CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Pediatric Preventive Screening — Laboratory-Based Preventive Screening (Newborn through Age 18)

Defines coverage and clinical indications for laboratory-based preventive screening tests for individuals from newborn through age 18; excludes newborn genetic disorder screening handled by state programs. Applies to Blue Cross Blue Shield - Tennessee membership.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyPediatric Preventive Screening — Laboratory-Based Preventive Screening (Newborn through Age 18)

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateJul 1, 2023

Next Review DateN/A

Key ActionEnsure newborn screening panels comply with applicable state and federal laws and document age-appropriate risk assessments and indications for targeted screenings per AAP/Bright Futures guidance.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

35RUSP core newborn screening conditions listed

3.5 µg/dLCDC updated blood lead reference value cited

0-18Age range covered by policy

AAP/Bright FuturesPrimary guideline sources referenced

USPSTF/WHO

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Pediatric Preventive Laboratory Screening — Coverage Criteria

General coverage statement

Preventive laboratory screening is covered when consistent with federal/state requirements and guideline-based indications:

ALL of the following

Tests are laboratory-based preventive screening performed on individuals newborn through age 18 (except newborn genetic disorder screening handled by state newborn screening programs).
Application of coverage criteria depends on the individual's benefit coverage at time of request.

Newborn screening and immediate newborn tests

MEETS COVERAGE CRITERIA when state and federal recommendations are followed:

ANY of the following

Newborn screening panel that follows all applicable federal and state law recommendations
Screening for hyperbilirubinemia in all newborns
Screening for congenital hypothyroidism in all newborns using serum T4 and/or TSH
Screening for sickle cell disease in all newborns

Lead screening

Blood lead screening MEETS COVERAGE CRITERIA when age and risk-based criteria are met:

ANY of the following

Routine age-based screening
- Children ages 12 months to 2 years
Increased risk screening
- Children ages 6 months to 6 years who are at increased risk for lead exposure, as defined by the AAP
- Examples of increased risk: poverty, recent immigrants, older/poorly maintained housing, sibling/playmate with elevated blood lead, parental occupational exposure to lead, lived in or visited structure with deteriorated/remodeled lead-painted surfaces

Anemia (hemoglobin/hematocrit) screening

Screening MEETS COVERAGE CRITERIA per age and risk:

ALL of the following

All children at 12 months of age
ANY of the following
- Children 4 months and older if at risk for iron deficiency, as defined by the AAP
- AAP risk examples: history of prematurity or low birth weight; exposure to lead; exclusive breastfeeding beyond 4 months without supplemental iron; weaning to whole milk or complementary foods lacking iron-fortified cereal or iron-rich foods; feeding problems; poor growth; inadequate nutrition

Tuberculosis (TB) screening

TB screening MEETS COVERAGE CRITERIA for children at increased risk:

ALL of the following

Children age 1 month and older who are at increased risk
ANY of the following
- Born in a country other than the U.S., Canada, Australia, New Zealand, or Western Europe
- Traveled/had contact with residents for longer than 1 week in a country with high TB risk
- Has family member or contact with active TB or positive tuberculin skin test
- Is infected with HIV

Dyslipidemia screening

Screening MEETS COVERAGE CRITERIA per risk and age recommendations:

ALL of the following

ANY of the following
- Annually for children and adolescents at increased risk due to personal or family history as defined by AAP and Bright Futures
- Once for all children and adolescents during each age period: 9-11 years and 17-21 years
- Risk factors include: excessive saturated fat intake, elevated blood pressure, diabetes, physical inactivity, renal disease, BMI ≥ 85th percentile, unobtainable family history, parental/grandparental premature stroke/heart disease, parent with cholesterol ≥ 240 mg/dL or on cholesterol medication

Sexually transmitted infections (STI) and HIV screening

Screening MEETS COVERAGE CRITERIA when sexually active or at increased risk:

ALL of the following

Annual screening for Chlamydia, Gonorrhea, and Syphilis in sexually active adolescents and those at increased risk
ANY of the following
- Increased risk examples: men who have sex with men, sex workers, high-risk sexual behavior, exchange sex for drugs, history of other STIs, persons in adult correctional facilities
Annual screening for Hepatitis B virus in asymptomatic nonpregnant adolescents at high risk (detailed risk list included in policy)
Screening for HIV infection MEETS COVERAGE CRITERIA (USPSTF/AAP alignment); routine adolescent screening recommendations (see guidelines)

Hepatitis B specific high-risk groups

Hepatitis B screening MEETS COVERAGE CRITERIA for asymptomatic nonpregnant adolescents who meet any of the following:

ANY of the following

Born in regions with HBsAg prevalence >2%
U.S.-born not vaccinated as infants whose parents were born in regions with HBsAg prevalence >8%
Injection-drug users
Men who have sex with men
Persons with elevated ALT/AST of unknown etiology

Key Numerical Thresholds Cited

CDC Blood Lead Reference Value (BLRV)3.5 µg/dL

This policy references the federal Recommended Uniform Screening Panel (RUSP) as the national standard for newborn screening content. The RUSP advisory committee’s listing includes 35 core disorders that are commonly used to define state newborn screening panels; states determine their own required panels and may vary from the federal RUSP list (RUSP core = Newborn → 35 core disorders).

Other policy metrics referenced in the document include the CDC’s updated blood lead reference value (BLRV = 3.5 µg/dL), the age range covered by this policy (0–18 years), alignment with primary guideline sources (AAP/Bright Futures), and the policy effective date (2023-07-01).

Required Provider Documentation and Operational Actions

Documentation Required

Follow state newborn screening mandates

Ensure newborn screening panels follow all applicable federal and state laws and verify that newborns have received required state metabolic screenings — especially for infants born outside a hospital setting or born in another state. If state requirements differ from the RUSP or federal guidance, follow the applicable state newborn screening mandates for that member.

Confirm the newborn screening panel follows applicable federal and state law recommendations (RUSP/state mandates).
Verify the newborn received state-required metabolic screenings prior to discharge or at the first visit when birth occurred outside a hospital or out of state.
Document which state program and which conditions were screened, and arrange confirmatory testing or referral if screenings are incomplete or abnormal.

Documentation Required

Risk assessment and periodicity adherence

Perform and document age-appropriate risk assessments per the AAP/Bright Futures periodicity schedule and record clinical indications that justify targeted screening (e.g., lead, anemia, TB, dyslipidemia, STIs, HBV/HIV) according to the patient's age and identified risk factors.

Clinical and Policy Background

This pediatric preventive screening policy aligns BlueCross BlueShield of Tennessee coverage with major guideline sources including the American Academy of Pediatrics’ Bright Futures periodicity recommendations, the United States Preventive Services Task Force (USPSTF) guidance, the Centers for Disease Control and Prevention (CDC) recommendations, and the federal Recommended Uniform Screening Panel (RUSP). The policy adopts Bright Futures’ age-based approach to preventive screening and directs providers to perform age-appropriate risk assessments and periodicity-based testing consistent with those sources.

The policy notes important state-level variability for newborn screening panels: while the RUSP provides a federal Recommended Uniform Screening Panel, each state ultimately decides which conditions are required in its newborn screening program. Providers are expected to follow applicable state and federal newborn screening mandates and to verify that state-required metabolic screenings have been completed, particularly when birth occurs outside the birth hospital or out of state.

The policy also recognizes the role of targeted, risk-based testing in children and adolescents—consistent with AAP/Bright Futures and CDC guidance—where screening beyond routine age- or population-based tests is recommended for individuals with defined risk factors (for example, targeted lead testing, TB testing, STI/HBV/HIV testing, and risk-based dyslipidemia or anemia screening).

Defined Terms

Bright FuturesAAP-led national health promotion and prevention initiative with age-based periodicity recommendations.

RUSPRecommended Uniform Screening Panel — federal list of core and secondary conditions for newborn screening.

BLRVBlood Lead Reference Value — CDC metric for elevated lead (3.5 µg/dL cited).

OpenPayer

Pediatric Preventive Screening — Laboratory-Based Preventive Screening (Newborn through Age 18)

Pediatric Preventive Laboratory Screening — Coverage Criteria

Key Numerical Thresholds Cited

Required Provider Documentation and Operational Actions

Clinical and Policy Background

Defined Terms

Policy Update Changes