required

Prior Authorization

Prior authorization for BRCA services — may require PA

BRCA counseling and testing services follow Medical Policy and may require prior authorization. Providers should confirm applicability of preventive-level reimbursement and obtain any required preauthorization before scheduling testing or extended counseling sessions.

Affected codes include: 81212, 81215–81217, 81162–81167, 99385–99387, 99395–99397, 99401–99404, G0463, S0265, 96041
Action: Check Medical Policy and request PA when indicated

Prior Authorization

Preauthorization for lung cancer LDCT — may require PA

Low-dose CT lung cancer screening (LDCT, CPT 71271) is subject to Medical Policy criteria and may require preauthorization. Procedure code 71271 is reimbursable at the preventive level only when medical policy criteria are met and the required smoking-related diagnosis codes are billed.

Affected codes: 71271
Required diagnosis examples: F17.200, F17.201, F17.210, F17.211
Action: Confirm medical necessity against policy and obtain preauthorization when required

Documentation Required

Benefit verification recommended — contact member card for benefit and pharmacy details

Always verify member benefits prior to service. For details about covered services, prior authorization requirements, and pharmacy benefit management, contact the phone number on the member's BCBSNM ID card. A patient's pharmacy benefit may be managed by a third party, which can affect coverage and where contraceptives or other medications are billed.

Action: Call the number on the member card to confirm medical and pharmacy benefits, coverage rules, and any prior authorization or step edits
Note: Pharmacy-covered contraceptives may be managed by another company

Billing Rule

Contraception billing guidance — medical vs pharmacy benefit; modifier 33 notes

Contraceptive methods that require a prescription may be covered under either the medical or pharmacy benefit. For pharmacy benefit coverage details and whether a prescription or prior authorization is required, contact the number on the member’s BCBSNM card. Certain contraceptive procedures are reimbursable at the preventive level only with proper diagnosis codes or modifier 33.

Procedure code 58340: reimbursable at preventive level only when accompanied by modifier 33 or diagnosis codes 230.2, 230.40, 230.42, 230.49, 298.51
Procedure codes 11981–11983: covered only when FDA-approved contraceptive IUDs are used
Action: Verify whether coverage is medical vs pharmacy and obtain PA or use modifier 33 when required

Billing Rule

Breastfeeding equipment reimbursement rules and provider billing actions

Coverage rules for breastfeeding equipment and supplies vary by item and provider type. Manual pumps (E0602) are purchasable and covered at the preventive level when obtained in-network or from retail providers; electric pumps (E0603) may be purchased or rented, one per benefit period; hospital-grade pumps (E0604) are limited to rental in-network and subject to purchase-price/$1,000 or 12-month rental limits. G0513 and G0514 are payable when billed with a Diagnosis List 1 code. Non-physician lactation providers (e.g., Certified Lactation Counselors, IBCLCs) are reimbursable only for specific codes.

E0602 — manual pump: purchase allowed, preventive-level when in-network/retail
E0603 — electric pump: purchase or rental, one per benefit period; upgraded models may balance-bill the member
E0604 — hospital grade: rental only in-network, coverage up to $1,000 or 12 months; unit must be returned at end of coverage
Supply HCPCS: A4281, A4282, A4283, A4284, A4285, A4286 — preventive-level when allowed
G0513, G0514 — payable when billed with a Diagnosis List 1 code
Non-physician lactation codes payable: S9443, 98960, 98961, 98962
Action: Providers should verify member eligibility, bill with the correct diagnosis codes or modifiers, and follow rental vs purchase rules to avoid denials

Key Definitions and Lists

United States Preventive Services Task Force (USPSTF)

AcronymUSPSTF = United States Preventive Services Task Force

RoleIdentifies preventive screening and counseling recommendations referenced for coverage determinations

ApplicationUSPSTF A or B recommendations are used to determine preventive services covered at no member cost-share for non-grandfathered plans

Advisory Committee on Immunization Practices (ACIP)

AcronymACIP = Advisory Committee on Immunization Practices

RoleProvides vaccine recommendations used to determine preventive vaccine coverage

ApplicationACIP recommendations cited for vaccine product and administration coverage at preventive level

Health Resources and Services Administration (HRSA)

AcronymHRSA = Health Resources and Services Administration

RoleSource of Women's Preventive Services Initiative recommendations (e.g., gestational diabetes, breastfeeding) used for coverage determinations

ApplicationHRSA recommendations referenced for pregnancy-related screening and women's preventive services

preventive-level

DefinitionPreventive-level reimbursement: payment of specified services without member cost-share when services align with federal preventive recommendations and are billed with appropriate preventive diagnosis codes

Billing conditionClaims must include preventive procedure and an appropriate diagnosis from Diagnosis List 1 to qualify for preventive-level payment

ApplicabilityApplies to non-grandfathered plans and in-network services unless otherwise noted

Diagnosis List 1

ReferenceDiagnosis List 1 = the set of diagnosis codes referenced throughout the policy that must be used to qualify many services for preventive-level reimbursement

UsageFrequently required when billing preventive services (vaccines, screenings, certain procedures, breastfeeding equipment) to receive preventive-level payment

LocationDiagnosis List 1 codes are enumerated in the document and referenced in service-specific billing rules

Electric breast pump

DefinitionElectric breast pump (E0603) — durable medical equipment for lactation support; covered (purchase or rental) and limited to one per benefit period

CodesHCPCS code E0603 for electric breast pumps; replacement supplies A4281–A4286 reimbursable at preventive level

Member cost/balance-billingMember may balance-bill for upgraded electric models above the standard allowance

Hospital-grade breast pump

DefinitionHospital-grade breast pump — high-capacity pump intended for clinical or intensive home use that is covered as rental-only equipment

BillingReimbursable via rental codes (e.g., G0513, G0514) when billed with an appropriate Diagnosis List 1 code and rented In-Network

Coverage limitsCoverage limited to rental; purchase coverage not provided except as rental cost up to $1,000 or 12 months as specified

Preventive vs Diagnostic services

Preventive servicesServices intended to prevent illness or identify issues before symptoms are evident (e.g., screening tests, counseling interventions)

Diagnostic servicesServices for diagnosis of existing symptoms, treatment, ongoing management, or to investigate clinical concerns

Distinguishing factorPreventive vs diagnostic status affects benefit application and member cost-share under the plan

Benefit period

DefinitionBenefit period = the plan-defined interval during which a member is allowed one electric breast pump (one per benefit period)

Frequency implicationElectric and hospital-grade pump allowances are enforced per benefit period (one pump per benefit period)

Out-of-network noteBreast pumps obtained Out of Network are reimbursable at the out-of-network preventive benefit level and may include cost sharing