Reference preauthorization list for applicable preventive services

Some preventive services listed in these Guidelines may require prior authorization; providers and members should reference the preauthorization list to determine if authorization is needed prior to service delivery.

Prescribe statins via pharmacy benefit (ages 40–75)

Statin therapy for primary prevention in adults aged 40–75 is handled through the pharmacy benefit manager and requires a prescription (not a medical prior authorization) to be processed under the pharmacy benefit.

Use specified CPT/HCPCS codes for preventive imaging and endoscopy

Bill screening imaging and endoscopy using the listed CPT/HCPCS codes for preventive coverage (examples include CT colonography 74263 and abdominal aortic aneurysm ultrasound 76706; colonoscopy screening codes G0105 and G0121 are also specified).

• CT colonography: 74263
• Abdominal aortic aneurysm ultrasound: 76706
• Colonoscopy screening: G0105, G0121

One breast pump per pregnancy via participating HME supplier

Breast pump benefit is limited to one pump per pregnancy when purchased through a participating Home Medical Equipment Supplier; supplier/policy processes may require verification at time of purchase.

• Allowed HCPCS: E0602, E0603 and A428-series for pump and supplies
• Purchase must be through a participating Home Medical Equipment Supplier

Date-of-service and turnaround for preventive imaging/pathology

For preventive radiology and surgical pathology services, use the same date of service for professional and technical components when applicable and complete review/interpretation/reporting as soon as possible, no later than 14 days from the date of the preventive service.

Document screenings with listed procedure and diagnosis codes

Document preventive screenings using the appropriate CPT/HCPCS and diagnosis codes and include screening details (e.g., screening type and results) for items such as anxiety, depression, HIV counseling/screening, TB testing, blood pressure, and colorectal screening.

• Use CPT/HCPCS codes listed for each screening (e.g., 99401–99404, 96127, G0432)
• Include relevant ICD-10 screening/encounter codes where applicable

Record age and screening interval (due dates)

Document the member's age and the screening interval used (for example: colonoscopy every 10 years, FIT annually, FIT‑DNA every 3 years) and record when the patient is due for the next screening.

• Colonoscopy interval: every 10 years
• FIT (fecal occult blood) frequency: annually
• FIT‑DNA interval: every 3 years

Use maternity ICD‑10 diagnosis codes for prenatal services

When providing prenatal screening services (e.g., hepatitis B, gestational diabetes, Rh incompatibility, breast pump), use maternity diagnosis ICD‑10 codes as indicated in the Guidelines.

• Maternity diagnosis examples referenced: Z00.121, Z00.129, Z39.1

Verify member's written Benefit Plan and preauthorization requirements

Coverage and payment are governed by the terms of the member's written Benefit Plan; preventive services may require prior authorization per the preauthorization list and may not be covered depending on plan terms.

Follow document guidance where diagnosis codes are noted 'not applicable'

Some counseling and screening entries (for example certain HIV and FIT‑DNA items) indicate that diagnosis code requirements are 'not applicable'; follow the document-specific code guidance when billing.

• Counseling and Screening for HIV: document notes 'Diagnosis code requirements are not applicable'
• FIT‑DNA entries note 'Diagnosis code requirements are not applicable'

Schedule follow‑up colonoscopy within 12 months after positive stool test

If a stool‑based test (FIT/FOBT/FIT‑DNA) is positive or abnormal, schedule and document a follow‑up colonoscopy within 12 months to remain consistent with preventive screening processing.

• Follow‑up colonoscopy allowed within 12 months after positive stool‑based test or abnormal findings on other modalities

Breast pump claims limited to one pump per pregnancy via participating supplier

The breast pump benefit is limited to one pump per pregnancy and the pump must be purchased through a participating Home Medical Equipment Supplier; claims that do not meet supplier or purchase rules may be denied.

• Benefit limit: one pump per pregnancy
• Required purchase channel: participating Home Medical Equipment Supplier
• Relevant HCPCS: E0602, E0603, A4281–A4288

Documentation reminder for preventive imaging/pathology

Use this documentation reminder: when preventive radiology or surgical pathology services are rendered, providers are encouraged to use the same date of service for both professional and technical components and complete reporting within 14 days.