Currentblue cross blue shield - tennesseePolicy N/A

Pediatric Preventive Screening (laboratory-based)

Customize your policy alerts

Sign up for all blue cross blue shield - tennessee policy alerts

Know when blue cross blue shield - tennessee releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Governs laboratory-based preventive screening tests for individuals from newborn through age 18 (excluding newborn genetic disorder screening governed by state mandates); applies to Blue Cross Blue Shield - Tennessee members per benefit coverage.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyPediatric Preventive Screening (laboratory-based)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2023

Next Review DateN/A

Key ActionVerify member benefits and state-mandated newborn screening coverage before ordering tests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

Currentblue cross blue shield - tennesseePolicy N/A

Pediatric Preventive Screening (laboratory-based)

Customize your policy alerts

Sign up for all blue cross blue shield - tennessee policy alerts

Know when blue cross blue shield - tennessee releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyPediatric Preventive Screening (laboratory-based)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2023

Next Review DateN/A

Key ActionVerify member benefits and state-mandated newborn screening coverage before ordering tests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

newborn–18age range covered

35 core / 26 secondaryRUSP counts

~4Mnewborns screened (US est.)

$30estimated cost

3.5CDC BLRV (µg/dL)

Coverage criteria for pediatric preventive screening

Covered screenings and criteria

Covered when ALL of the following meet the specified criteria or risk conditions:

Newborn screenings: Newborn screening panel meets coverage criteria when it follows all applicable federal and state law recommendations (states set required screenings; RUSP recommended core/secondary lists).legal/state compliance

See RUSP lists for core and secondary conditions

Newborn condition screenings: Screening for hyperbilirubinemia, congenital hypothyroidism (serum T4 and/or TSH), and sickle cell disease in all newborns meets coverage criteria.universal newborn

Blood lead screening meets coverage criteria for children ages 12 months to 2 years, and for ages 6 months to 6 years who are at increased risk as defined by the AAP (poverty, recent immigrants, older housing, sibling/playmate with elevated lead, parental occupational exposure, exposure to structures with deteriorated lead paint).age and risk-based

AAP-targeted testing for immigrants/refugees at arrival also recommended

Anemia screening: Screening for anemia with hemoglobin or hematocrit meets coverage criteria for all children at 12 months, and for children >=4 months if at risk for iron deficiency (prematurity, exclusive breastfeeding beyond 4 months without iron, poor dietary iron intake, feeding problems, low growth).age and risk-based

Tuberculosis screening meets coverage criteria for children age >=1 month who are at increased risk (born in high-risk countries, prolonged travel to high-risk countries, household contact with TB or positive tuberculin test, or HIV infection).risk-based

Dyslipidemia screening: Screening for dyslipidemia with fasting lipid profile or non-fasting non-HDL-C meets coverage criteria annually for children/adolescents at increased risk per AAP/Bright Futures; and once for all children during ages 9-11 and 17-21, plus screening at 24 months and every 2 years starting at 4 years as per AAP periodicity.age and risk-based

Annual risk assessments recommended starting at 12 through 16

STI/HIV/HBV screening: Annual screening for chlamydia, gonorrhea and syphilis meets coverage criteria in sexually active adolescents and those at increased risk. Hepatitis B screening meets coverage criteria in asymptomatic nonpregnant adolescents at high risk (e.g., born in high-prevalence regions, not vaccinated as infants whose parents were born in high-prevalence regions). HIV screening meets coverage criteria per stated guidance (routine confidential screening once between ages 15-21; earlier if risk factors).sexually active or high-risk

USPSTF and AAP guidance referenced

Condition- and age-specific screening recommendations

Coverage and recommended screening by condition/age when following cited guideline statements:

Hepatitis B and C, HIV, STIs: USPSTF: screen HBV in adolescents/adults at increased risk (Grade B); screen HCV in adults 18-79 (Grade B). Screen adolescents >=15 for HIV, younger if at increased risk (Grade A). Screen sexually active women <=24 for chlamydia and gonorrhea (Grade B). Screen syphilis in asymptomatic at-risk adolescents/adults (Grade A). AAFP/AAP align for adolescent STI screening and risk-based HBV/HIV screening.age/risk-based per source

References: USPSTF, AAFP/AAP

Lipid screening: USPSTF: insufficient evidence to recommend universal screening in children/adolescents <=20. AAP/Bright Futures recommend risk-based screening at ages 2, 4, and 6 and targeted screening once between 9-11 and once between 17-21; dyslipidemia screening schedule also includes screening at 24 months and every 2 years starting at 4 years.age/risk-based per source

Do not routinely screen low-risk children; follow risk factors (family history, obesity)

The federal Recommended Uniform Screening Panel (RUSP) categorizes newborn conditions into core and secondary lists and also identifies conditions for which newborn screening is not indicated. Examples of conditions the RUSP lists as not indicated for routine newborn screening include Krabbe disease, Pompe disease, certain lysosomal storage disorders, Fragile X syndrome, Duchenne/Becker muscular dystrophy, congenital cytomegalovirus, α1-antitrypsin deficiency, and familial heterozygous hypercholesterolemia.

The USPSTF has concluded that the evidence is insufficient to recommend universal screening for lipid disorders in children and adolescents aged 20 years or younger, and similarly finds the evidence insufficient to assess benefits and harms of routine screening for elevated blood lead levels in asymptomatic children aged 1–5 years.

States determine the final composition of their newborn screening panels; while HHS provides the RUSP to promote standardization, state public health programs set required screens. Tests or conditions not included on a state's mandated panel may therefore not be universally covered by the payer.

USPSTF guidance specifically notes insufficient evidence to assess universal lipid screening in children and adolescents ≤20 years and also reports insufficient evidence to recommend screening for elevated blood lead levels in asymptomatic children ages 1–5; AAP recommendations emphasize risk-based or targeted screening instead.

Based on cited sources, routine universal screening for lipids and for lead in asymptomatic children is not recommended; the USPSTF assigns an insufficient evidence (Grade I) status for these universal screens and national pediatric guidance (AAP) favors targeted, risk-based approaches.

Age windows, screening ages, and reference values

Age windows for dyslipidemia screening

Dyslipidemia screening windowsOnce between ages 9–11 and once between ages 17–21; additionally, screening at 24 months and every 2 years beginning at age 4 years.

Annual risk-based screeningAnnually for children and adolescents at increased risk per AAP/Bright Futures (eg, obesity, diabetes, family history, elevated BP, renal disease, BMI ≥85th percentile).

Screening modalitiesFasting lipid profile or non-fasting non-HDL cholesterol meet coverage criteria.

Lead screening ages

Routine lead screening agesRoutine screening for children ages 12 months to 2 years.

Expanded targeted agesChildren ages 6 months to 6 years who are at increased risk for lead exposure (per AAP) should be screened.

Provider responsibilities and operational requirements

Prior Authorization

Prior authorization and benefit verification

Verify prior authorization and member benefits before ordering newborn and pediatric screening tests. Coverage determinations depend on the member's benefit plan and the date of service; Medicare and Medicaid may have different requirements and limits.

Prior authorization and benefit verification may be required for certain screenings (e.g., newborn screening panels, hyperbilirubinemia, congenital hypothyroidism, sickle cell disease, lead, anemia, tuberculosis).
Confirm eligibility and benefit details at time of service to avoid denials or unexpected member liability.

Note

Follow government coverage determinations

When there is a conflict between this payer policy and an applicable government coverage determination (for example, Medicare or state Medicaid Local Coverage Determinations or National Coverage Determinations), follow the government determination.

Use LCDs, NCDs, and state Medicaid coverage rules to resolve coverage conflicts.

Background and intent of pediatric preventive screening

Preventive screening is intended to identify disease in asymptomatic individuals to enable earlier detection and improved outcomes. Newborn screening programs—typically using heel‑prick dried blood spot samples analyzed by established laboratory methods—are implemented at the state level and are guided by federal recommendations such as the RUSP, with clinical schedules and periodicity informed by sources like Bright Futures and the American Academy of Pediatrics.

Key definitions and abbreviations

Recommended Uniform Screening Panel (RUSP)

RUSP definitionRecommended Uniform Screening Panel (RUSP) is a federal list created by HHS to standardize recommended conditions for newborn screening.

PurposeProvides HHS recommendations to help standardize newborn screening across states.

AbbreviationRUSP = Recommended Uniform Screening Panel.

Adolescent

Adolescent age range (WHO)Adolescent defined as persons aged 10–19 years (WHO).

Context in policyWHO definition referenced for pediatric preventive screening population descriptions.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyPediatric Preventive Screening (laboratory-based)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2023

Next Review DateN/A

Key ActionVerify member benefits and state-mandated newborn screening coverage before ordering tests.

SourceLink

On This Page

Iron deficiency/anemia:

USPSTF: insufficient evidence for routine screening in children 6-24 months. AAP recommends testing at 12 months and risk-based follow-up for preterm or exclusively breastfed infants; clinicians may assess and screen high-risk infants at additional intervals (15 and 30 months) and annually for at-risk 2-5 year olds.

age/risk-based per source

Follow AAP/Bright Futures schedules for infants and high-risk children

Lead screening: USPSTF: insufficient evidence to recommend screening asymptomatic children 1-5 without increased risk. CDC updated Blood Lead Reference Value (BLRV) to 3.5 µg/dL. AAP and state laws recommend targeted screening of high-risk individuals and provide specific schedules (example: Massachusetts initial 9-12 months, annual 2 and 3 years, etc.).BLRV 3.5 µg/dL; state schedules vary

Follow state-specific lead screening laws and risk assessments

Newborn metabolic and genetic screening: USPSTF/AAFP/AAP recognize newborn screening for hemoglobinopathies, congenital hypothyroidism, phenylketonuria, and other RUSP-listed conditions as important; final panel and requirements are state-determined.state-specific RUSP implementation

Verify newborn has received state-required newborn metabolic screenings

Tuberculosis screening: Screen patients at high risk for TB across the pediatric age span; use TST for those without prior BCG and certain follow-up, and consider IGRA for BCG-vaccinated individuals when follow-up is uncertain. Repeat testing based on ongoing exposure likelihood.risk-based

Repeat testing based on exposure likelihood

Hepatitis C in exposed children: For children born to HCV-infected mothers, perform anti-HCV testing after 12 months of age. CDC recommends one-time adult screening (18-79) and periodic testing for high-risk individuals; apply pediatric testing recommendations for exposed infants and risk-based adolescent testing.postnatal age >12 months for exposed infants

Risk-based testing for adolescents per CDC/USPSTF

AAP periodic schedule examplesAAP/Bright Futures periodicity: screening considerations at 6, 9, 12, 18, and 24 months and annually from 3–6 years when indicated by risk or state guidance.

Blood Lead Reference Value (BLRV)

Current BLRV value3.5 µg/dL (CDC updated value).

Definition contextBLRV is used to identify children with blood lead levels higher than most other children's levels (97.5th percentile).

Check CMS and state Medicaid websites for the most current determinations prior to claim adjudication.

Documentation Required

Confirm state-mandated newborn screening coverage

Coverage for newborn screening panels must comply with applicable federal and state law and the state's newborn screening program choices. Providers should confirm which conditions are included in the state-mandated panel and whether additional testing is covered by the member's plan.

State newborn screening panels vary — verify state-mandated conditions before ordering.
Additional or expanded panels beyond the state program may require prior authorization or may not be covered.

Documentation Required

Legal compliance for newborn screening

Ensure newborn screening follows applicable federal and state laws and recommendations to meet coverage criteria.

Documentation that testing followed state and federal requirements may be requested for coverage validation.
Providers must follow state reporting and follow-up requirements for abnormal newborn screening results.

Documentation Required

LDT validation and CLIA

Laboratory-developed tests (LDTs) used for screening must be validated and performed in-house under CLIA high-complexity requirements. Maintain documentation of validation and CLIA compliance in the laboratory record.

LDTs are not FDA-cleared/approved for clinical use but are regulated under CLIA as high-complexity tests.
Document analytical validation and quality-control procedures for each LDT used for screening.
Employ CLIA-compliant personnel and processes when performing LDTs.

Note

Pandemic care prioritization

During the COVID‑19 pandemic, prioritize in-person newborn visits and catch-up well-child care and vaccinations per CDC guidance to ensure newborn screening, feeding, weight, jaundice evaluation, and follow-up are completed.

Contact patients who missed well-child visits to schedule in-person appointments, prioritizing infants and children <24 months.
Ensure all components of newborn screening were completed with appropriate confirmatory testing and follow-up.

Laboratory-developed test (LDT)

LDT basic definitionLaboratory-developed test (LDT) = a test developed and performed in-house by a laboratory.

Regulation and validationLDTs must be validated and are regulated by CMS as high-complexity tests under CLIA '88.

FDA statusLDTs are not approved or cleared by the U.S. Food and Drug Administration for clinical use.

Blood Lead Reference Value (BLRV)

BLRV purposeA CDC-derived value used to identify children with blood lead levels higher than most other children's levels (97.5th percentile).

Current numeric valueCurrently set at 3.5 µg/dL by CDC (May 14, 2021 update).

LDT (laboratory-developed test) — additional note

LDT in-house developmentAn LDT is developed and performed within a single laboratory and must undergo internal validation prior to clinical use.

CLIA oversightLDTs are regulated under CLIA as high-complexity tests; documentation of validation and CLIA compliance is expected.

FDA clearanceLDTs are not FDA-approved or cleared, though FDA clearance is not currently required for clinical use.

RUSP — federal list and state implementation

Federal creation and state roleRUSP is created by HHS to provide standardization for newborn screening recommendations; however, each state ultimately decides which conditions to include in its newborn screening program.

ImplementationStates determine final newborn screening panels and implementation of RUSP recommendations.