CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP006

Preventive Services Policy

This Clinical Payment and Coding Policy (CPCP) governs reimbursement and coding for preventive services for BCBSOK members, describing coverage criteria, required codes, and when services are payable at the preventive (no member cost-share) level for applicable plans and providers.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPreventive Services Policy

Policy CodePolicy CPCP006

Change TypeNo material changes

Effective DateJul 1, 2023

Next Review Date

Key ActionSubmit claims with a preventive diagnosis and procedure code and include required documentation to process services at the preventive (no member cost-share) level.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2023-07-01effective date

1.0policy version

manycodes included

somepreauth flagged

annualannual well-woman

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Preventive coverage criteria and rules

This section describes preventive coverage criteria, applicable recommendations (USPSTF, ACIP, HRSA, Bright Futures), and operational reimbursement rules to ensure services process at the preventive level.

ALL of the following

Preventive services that are eligible under PPACA and/or applicable state mandates include screenings, immunizations, and other services recommended by USPSTF, ACIP, HRSA, or Bright Futures.
Source: Reimbursement Information; USPSTF/ACIP/HRSA/Bright Futures grids must be consulted for specific services and codes.
To process at the preventive level with no member cost-share, claims must: include a preventive diagnosis code; include a preventive procedure code; meet medical policy review criteria; and align with the applicable USPSTF, ACIP, HRSA or Bright Futures guideline.
Claims lacking the preventive diagnosis/procedure combination or not meeting guideline criteria may be processed as non-preventive and be subject to member cost share. (chunk 5)
Preventive coverage determinations reference the authoritative recommendations; the policy includes code lists mapping recommended procedures to preventive billing (examples include AAA screening 76706 when billed with listed preventive diagnoses; cervical cancer cytology and hrHPV codes; gestational diabetes lab panels; hepatitis B/C screening codes; lung LDCT 71271 when criteria met and billed with smoking-related diagnosis codes).
See specific recommendation blocks and code lists in the policy for full mapping. (chunks 6,12,18,20,27,32)
Certain preventive services for pregnant persons (eg, hepatitis B screening at first prenatal visit, Rh(D) testing at first visit and repeated at 24–28 weeks, gestational diabetes screening at 24 weeks or after) are reimbursable at preventive level when billed with a pregnancy diagnosis or an allowed diagnosis from Diagnosis List 1 per the recommendation notes.
(chunks 18,20,32)
Well-woman visits and HRSA-recommended women's preventive services (including breastfeeding support, contraceptive counseling and provision, urinary incontinence screening) are covered as preventive services; some items (eg, contraceptives) may fall under medical or pharmacy benefit—verify member drug benefit administrator for pharmacy-covered contraceptives.
Hospital-grade breast pumps: rental only; G0513/G0514 payable with Diagnosis List 1; non-physician lactation providers limited to specified codes. (chunks 41,43,55)
Behavioral counseling services recommended by USPSTF and Bright Futures (eg, unhealthy alcohol use, cardiovascular disease prevention, weight-loss interventions, tobacco cessation counseling, STI counseling) are preventive when delivered per guideline frequency and billed with appropriate preventive codes listed in the policy.
Refer to code lists for counseling CPT/G codes. (chunks 6,18,27,36,59)
Tobacco cessation: clinicians should ask all adults and pregnant women about tobacco use and provide behavioral interventions and FDA‑approved pharmacotherapy. Pharmacy coverage details may be managed by a separate pharmacy benefit manager; prescription required for OTC and prescription meds. Up to two 90-day treatment regimens per benefit period at provider discretion; covered agents include nicotine replacement therapies, bupropion SR, varenicline, and specified branded products.
(chunks 36,37)
HIV, hepatitis, lead, anemia, newborn screenings, and other Bright Futures/USPSTF-recommended pediatric screenings are preventive when billed with appropriate diagnosis codes and procedure codes listed; many pediatric labs require a diagnosis from Diagnosis List 1 to be reimbursable at preventive level.
(chunks 24,59,61)
Lung cancer screening with LDCT (71271) is recommended annually for adults aged 50–80 with ≥20 pack-year history who currently smoke or quit within 15 years; screening should be discontinued after 15 years of cessation or if life expectancy/ability to tolerate curative surgery is limited. LDCT preventive reimbursement is subject to meeting medical policy criteria and may require preauthorization; bill with an approved smoking-related preventive diagnosis (F17.* or Z codes listed) to process at preventive level.
(chunk 27)
Where the guideline or code list indicates ‘Payable with a diagnosis code in Diagnosis List 1’, services must be billed with an approved diagnosis from Diagnosis List 1 to be reimbursed at preventive level.
(multiple chunks)
Providers must exercise independent medical judgment; this policy does not dictate clinical care. The code lists and recommendation references are illustrative—refer to the policy’s full code grids and referenced guidance (ACIP, USPSTF, HRSA, Bright Futures) for complete coding and frequency rules.
(chunk 5 and references)

Preventive Procedure, Vaccine and Diagnosis Codes

Covered CPT/HCPCS Codes (examples)mixedCovered

76706	Ultrasound, abdominal aorta (AAA) screening
71271	CT, low dose for lung cancer screening; effective 01/01/2021 reimbursable preventive when criteria met
G0296	Counseling visit to discuss cessation of tobacco use, intermediate, per session
99384	Preventive medicine established patient, adolescent (example well-woman/ preventive visit series)
99385	Preventive medicine new patient/adult (example well visit)
G0101	Cervical or vaginal cancer screening; pelvic and clinical breast examination
Q0091	Screening Papanicolaou smear; obtaining cervical or vaginal smear
36415	Collection of venous blood by venipuncture (commonly listed with prenatal labs)
82947	Glucose; quantitative, blood (gestational diabetes screening example)

Gestational Diabetes Screening (example covered codes)CPTCovered

82947	Glucose; quantitative, blood (gestational diabetes screening)
36415	Collection of venous blood by venipuncture
83036	Hemoglobin; glycosylated (A1c) (referenced in guidance)

Lung Cancer Screening — LDCT (example covered)CPTCovered

71271

Low dose CT scan for lung cancer screening (reimbursable at preventive level when medical policy criteria met and billed with eligible diagnosis codes)

Tobacco Cessation — counseling and pharmacotherapy (examples)mixedCovered

G0296	Tobacco cessation counseling visit (example counseling code)
99406	Smoking and tobacco use cessation counseling visit, intermediate
99407	Smoking and tobacco use cessation counseling visit, intensive
NDC	Multiple FDA-approved smoking cessation pharmacotherapies — see pharmacy benefit for formulary/NDCs

Well‑Woman / Preventive Visit Codes (examples)CPTCovered

99384	Initial comprehensive preventive visit, adolescent (example well‑woman visit)
99385	Initial comprehensive preventive visit, adult
99395	Periodic comprehensive preventive visit, established adult

Preventive Vaccines & Immunization Administration (examples)mixedCovered

90658	Influenza vaccine (example)
90707	MMR vaccine
90460	Immunization administration; first vaccine/toxoid component

Policy update / coding-neutral entries (history examples)mixed

71271	Added effective 01/01/2021 note re: preventive reimbursement when criteria met
G0296	Included as counseling example for tobacco cessation guidance

Billing, Prior Authorization & Provider Responsibilities

Prior Authorization

Prior authorization / documentation for certain preventive services

Certain preventive services are subject to medical policy and may require prior authorization or medical policy review; providers should submit requested documentation to support medical necessity and preventive-level processing. Claims must include a preventive diagnosis code and preventive procedure code and meet medical policy review criteria to process at the preventive level with no member cost-share.

Submit requested documentation when prior authorization or medical policy review is indicated.
Include preventive diagnosis and preventive procedure codes on claims to enable preventive-level processing.

Prior Authorization

Prior authorization note for lung cancer (LDCT)

Low-dose CT (LDCT) lung cancer screening is subject to medical policy criteria and may require preauthorization; CPT 71271 is reimbursable at the preventive level only if it meets medical policy criteria and is billed with one of the specified diagnosis codes.

Ensure patient meets eligibility (age 50–80, ≥20 pack-year, current smoker or quit ≤15 years).
Bill CPT 71271 with one of the listed diagnosis codes (e.g., F17.200, Z12.2, Z87.891) and follow preauthorization requirements if indicated.

Documentation Required

Contact pharmacy benefit via member ID card for medication coverage

For coverage of medications (e.g., PrEP, statins, tobacco cessation pharmacotherapy) under the pharmacy benefit, contact the telephone number on the member's BCBS ID card because pharmacy benefits may be managed by a separate company.

Verify pharmacy benefit coverage and prescription requirements via the member's ID card number.
Refer to the member's drug list for specific formulary and coverage details (e.g., Truvada for PrEP).

Billing Rule

Bill pregnancy-related preventive procedures with pregnancy diagnosis or Diagnosis List 1

Several prenatal screening procedures are payable at the preventive level only when billed with a pregnancy diagnosis or a diagnosis from Diagnosis List 1; providers must bill with the appropriate pregnancy diagnosis to obtain preventive-level reimbursement.

Bill prenatal screening procedure codes (examples listed in policy) with a pregnancy diagnosis or a Diagnosis List 1 code.
Verify that timing (e.g., first prenatal visit, 24–28 weeks for GDM testing) aligns with guidance to support preventive payment.

Documentation Required

Tobacco cessation counseling and pharmacotherapy requirements

Behavioral interventions and FDA‑approved pharmacotherapy for tobacco cessation are covered; prescriptions are required for both OTC and prescription cessation products, and pharmacy coverage details should be confirmed via the member's ID card. The plan limits two 90‑day treatment regimens per benefit period at provider discretion.

Provide behavioral counseling codes (e.g., 99406, 99407, G9016, S9453) as applicable.
Obtain prescriptions for OTC nicotine replacement products if member seeks pharmacy reimbursement.
Limit pharmacotherapy to two 90‑day regimens per benefit period unless otherwise directed.

Billing Rule

Reimbursement rules for non‑physician lactation providers

Non-physician lactation providers (Certified Lactation Counselors, International Board‑Certified Lactation Consultants) are eligible for reimbursement only for the specified lactation counseling/education codes listed in the policy (e.g., S9443, 98960–98962).

Bill only the listed codes (S9443, 98960, 98961, 98962) for reimbursement to non-physician lactation providers.
Ensure services are documented to support preventive-level payment when billed with appropriate diagnosis codes per policy.

Billing Rule

Breastfeeding equipment purchase/rental and billing actions

Manual breast pumps (E0602) may be purchased in‑ or out‑of‑network and are covered at the preventive level; electric pumps (E0603) must be purchased or rented from an in‑network provider or contracted DME supplier, and hospital‑grade pumps (E0604) are limited to in‑network rental only with coverage up to $1,000 or 12 months. Supplies A4281–A4286 are reimbursable at the preventive level.

Provide E0603 purchases/rentals through in‑network or contracted DME suppliers to secure preventive-level coverage; members choosing upgraded models may be balance billed for the difference.
Rent hospital‑grade pumps (E0604) in‑network; coverage capped at $1,000 or 12 months and the unit must be returned at end of coverage.
Submit supply codes A4281–A4286 for reimbursable replacement parts per policy; excluded items (e.g., batteries, cleaning supplies) are not reimbursable at preventive level.

Note

References to ACIP, CDC, AAP, USPSTF, HRSA, FDA for preventive guidance

Use the listed external clinical and coding references when applying preventive coding and coverage rules: ACIP vaccine recommendations and CDC immunization schedules, AAP Bright Futures coding and preventive care guidance, USPSTF recommendation statements, HRSA women's preventive services, and FDA vaccine licensing information.

Reference ACIP/CDC for vaccine‑specific recommendations and schedules.
Consult AAP Bright Futures for pediatric preventive coding and periodicity guidance.
Use USPSTF, HRSA, and FDA sources cited in the policy to support preventive coverage decisions.

Key Terms and Acronyms

United States Preventive Services Task Force (USPSTF)

AcronymUSPSTF — United States Preventive Services Task Force.

RolePublishes evidence-based preventive service recommendations that inform coverage under this policy.

Grade useCoverage generally follows USPSTF Grade A and B recommendations for no member cost-share when applicable.

Advisory Committee on Immunization Practices (ACIP)

AcronymACIP — Advisory Committee on Immunization Practices.

RolePublishes vaccine recommendations and immunization schedules referenced by this policy.

ReferencePolicy cites ACIP recommendations and CDC immunization schedules for vaccine-specific coverage decisions.

Health Resources and Services Administration (HRSA)

AcronymHRSA — Health Resources and Services Administration.

RoleIssues women's preventive services guidelines referenced in this policy (e.g., lactation support recommendations).

Reference linkPolicy references HRSA Women's Preventive Services Guidelines for applicable services.

LDCT — low-dose computed tomography for lung cancer screening

AcronymLDCT — low‑dose computed tomography for lung cancer screening.

PurposeAnnual screening modality recommended by USPSTF for eligible adults (50–80 years with 20 pack-year history).

Payment noteProcedure code 71271 is listed for LDCT screening and reimbursable at the preventive level when medical policy criteria and diagnosis requirements are met.

PrEP — preexposure prophylaxis for HIV prevention

AcronymPrEP — preexposure prophylaxis with antiretroviral therapy for HIV prevention.

Coverage noteCoverage includes brand and/or generic Truvada for prevention with a prescription; refer to member's drug list for details and contact pharmacy benefits via member card.

Pharmacy instructionPharmacy benefit may be managed by a company other than BCBS; providers/ members should contact the number on the member card for coverage specifics.

Benefit period

DefinitionBenefit period — the policy-defined timeframe used to limit certain services and equipment frequency (e.g., one breast pump per benefit period; two 90-day tobacco cessation regimens per benefit period).

Usage examplesUsed to enforce frequency limits for breast pump provision and tobacco cessation pharmacotherapy in this policy.

ImplicationLimits reset per benefit period as defined by the member's plan; verify plan contract for exact period definitions.

Breastfeeding equipment coverage

Coverage prioritizationAccess to double electric breast pumps should be a priority and not predicated on prior failure of a manual pump; supplies are reimbursable at preventive level.

Hospital-grade limitationHospital-grade pumps (E0604) are limited to rental only and subject to coverage limits (rental up to $1,000 or 12 months).

Provider sourcing rulesManual pumps (E0602) may be purchased from in-network or out-of-network/retail; electric pumps (E0603) must be rented/purchased in-network; members may be balance-billed for upgraded electric models.

Preventive — definition

DefinitionPreventive — services and screenings intended to prevent illness or identify issues before symptoms are evident; includes counseling and age-appropriate screenings per USPSTF/ACIP/HRSA/Bright Futures.

Coverage effectWhen delivered in-network and meeting guideline criteria, preventive services are payable with no member cost-share for non-grandfathered plans.

ExamplesIncludes screenings, immunizations, counseling interventions, and periodic preventive visits defined by referenced guideline sources.

Diagnostic — definition

DefinitionDiagnostic — services intended to diagnose existing symptoms, treat conditions, or manage ongoing health issues (distinct from preventive services).

Implication for billingServices performed for diagnostic purposes are not processed as preventive and may incur member cost-share or be billed under other medical benefits.

ExamplesMammogram for a palpable lump, tests to manage a diagnosed chronic disease, or visits for symptomatic complaints.

ACIP/CDC guidance

RoleACIP/CDC guidance — provides vaccine‑specific recommendations and official immunization schedules used as authoritative references in this policy.

Reference sourcesPolicy cites ACIP recommendations and CDC immunization schedules for administration and vaccine coverage decisions.

ExclusionsTravel vaccines and certain non‑PPACA vaccines (e.g., Anthrax, BCG, Rabies) are excluded from preventive service coverage per ACIP/CDC context.

AAP Bright Futures

DefinitionAAP Bright Futures — the American Academy of Pediatrics' preventive pediatric care and periodicity schedule referenced for pediatric preventive services and coding.

Use in policyBright Futures recommendations and associated CPT codes are used to determine preventive-level reimbursement for pediatric screenings and visits.

ExamplesBright Futures codes include hematocrit/hemoglobin screening, lead screening, maternal depression screening, and preventive medicine visit codes when billed with Diagnosis List 1 as required.

OpenPayer

Preventive Services Policy

Preventive Coverage Criteria & Clinical Rules

Preventive Procedure, Vaccine and Diagnosis Codes

Billing, Prior Authorization & Provider Responsibilities

Key Terms and Acronyms