CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP006

Preventive Services Policy

Defines coverage, coding, and reimbursement rules for preventive services mandated by PPACA and related federal recommendations for BCBSNM members and network providers.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyPreventive Services Policy

Policy CodePolicy CPCP006

Change TypeNo material change

Effective DateNov 1, 2023

Next Review Date

Key ActionSubmit preventive claims with a preventive diagnosis code and preventive procedure code and follow medical policy criteria; some services may require prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1.0policy version

2023-11-01effective date

2023-10-16approval date

USPSTF/ACIP/HRSApreventive recommendations

~60+codes listed

Preventive Service Coverage Criteria

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inv-01: Preventive Coverage Criteria

Covered when ALL of the following are met:

Non-grandfathered plans: USPSTF Grade A and B recommendations, ACIP, HRSA, and Bright Futures preventive services are covered with no copay, deductible, or coinsurance when obtained from an in-network provider.

Claims must include a preventive diagnosis code and a preventive procedure code, meet medical policy review criteria, and fall within the applicable USPSTF/ACIP/HRSA/Bright Futures guideline to process at the preventive level with no member cost-share.

Services obtained out-of-network are subject to the member's plan copay, deductible, and coinsurance per plan documents.

Grandfathered plans are not required to provide preventive services at no member cost-share but may elect to do so.

Some preventive services may be subject to medical policy criteria and prior authorization; providers should submit additional documentation upon request and follow medical policy review criteria for preventive processing.

inv-02: Preventive coverage criteria and billing conditions

Selected preventive services and the billing conditions under which they are reimbursable at the preventive level or require specific diagnosis codes, pregnancy diagnosis, or preauthorization:

Hepatitis B screening in pregnant women payable when billed with a pregnancy diagnosis or a diagnosis code from Diagnosis List 1.

Hepatitis C screening payable with a pregnancy diagnosis or a diagnosis code from Diagnosis List 1.

Hypertension screening/out-of-office blood pressure monitoring procedure codes (e.g., 93784, 93786, 93788, 93790, 99473, 99474) are reimbursable at the preventive level when billed with specified diagnosis codes (e.g., R03.0, R03.1, 201.30, 201.31).

HIV screening and PrEP-related services: HIV screening payable with a Diagnosis List 1 code where specified; baseline and monitoring services related to PrEP are reimbursable at the preventive level. Pharmacy benefit details should be confirmed via the number on the member's BCBS card.

Lung cancer screening (LDCT) is subject to medical policy criteria and requires preauthorization; procedure code 71271 is reimbursable at the preventive level only if criteria are met and it is billed with one of the specified smoking-related diagnosis codes.

inv-03: HRSA/USPSTF preventive service coverage criteria (excerpted)

Excerpts of HRSA/USPSTF/ACIP recommendations with key reimbursement notes:

Anxiety screening (HRSA): procedure code 96127 is reimbursable at the preventive level only when billed with an approved diagnosis code (examples listed in policy).

Breastfeeding services and supplies (HRSA): comprehensive lactation support including double electric breast pumps is recommended; electric pumps are limited to one per benefit period and hospital-grade pumps are rental-only; certain lactation service and equipment codes (e.g., E0602, E0603, E0604, A4281–A4286, G0513, G0514) are listed for reimbursement rules.

Cervical cancer screening (HRSA): age- and interval-based screening recommendations are provided (21–29 cytology every 3 years; 30–65 cotesting every 5 years or cytology every 3 years) with listed procedure codes for billing.

Contraceptive methods and counseling (HRSA): full range of FDA‑approved contraceptives and related services recommended; some procedures may be reimbursable at the preventive level only with specific modifiers or diagnosis codes; pharmacy coverage varies by plan.

inv-04: Preventive services coverage criteria

Preventive vaccines, Bright Futures pediatric services, and breast pump/supply reimbursement rules and limits:

ACIP vaccines and administration codes listed in the policy are payable at the preventive level when they correspond to ACIP recommendations and plan terms; specific vaccine codes are enumerated in the ACIP section of the policy.

Bright Futures pediatric screening and counseling services are payable when billed with an appropriate diagnosis code from Diagnosis List 1 when required; many listed Bright Futures procedure codes require Diagnosis List 1 for preventive-level reimbursement.

Breast pump coverage rules: manual pumps (E0602) are covered at the preventive level when obtained in-network or from retail; electric pumps (E0603) must be rented or purchased from an in‑network provider or contracted DME supplier and members are allowed one electric pump per benefit period; hospital‑grade pumps (E0604) are covered only when rented in‑network up to a purchase price limit of $1,000 or 12 months, whichever comes first; listed pump supplies (A4281–A4286) are reimbursable at the preventive level.

Limitations and exclusions: breastfeeding equipment and supplies not listed (e.g., batteries, creams, storage bags, cleaning supplies, travel cases, infant scales, nursing bras) are excluded; immunizations not published in CDC MMWR or not FDA-licensed are excluded; pharmacy coverage may vary and may require prescriptions or step therapy per plan terms.

Accepted Codes, Examples, and Coding Guidance

Accepted code sets and coding guidancemixed

CPT, HCPCS, ICD-10, NDC, DRG

Acceptable code sets and coding guidelines expected for claims submission

Example preventive procedure codesCPTCovered

76706

AAA screening ultrasound — reimbursable as preventive when submitted with specified diagnosis codes

USPSTF-specific code examplesmixedCovered

77061-77067	Screening mammography codes — payable with Diagnosis List 1
G0101, G0123, G0141, 88141-88175, 87623	Cervical cancer screening and cytology/HPV testing codes
45378, 45380-45384, G0106, 82270, 82274	Colorectal cancer screening procedure codes

Representative CPT/HCPCS codes referencedmixed

G0447	Intensive behavioral counseling for obesity
71271	Low-dose CT for lung cancer screening (LDCT)
93784	Ambulatory blood pressure monitoring (example code for hypertension screening)
80055	Hepatitis B panel (example code listed under hepatitis B screening in pregnancy)
36415	Collection of venous blood (listed with multiple prenatal and infectious disease screenings)
96127	Brief emotional/behavioral assessment (listed under anxiety screening HRSA)

General lab panelsCPTCovered

80050	General lab panel (preventive services reference)
80053	Comprehensive metabolic panel / general lab panel

Selected preventive service and vaccine codesmixedCovered

96127	Brief emotional/behavioral assessment (anxiety screening) — preventive-level reimbursable with specified diagnosis codes
G0444	Annual depression screening
G0101	Cervical cancer screening (Pap)
G0432	HIV screening services
90707	MMR vaccine
90649	HPV vaccine
90630	Influenza vaccine

ACIP vaccine and administration codesCPT | HCPCS | mixedCovered

91318, 91319, 91320, 91321, 91322, 91304	COVID-19 vaccine product codes listed
90696, 90698, 90700, 90702, 90723	DTaP vaccine codes
90632, 90633, 90634, 90636	Hepatitis A vaccine codes
90739, 90740, 90743, 90744, 90746, 90747, 90748, 90759	Hepatitis B vaccine codes
90647, 90648	Hib vaccine codes
90649, 90650, 90651	HPV vaccine codes
90630, 90653, 90654, 90658, 90660, 90661, 90662, 90666, 90667, 90668, 90672, 90673, 90674, 90682, 90685, 90686, 90687, 90688, 90689, 90694, 90756, Q2034, Q2035, Q2036, Q2037, Q2038, Q2039	Influenza vaccine codes (multiple)
90707, 90710	MMR and MMRV vaccine codes
90644, 90733, 90734, 90619, 90620, 90621	Meningococcal vaccine codes
90670, 90677, 90732	Pneumococcal vaccine codes

1–10 of 17

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Bright Futures preventive service codesCPT | HCPCS | mixedCovered

99408, 99409	Alcohol and drug use assessment codes
85014, 85018, 36415, 36416, 83655	Anemia/hematocrit/hemoglobin and lead screening lab codes
96110	Depression and developmental/autism screening
92558, 92567, 92551, 92650-92653, V5008	Hearing screening and diagnostic audiology codes
87389-87391, 87806, G0432, G0433	HIV screening codes
86580, 99211	Tuberculosis testing and associated visit code
99173	Vision screening code
99381-99386, 99394-99395, 99401-99404	Preventive medicine and prenatal visit codes

Preventive processing requirements — claim-level requirements

Claim coding requirementsClaim must include a preventive diagnosis code and a preventive procedure code to process at the preventive level (no member cost-share)

Policy review requirementClaim must meet medical policy review criteria as described in the reimbursement information section

Alignment with authoritative guidelinesService must fall within USPSTF, ACIP, HRSA, or Bright Futures guidelines to qualify as preventive

In-network requirementPreventive-level processing (no cost-share) applies when services are provided by an in‑network provider per plan terms

Out-of-network impactPreventive services obtained out-of-network are subject to copay, deductible, and coinsurance per member's benefit plan

Lung cancer screening age and pack-year threshold — LDCT eligibility

Age rangeAdults 50 to 80 years

Smoking history threshold20 pack-year smoking history

Current or recent smoking statusCurrent smokers or those who quit within the past 15 years

Screening modality and codeAnnual low-dose computed tomography (LDCT) — CPT 71271 when criteria met

PreauthorizationSubject to medical policy criteria and requires preauthorization for preventive-level reimbursement

Statin preventive medication age/risk threshold

Age range for statin preventive therapyAdults aged 40 to 75 years

Risk factor requirementAt least 1 CVD risk factor (dyslipidemia, diabetes, hypertension, or smoking)

Estimated risk thresholdEstimated 10-year cardiovascular event risk of 10% or greater

Pharmacy benefit noticeFor drug coverage details contact number on patient's BCBS member card (pharmacy may be managed by another vendor)

Breast pump limit — electric/hospital-grade pump quantity and rental notes

Electric/hospital-grade pump availabilityBreastfeeding equipment includes double electric breast pumps, pump parts, and supplies as recommended by HRSA

Electric pump sourcingElectric pumps (E0603) must be rented or purchased from an in-network provider or contracted DME supplier

Quantity and rental ruleAccess to double electric pumps should be prioritized; electric pumps limited to one per benefit period; hospital-grade pumps limited to rental only

Supplies and provider reimbursementCertain lactation counseling and equipment codes (e.g., S9443) payable when billed as specified; non-physician lactation providers eligible for limited codes

Newborn Hep B — newborn Hep B vaccination preventive-level reimbursement notes (inpatient <90 days)

Newborn Hepatitis B preventive reimbursementHepatitis B vaccination is payable at the preventive level for newborns under 90 days of age when obtained in the inpatient setting from an in‑network provider

Relevant codesHepatitis B vaccine CPT/HCPCS codes listed in ACIP section (e.g., 90739, 90740, 90743, 90744, 90746, 90747, 90748, 90759)

Inpatient and network conditionPayment at preventive level applies only when administered inpatient and by an in‑network provider

Hospital grade pump coverage limit — dollar/period limit

Hospital-grade pump rental limitCoverage up to the purchase price of $1,000.00 or 12 months, whichever comes first (unit must be returned at end of coverage)

In-network rental requirementHospital grade breast pumps (E0604) only covered when rented in‑network or from an in‑network DME supplier

Return requirementAt the end of the rental/coverage period the unit must be returned to the DME supplier

Electric breast pump quantity limit — one electric pump per benefit period

Quantity limitOne electric breast pump (E0603) per benefit period

Sourcing requirementElectric pumps must be rented or purchased from an in‑network provider or contracted DME supplier

Manual pump and suppliesManual pumps (E0602) covered at preventive level and available for purchase in-network, out-of-network, or retail (sales tax excluded for retail)

Provider Requirements, Preauthorization, and Billing Notes

Prior Authorization

Prior Authorization and Documentation — submit documentation and obtain auth when required

Certain services may require prior authorization and supporting documentation to be reimbursed at the preventive level. To ensure preventive-level processing with no member cost share, providers must submit claims with an applicable preventive diagnosis code and preventive procedure code, and include any medical policy documentation requested. When a service is subject to prior authorization, obtain approval before rendering the service and attach authorization details and clinical documentation to the claim as required.

Preventive claims must include a preventive diagnosis code and preventive procedure code.
Services subject to medical policy criteria may require preauthorization — check medical policy and prior auth portals before scheduling.
Submit clinical documentation to support preventive-level billing (e.g., screening indication, risk factors, test results).

Billing Rule

Contraception coverage and billing notes

The full range of FDA‑approved contraceptives is covered at the preventive level. Contraceptive methods that require a prescription may be covered under either the member's medical benefit or pharmacy benefit; confirm benefit assignment via the member's BCBS member card or eligibility inquiry. For certain procedures (for example, insertion or removal), use appropriate procedure codes and modifiers: bill procedure code 58340 at the preventive level only when accompanied by modifier 33 or an acceptable preventive diagnosis from Diagnosis List 1. Codes for device insertion/removal (e.g., 11981–11983) are covered only when billed with appropriate diagnosis and in accordance with medical policy.

Full range of FDA‑approved contraceptives covered.
Prescription contraceptives may be billed to medical or pharmacy benefit — verify via member card.
Procedure code 58340 payable at preventive level only with modifier 33 or a Diagnosis List 1 code.
Codes 11981, 11982, 11983 covered only per medical policy and applicable diagnosis/modifier requirements.

Billing Rule

Vaccine coding and limited reimbursement notes

Vaccines recommended by ACIP are covered at the preventive level when billed with the appropriate vaccine CPT/HCPCS code and a preventive diagnosis as applicable. Some vaccine reimbursements have vaccine‑specific rules or age/setting limitations (for example, newborn Hepatitis B inpatient reimbursement). Verify vaccine billing rules and any additional reimbursement criteria prior to administration.

COVID‑19: 91318, 91319, 91320, 91321, 91322, 91304
DTaP: 90696, 90698, 90700, 90702, 90723
Hepatitis A: 90632, 90633, 90634, 90636
Hepatitis B: 90739, 90740, 90743, 90744, 90746, 90747, 90748, 90759 (newborn Hep B inpatient coverage for <90 days when in‑network)
HPV: 90649, 90650, 90651 (payable with Diagnosis List 1)
Influenza: 90630, 90653, 90654, 90658, 90660, 90661, 90662, 90666, 90667, 90668, 90672, 90673, 90674, 90682, 90685, 90686, 90687, 90688, 90689, 90694, 90756, Q2034

Documentation Required

Breastfeeding equipment coverage and provider sourcing requirements

Non‑grandfathered plans cover manual (E0602), electric (E0603), and hospital‑grade (E0604) breast pumps and related supplies at the preventive level, subject to in‑network sourcing and benefit limits. Electric pumps (E0603) must be rented or purchased from an in‑network provider or contracted DME supplier; members are allowed one electric pump per benefit period. Hospital‑grade pumps (E0604) are rental only in‑network and limited to either the purchase price cap of $1,000 or 12 months rental, whichever comes first; the unit must be returned at the end of coverage. Manual pumps (E0602) may be purchased from in‑network, out‑of‑network, or retail providers but retail purchases are considered out‑of‑network for non‑licensed vendors. Members selecting an upgraded pump model may be balance billed for the difference between the standard allowance and the upgraded cost.

E0602 – Manual breast pump: purchase coverage; retail purchases considered out‑of‑network when vendor not a licensed medical provider.
E0603 – Electric breast pump: must be rented/purchased from in‑network or contracted DME; one per benefit period.
E0604 – Hospital‑grade pump: rental only in‑network; limited to $1,000 purchase price or 12 months rental; return required at end of coverage.
Breast pump supplies payable at preventive level include: A4281, A4282, A4283, A4284, A4285, A4286.
Out‑of‑network breast pumps reimbursed at out‑of‑network benefit level; sales tax excluded from retail purchases.

Billing Rule

Bright Futures preventive services billing notes

Bright Futures services (screenings, counseling, and preventive visits) are payable at the preventive level when billed with the recommended procedure codes and an applicable Diagnosis List 1 code where required. Pediatric screening and counseling codes (including preventive medicine E/M codes for new and established patients and specific screening CPTs) should be billed with the preventive diagnosis to ensure no member cost share. Some Bright Futures services have age or diagnosis restrictions to qualify for preventive reimbursement — verify age/diagnosis applicability and medical policy criteria.

Preventive medicine codes for new patients: 99381–99385; established patients: 99384–99395 (bill with preventive diagnosis when applicable).
Hearing and developmental screening codes (e.g., 92551, 92558, 92567, 92650–92653) payable at preventive level only when billed with appropriate age and diagnoses (Z01.10, Z01.118, Z01.11 for ages ≤22) and meeting medical policy criteria.
Bright Futures behavioral screenings (e.g., 99408, 99409) and hematocrit/hemoglobin (36415, 36416, 85014, 85018) payable when billed per guidance and with Diagnosis List 1 code when required.

Key Terms and Acronyms

United States Preventive Services Task Force (USPSTF)

USPSTFUnited States Preventive Services Task Force — federal panel issuing preventive service recommendations used to determine no-cost preventive coverage

Role in coverageUSPSTF A and B recommendations are covered at no member cost-share for non-grandfathered plans under PPACA Section 2713

Reference locationUSPSTF recommendations referenced throughout the preventive services policy

Advisory Committee on Immunization Practices (ACIP)

ACIPAdvisory Committee on Immunization Practices — CDC committee issuing vaccine recommendations used for preventive coverage determination

Vaccine linkageACIP vaccine and administration CPT/HCPCS codes are listed in the policy for preventive reimbursement when matching recommendations

Health Resources and Services Administration (HRSA)

HRSAHealth Resources and Services Administration — issues women's and pediatric preventive service guidelines referenced by policy

ScopeHRSA guidance cited for breastfeeding services and other women's preventive recommendations

Low-dose computed tomography for lung cancer screening (LDCT)

LDCTLow‑dose computed tomography for lung cancer screening — annual LDCT recommended by USPSTF for eligible adults

Associated codeCPT 71271 referenced for LDCT when medical policy criteria are met

Pre-exposure prophylaxis for HIV prevention (PrEP)

PrEPPre‑exposure prophylaxis for HIV prevention — antiretroviral therapy offered to persons at high risk per USPSTF; baseline and monitoring reimbursable at preventive level

Pharmacy benefit noteFor pharmacy coverage details contact the number on the patient's BCBS member card; pharmacy benefit may be managed by another vendor

Breastfeeding equipment and supplies

Breastfeeding equipment and suppliesIncludes manual (E0602), electric (E0603), and hospital‑grade (E0604) breast pumps, pump parts, and breast milk storage supplies as part of HRSA recommendations

Coverage contextCovered at the preventive level for non‑grandfathered plans when provided per sourcing and quantity rules

Gestational Diabetes Screening

Gestational Diabetes ScreeningScreen pregnant women after 24 weeks (preferably 24–28 weeks); postpartum screening for women with prior GDM ideally within first year (as early as 4–6 weeks)

Diagnosis/payment noteScreening tests payable with a pregnancy diagnosis or Diagnosis List 1 as specified

ACIP vaccine recommendations — shorthand for vaccine code references

ACIP vaccine code shorthandACIP-recommended vaccine product and administration codes are enumerated in the policy (see ACIP section for CPT/HCPCS code lists)

Preventive payment conditionVaccines listed are payable at the preventive level when consistent with ACIP recommendations and plan terms

Preventive — definition describing preventive services

Preventive definitionServices intended to promote health and early detection/prevention of disease (screenings, counseling, immunizations) rather than to diagnose or treat existing conditions

ExamplesIncludes age‑ and risk‑based screenings, counseling interventions, immunizations per USPSTF/ACIP/HRSA/Bright Futures

Cost‑share implicationPreventive services recommended by USPSTF A/B, ACIP, or HRSA are covered without member cost‑share for non‑grandfathered plans when provided in‑network

Diagnostic — definition describing services intended to diagnose or manage existing conditions (not preventive)

Diagnostic definitionServices intended to diagnose existing symptoms, treat specific health conditions, or manage ongoing care (not preventive)

Distinguishing noteDiagnostic services are not eligible for preventive-level processing and may be subject to standard cost‑sharing per plan terms

Claim coding implicationClaims that reflect diagnostic rather than preventive intent should be billed with appropriate diagnostic codes and will not qualify for no-cost preventive processing