Blue Cross Blue Shield SC ACA Preventive Coverage

Coverage Criteria — Preventive Services

General Preventive Coverage Criteria

Covered when consistent with authoritative preventive recommendations

Primary coverage conditions: Service is a USPSTF Grade A or B recommendation OR an immunization recommended by ACIP/HRSA and administered within FDA labeling (including applicable age/gender limits) and delivered by an in-network provider for non-grandfathered plans.

Coverage follows applicable USPSTF, ACIP, HRSA and FDA guidance; updates take effect as required by law.

Breast Pump Medical Necessity

Breast pump coverage conditions

Breast pump sourcing and device rules: Breast pumps are covered for all women who choose to breastfeed when obtained from contracted network providers for in‑network benefits. Specific models (Ameda Mya Joy Plus, Ameda One Hand Manual, Medela Pump In‑Style Advanced) are allowed without cost sharing. A standard electric pump (E0603) purchase is covered. Rental of a heavy‑duty hospital‑grade electric pump (E0604) is medically appropriate while mother and infant are separated and the infant remains hospitalized; continued rental after infant discharge is not medically necessary. Supplies necessary for pump use (A4281 tubing, A4282 adapter) are covered; replacement supplies primarily for comfort/convenience (A4283–A4286) and milk storage products are not covered.

See CAM 046 for full device and supply rules; applicable HCPCS: E0602–E0604, A4281, A4282.

Abdominal aortic aneurysm (AAA) screening

Covered when ALL of the following are met for AAA screening:

AAA screening criteria: One‑time abdominal aortic aneurysm (AAA) screening for men ages 65–75 who have ever smoked.Age 65–75 and history of ever smoking

Relevant CPT/HCPCS: G0389; Ultrasound code: 76706; ICD‑10 examples: Z13.6, Z87.891

Colorectal cancer screening

Covered colorectal cancer screening approaches (examples):

Colorectal cancer screening methods: Adults beginning at age 45 and continuing until age 75. Covered methods include fecal occult blood testing, sigmoidoscopy, and colonoscopy; selection of method should weigh risks and benefits.Age 45–75

Use modifier -33 where appropriate to identify preventive procedures; example codes: 45330–45349, 45378–45392, 82270, G0104–G0106.

Lung cancer screening (adults)

Covered lung cancer screening criteria:

Lung cancer screening eligibility: Adults ages 55–80 years with a ≥30 pack‑year smoking history who currently smoke or who have quit within the past 15 years.55–80 years; ≥30 pack‑year; current smoker or quit ≤15 years

Annual low‑dose CT recommended; example codes: LDCT/CT thorax 71250 (modifier 52 referenced), HCPCS: S8032, G0296, G0297. Discontinue screening after 15 years smoke‑free or if life expectancy/preferred treatment limits apply.

Depression screening

Depression & developmental screening:

Depression screening (adolescents and adults): Screen for major depressive disorder when systems are in place to ensure accurate diagnosis, access to psychotherapy (eg, cognitive‑behavioral or interpersonal) and follow‑up care; screen adolescents ages 12–18 and adults as clinically indicated.Presence of staff‑assisted depression care supports

Relevant codes: 99420, 96160, 96161, G0444.

Developmental screening (children): Begin structured developmental screening at recommended well‑child visits (eg, 9 months, 18 months, 2½ years) per HRSA/Bright Futures guidance.Age‑specific schedule per Bright Futures

Codes: 96110 or G0451 for autism/developmental screening.

Hepatitis C virus (HCV) screening

HCV screening:

HCV screening groups: Screen pregnant women at their first prenatal visit; screen persons at high risk for HCV infection; offer one‑time screening for adults born 1945–1965.As above (pregnancy, high‑risk, birth cohort)

Example lab/test codes: 80055, 80081, 87340; HCV test codes: 86803, 86804, G0472.

Nutrition/Obesity screening & counseling

Nutrition and obesity counseling:

Nutrition counseling for adults: Offer or refer adults who are overweight or obese and have additional cardiovascular disease risk factors to intensive behavioral counseling interventions to promote healthy diet and physical activity.Overweight/obese with additional CVD risk factors

Codes: 97802–97804, G0270, S9470.

Obesity screening and intervention: Screen all adults and children age ≥6 for obesity. For adults with BMI ≥30 kg/m2 (and children meeting criteria), offer or refer to intensive multicomponent behavioral interventions.BMI ≥30 kg/m2 (adults); children aged ≥6 per guidance

HRSA/Bright Futures and Expert Committee recommendations apply; counseling codes include 99401–99404 and G0447.

Lung cancer screening (LDCT)

Covered preventive screenings when population criteria met

Lung cancer screening: Adults ages 55–80 with a ≥30 pack‑year smoking history who currently smoke or have quit within the past 15 years should receive annual low‑dose CT screening when appropriate; discontinue after 15 years smoke‑free or if limited life expectancy or inability/unwillingness to undergo curative surgery.55–80 yrs; ≥30 pack‑year; current smoker or quit ≤15 yrs

LDCT coding examples: 71250 (with modifier 52 noted), HCPCS: S8032, G0296, G0297.

Perinatal and osteoporosis screening/counseling

Covered counseling and screening recommendations

Perinatal depression counseling: Provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions.Increased risk per clinical assessment

Use modifier -33 when reporting perinatal depression counseling services; code example: 96160.

Osteoporosis screening: Screen women age ≥65 years and younger postmenopausal women whose fracture risk equals or exceeds that of a 65‑year‑old white woman with no additional risk factors.Age ≥65 or equivalent elevated fracture risk

DXA bone density code example: 77080.

Substance use and tobacco counseling

Behavioral counseling coverage

Unhealthy alcohol use screening and brief intervention: Screen adults (including pregnant women) and school‑aged children for unhealthy alcohol use and provide brief behavioral counseling interventions for persons engaged in risky or hazardous drinking.Per HRSA/USPSTF recommendations

Relevant codes: 99408, G0396, G0443 (brief intervention) and counseling ranges noted.

Tobacco use screening and cessation: Screen for tobacco use at clinical encounters and provide cessation counseling and FDA‑approved pharmacotherapy as appropriate; provide interventions to prevent initiation in youth.As clinically indicated

Counseling codes include 99406, 99407 and associated G‑codes; HRSA guidance recommends screening at most visits for school‑aged children and adolescents.

Newborn/pediatric screening

Newborn and pediatric screening coverage

Newborn screenings: Newborn screening tests (eg, bilirubin, PKU, syphilis, tuberculosis as indicated) are typically performed prior to hospital discharge; follow local HRSA/Bright Futures timing for pediatric TB risk screening (eg, 1, 6, 12 months then annually if indicated).Per newborn/pediatric schedule

Example codes: newborn bilirubin 82247/82248; PKU 84030; syphilis 86592/86780; TB tests 86480/86580; metabolic screening S3620 referenced.

Primary prevention statin therapy

Statin preventive medication coverage criteria

Statin preventive medication: Adults ages 40–75 without a history of cardiovascular disease who have one or more CVD risk factors (eg, dyslipidemia, diabetes, hypertension, or smoking) and a calculated 10‑year cardiovascular risk ≥10% are eligible for low‑ to moderate‑intensity statin therapy for primary prevention.Age 40–75 and 10‑year risk ≥10%

Specific statin agents and doses are enumerated in the policy; universal lipid screening (eg, 80055/80081) is required to identify dyslipidemia and calculate risk.

Immunizations are covered when administered in accordance with ACIP guidance and within FDA labeling. Conversely, an immunization that does not meet Vaccine Policy requirements for FDA labeling (including any age or gender limitations) or that lacks definitive ACIP recommendations published in the CDC’s MMWR is considered not medically necessary and is not covered under the preventive benefits guidance.

For rotavirus vaccination, do not begin the vaccine series in infants older than 14 weeks 6 days. If prior doses used a different or unknown brand, administer a total of three doses as appropriate and observe the minimum interval of four weeks between doses when indicated.

The folic acid supply billed with HCPCS A9152 is not routinely covered for all women capable of pregnancy. Coverage is limited and not provided universally to all women of childbearing potential under this preventive services guidance.

Instrument-based ocular screening performed by non–eye-care professionals is acceptable for selective screening in younger children, but for members aged 6 years and older instrument-based ocular screening is considered not medically necessary, except where selective screening by an eye-care professional is indicated.

An immunization that fails to meet the Vaccine Policy requirements — including adherence to FDA labeling (age and gender limits) and definitive ACIP recommendations in the MMWR — is classified as not medically necessary and therefore excluded from preventive coverage.

Restating the coverage position for folic acid: provision of folic acid supply (HCPCS A9152) is not routinely covered for all women capable of pregnancy under this preventive services policy.

Instrument-based ocular screening for members aged 6 years and older is considered not medically necessary. Providers should rely on selective screening by eye-care professionals when clinically indicated rather than routine instrument-based screening in this age group.

Coding — CPT / HCPCS / ICD-10 Crosswalks

Immunization Administration CPT/HCPCSCPTCovered

90460	Immunization administration through 18 years; first or only component with counseling
90461	Immunization administration through 18 years; each additional vaccine component with counseling
90471	Immunization administration; one vaccine (single or combination)
90472	Immunization administration; each additional vaccine (single or combination)
90473	Immunization administration by intranasal or oral route; one vaccine
90474	Immunization administration by intranasal or oral route; each additional vaccine
G0008	Administration of influenza virus vaccine
G0009	Administration of pneumococcal vaccine
G0010	Administration of hepatitis B vaccine

Vaccine CPT Codes (covered)CPTCovered

90702	Diphtheria and tetanus (DT) for individuals younger than 7 years
90696	DTaP-IPV for children 4-6 years
90698	DTaP-IPV/Hib combination
90700	DTaP for individuals younger than 7 years
90721	DTaP and Hib combination
90719	Diphtheria toxoid, IM
90645	Hib vaccine, HbOC conjugate
90646	Hib PRP-D conjugate (booster)
90647	Hib PRP-OMP conjugate, 3-dose
90648	Hib PRP-T conjugate, 4-dose

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Breast pump and supplies HCPCSHCPCS

E0602	Electric breast pump, hospital-grade - rental or purchase per policy specifics
E0603	Standard electric breast pump
E0604	Heavy-duty hospital grade electric breast pump (rental)
A4281	Breast pump tubing (covered as necessary)
A4282	Breast pump adapter (covered as necessary)
A4283	Breast pump replacement supplies (comfort/convenience - not covered)
A4284	Breast pump replacement supplies (not medically necessary)
A4285	Breast pump replacement supplies (not medically necessary)
A4286	Breast pump replacement supplies (not medically necessary)

HPV Vaccine CPTCPT

90651

Human Papillomavirus vaccine, nonavalent (9vHPV), 2- or 3-dose schedule, intramuscular; indicated ages 9-26 years

HPV Vaccine Additional Codes (historical)CPT

90649	HPV4 (quadrivalent), 3-dose schedule (historical entry)
90650	HPV2 (bivalent), 3-dose schedule (historical; females 9-26 yrs)

Meningococcal Vaccine CPTCPT

90620	Meningococcal recombinant protein and outer membrane vesicle vaccine, serogroup B (MenB-4C), 2-dose schedule
90621	Meningococcal recombinant lipoprotein vaccine, serogroup B (MenB-FHbp), 2 or 3 dose schedule
90644	Meningococcal conjugate vaccine, serogroups C & Y and Hib (Hib-MenCY), pediatric schedule
90733	Meningococcal polysaccharide vaccine, quadrivalent (MPSV4)
90734	Meningococcal conjugate vaccine, quadrivalent (MenACWY), IM

Meningococcal Administration/Related CPTCPT

90704	Mumps virus vaccine, live (used in mapping entries)
90705	Measles virus vaccine, live (mapping context)
90706	Rubella virus vaccine, live (mapping context)
90707	MMR vaccine (mapping context)
90708	Measles and rubella vaccine (mapping context)
90710	MMRV (mapping context)

Pneumococcal Vaccine CPT/HCPCSmixed

90669	Pneumococcal conjugate vaccine, 7-valent (PCV7)
90670	Pneumococcal conjugate vaccine, 13-valent (PCV13)
S0195	Pneumococcal conjugate vaccine, polyvalent, intramuscular (children 5-9 yrs who haven't previously received)
90732	Pneumococcal polysaccharide vaccine, 23-valent (PPSV23)

Polio and Tetanus/Tdap CPTCPT

90713	Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use
90703	Tetanus toxoid adsorbed, for intramuscular use
90714	Tetanus and diphtheria (Td), preservative-free, for individuals 7 years and older
90715	Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), for individuals 7 years and older

Polio/Tetanus Mapping CodesCPT

90704	Mapping context codes referenced in original document
90705	Mapping context codes referenced in original document

Varicella / Zoster CPTCPT

90716	Varicella virus vaccine (VAR), live, subcutaneous
90736	Zoster (shingles) vaccine, live
90750	Zoster recombinant, sub-unit, adjuvanted (recombinant)

Varicella/Zoster Mapping CodesCPT

90704

Mapping context codes present in source

Rotavirus CPT (mixed)CPT

90680

Rotavirus vaccine, pentavalent (RV5) or human attenuated (RV1), oral

Influenza CPT (mixed mappings)CPT

90630	Influenza virus vaccine, quadrivalent (IIV4), split virus
90653	Additional seasonal influenza code (FDA-approved newer codes)
90654	Additional seasonal influenza code (FDA-approved newer codes)
90655	Seasonal influenza codes used for various age/dose distinctions
90656	Seasonal influenza codes used for various age/dose distinctions
90657	Seasonal influenza codes used for various age/dose distinctions
90658	Seasonal influenza codes used for various age/dose distinctions
90660	Influenza live (LAIV3) intranasal
90661	Influenza virus vaccine (ccIIV3) derived from cell cultures

Seasonal Influenza Q-series & Product HCPCSHCPCS

Q2034	Agriflu (split virus) - adult
Q2035	AFLURIA - ages 3+
Q2036	FLULAVAL - ages 3+
Q2037	FLUVIRIN - ages 3+
Q2038	Fluzone - ages 3+
Q2039	Influenza vaccine, split virus, not otherwise specified

Influenza vaccine CPT/HCPCS mappings (covered)mixedCovered

90756	Influenza virus vaccine, quadrivalent (IIV4), split virus, 0.5 mL dosage (mapped to ccIIV4 entry)
Q2034	Agriflu - adult
Q2035	AFLURIA - ages 3+
Q2036	FLULAVAL - ages 3+
Q2037	FLUVIRIN - ages 3+
Q2038	Fluzone - ages 3+
Q2039	Influenza vaccine, split virus (not otherwise specified)

AAA Screening CodesmixedCovered

G0389	Ultrasound for abdominal aortic aneurysm screening
76706	Ultrasound, retroperitoneal, limited or follow-up

AAA Screening ICD-10ICD-10Covered

Z136	Personal history of other malignant neoplasm (mapping context)
Z87891	Personal history of nicotine dependence (mapping context)

Various Preventive Service CPT/HCPCS/ICD-10 (covered)mixedCovered

99401	Preventive medicine counseling, individual; typically used for breast cancer preventive medication counseling entries
99402	Preventive medicine counseling, higher intensity
99420	Administration of health risk assessment (behavioral counseling context)
96110	Developmental screening
G0101	Cervical or vaginal cytology for screening
G0328	Colorectal cancer screening (non-specific)
77067	3D mammography (screening)
G0202	Screening mammography, bilateral (digital)
99406	Smoking and tobacco use cessation counseling
G0434	Annual wellness visit, initial

Examples of Preventive Screening CPTs (neutral)CPT

85014	Hemoglobin; hematocrit
85015	Automated hemoglobin
87086	Urine culture
87490	Chlamydia NAAT
87491	Chlamydia/GC combo NAAT
96160	Administration of health risk assessment or depression screening codes
96161	Admin scoring and documentation

Preventive screening CPTs (examples)CPT

81628	Colorectal cancer screening test (example)
82270	Fecal occult blood, immunoassay
81528	Colorectal cancer molecular test
45330	Colonoscopy, diagnostic
45378	Colonoscopy with therapy
G0104	Colorectal cancer screening counseling
G0106	Colorectal cancer screening high risk

Lung Cancer Screening HCPCS/G-codes (covered)mixedCovered

G0296	Low-dose CT for lung cancer screening, initial
G0297	Low-dose CT for lung cancer screening, subsequent
71250	CT chest low-dose screening (listed with modifier 52 in source)

Newborn & Infectious Disease Screening CPTs (covered)CPTCovered

82247	Bilirubin, total
82248	Bilirubin direct
86480	TB test (mapping)
86780	Syphilis test (mapping)
80055	Battery of newborn screenings (panel)
84030	Phenylketonuria (PKU) screening
S3620	Newborn metabolic screening (panel)

Counseling & Screening CPTs (covered)CPTCovered

99401	Preventive counseling, low intensity
99402	Preventive counseling, moderate intensity
99403	Preventive counseling, higher intensity
99404	Preventive counseling, highest intensity
G0444	Annual depression screening
99420	Administration of health risk assessment

Substance Use & Behavioral Counseling Codes (covered)CPTCovered

99406	Smoking cessation counseling, intermediate
99407	Smoking cessation counseling, intensive
99408	Alcohol/drug screening and brief intervention (15-30 minutes)
G0396	Alcohol misuse screening and counseling, per visit
G0443	Brief face-to-face behavioral counseling for alcohol misuse

Contraception CPT/HCPCS Crosswalks (covered)mixedCovered

11980	Contraceptive management mapping entries (see detailed crosswalk)
11981	Contraceptive management mapping entries
11982	Contraceptive management mapping entries
J7303	Intrauterine contraceptive device, levonorgestrel-releasing (example mapping)
J7304	IUD mapping variant
A4261	Contraceptive injection supply mapping
S4981	Contraceptive supply/service mapping

ICD-10-PCS Procedure Code Mappings for Contraception (neutral)ICD-10

0U553ZZ	ICD-10-PCS contraception procedure mapping example
0U567ZZ	ICD-10-PCS contraception procedure mapping example
0U568ZZ	ICD-10-PCS contraception procedure mapping example

Diagnosis / Z-code mappings (neutral)ICD-10

Z920	Personal history relevant mapping entries (contraception context)
Z30018	Encounter for contraceptive management (mapping examples)

Provider Actions — Billing, Documentation & Submission

Billing Rule

Contraception coding and submission

Contraceptive procedures and associated device/drug HCPCS/CPT mappings must be submitted using the procedure code filed; the procedure code (not the diagnosis) will be used to determine whether no cost-share applies. Ensure the claim uses the appropriate procedure/CPT/HCPCS code that corresponds to the service or device provided.

Use the procedure filed to determine no cost-share — not the diagnosis filed.
Submit the CPT/HCPCS or ICD-10-PCS code that reflects the contraceptive procedure or device supplied (see policy code mappings).

Documentation Required

Unlisted recently approved seasonal flu codes

Additional seasonal influenza vaccine codes that are recently FDA-approved but not enumerated in the code tables may be eligible for coverage as a preventive service. When administering or billing using a newly approved seasonal influenza code, document the FDA approval date and the vaccine product used in the medical record.

Background

Under the Affordable Care Act, non-grandfathered health plans are required to cover certain preventive services without member cost sharing when delivered by in-network providers. Covered services are based on USPSTF A/B recommendations and specified immunization guidance (ACIP/HRSA); the protection applies to plans that are not grandfathered and therefore subject to the ACA preventive services mandate.

Definitions and Terms

Non-grandfathered plan (definition & implications)

DefinitionNon-grandfathered plan: a plan that took effect after March 23, 2010 and has not maintained grandfathered status

Coverage implicationACA preventive service requirements apply; covered preventive services without cost-sharing when delivered by in-network providers

ExamplesIncludes individual and employer-sponsored (group) health plans that are not grandfathered

Basis for covered preventive services

Primary basesUSPSTF A and B recommendations; immunization guidance from ACIP and HRSA

Service requirementCovered when consistent with authoritative preventive recommendations and delivered by in-network providers

OpenPayer

Affordable Care Act Preventive Services (Provider Guide)

Coverage Criteria — Preventive Services

Coding — CPT / HCPCS / ICD-10 Crosswalks

Provider Actions — Billing, Documentation & Submission

Background

Definitions and Terms