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Pediatric Preventive Screening Coverage Criteria

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Governs coverage of laboratory-based preventive screening tests for individuals newborn through age 18 (excluding newborn genetic disorder screening programs managed by state mandates). Applies to pediatric preventive screening services and well-child related lab tests.

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Currentblue cross blue shield - tennesseePolicy N/A

Pediatric Preventive Screening Coverage Criteria

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Policy Summary

Payerblue cross blue shield - tennessee

PolicyPediatric Preventive Screening Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument beneficiary age and applicable risk factors or indications to support coverage for targeted or age-specific screenings.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

newborn–18age range covered

35 coreRUSP counts

>=20procedure codes listed

3.5 µg/dLCDC BLRV

Coverage Criteria for Pediatric Preventive Laboratory Screening

Covered pediatric preventive laboratory screenings

Covered when ALL of the following age- or risk-based conditions are met as specified below.

Newborn screening panel meets coverage criteria when it follows all applicable federal and state law recommendations.state-mandated/RUSP alignment

Excludes newborn genetic disorder screening managed per state mandates as described.

Newborn hyperbilirubinemia: Screening for hyperbilirubinemia for all newborns meets coverage criteria.newborn

Congenital hypothyroidism: Screening for congenital hypothyroidism utilizing serum T4 and/or TSH for all newborns meets coverage criteria.newborn

Sickle cell disease: Screening for sickle cell disease for all newborns meets coverage criteria.newborn

Blood lead screening meets coverage criteria for: (a) individuals ages 12 months to 2 years; (b) individuals ages 6 months to 6 years who have increased risk for lead exposure.age and risk-based

Risk factors per CDC/AAP (e.g., housing built before 1978, low-income household, recent immigrant/refugee/internationally adopted child, household occupational/hobby exposure).

Anemia screening: Screening for anemia with hemoglobin or hematocrit meets coverage criteria for: (a) all individuals at 12 months; (b) individuals 4 months and older who are at risk for iron deficiency.age and risk-based

Iron deficiency risk factors include prematurity, prolonged exclusive breastfeeding without iron supplementation, poor complementary feeding, lead exposure, and poor growth.

Tuberculosis screening meets coverage criteria for individuals 1 month of age or older who are at increased risk of contracting tuberculosis.risk-based

TB risk factors include close contact with infectious TB, suggestive radiographic/clinical findings, HIV risk, foreign birth/refugee status, immunosuppression, or travel to endemic areas.

Dyslipidemia screening: Screening for dyslipidemia using a fasting lipid profile or a non-fasting non-HDL-C meets coverage criteria in the following situations: (a) annually for children and adolescents at increased risk due to personal or family history; (b) once during each age period 9–11 years and at 17 years.age and risk-based

Timing informed by AAP/Bright Futures and specialty guidance; USPSTF has stated insufficient evidence for universal pediatric lipid screening in some age groups.

Coverage decision groups

Coverage aligned to guideline recommendations; where USPSTF grades indicate insufficient evidence, coverage follows risk-based or professional society recommendations.

USPSTF Grade B or A screening recommendations cited: USPSTF recommends HBV screening for adolescents/adults at increased risk (Grade B); HCV screening in adults 18–79 (Grade B); HIV screening in adolescents 15 and older (Grade A); chlamydia and gonorrhea screening for sexually active women ≤24 (Grade B); syphilis screening for sexually active adolescents at increased risk.

Used to inform coverage where applicable

Insufficient evidence statements: USPSTF concludes insufficient evidence for universal screening of lipid disorders in children/adolescents ≤20 years, for elevated blood lead in asymptomatic children 1–5 years without increased risk, for iron deficiency anemia in children 6–24 months, and for primary hypertension in asymptomatic children/adolescents.

Where USPSTF states insufficient evidence, AAP or other specialty guidelines' risk-based recommendations are referenced for coverage decisions

Newborn screening: Screening for newborn hemoglobinopathies (including sickle cell), congenital hypothyroidism, and phenylketonuria are recognized as important by USPSTF/RUSP and supported by AAP/Bright Futures; state newborn panels and S3620 code apply.

This policy governs laboratory-based pediatric preventive screening tests for individuals from newborn through age 18, but it expressly excludes newborn genetic disorder screening programs that are conducted under state-mandated newborn screening panels. States determine the specific conditions included in their mandated newborn panels; the policy recognizes RUSP core and secondary conditions as a federal reference but defers to state requirements for coverage of state-mandated newborn screening.

Newborn screening tests that are part of a state-mandated panel and that follow applicable federal and state law recommendations are addressed separately from the routine preventive laboratory screenings covered by this document. Providers should bill state-specified newborn panels using the appropriate newborn panel code (e.g., S3620) when applicable.

Routine hyperlipidemia screening in children and adolescents is addressed in the context of specialty and preventive guidance. The American Academy of Family Physicians communicates a 'don't routinely screen' message for universal lipid screening in youth, and the policy references age- and risk-based approaches recommended by pediatric and specialty societies rather than routine population screening.

Where guideline strength varies, this policy aligns coverage to the combination of professional society recommendations (e.g., AAP/Bright Futures, ADA, AACE/NLA) and USPSTF statements; for dyslipidemia this means emphasizing risk-based screening and targeted age-period screens (for example, once between ages 9–11 and again at 17 years) rather than routine annual screening of all asymptomatic children.

The reference citations listed in this policy do not, by themselves, state additional explicit coverage exclusions beyond the policy's exclusion of state-mandated newborn genetic disorder screening panels. The bibliography and guideline citations are provided to support the coverage rationale and timing recommendations rather than to enumerate further exclusionary coverage rules.

The USPSTF has identified insufficient evidence for several pediatric screening activities (for example, screening for lipid disorders in individuals ≤20 years, screening for elevated blood lead levels in asymptomatic children 1–5 years without risk factors, and screening for iron deficiency anemia in children 6–24 months). This policy notes those insufficiency findings in its evidence discussion and, where USPSTF evidence is insufficient, relies on risk-based or professional society recommendations to define coverage parameters rather than using the USPSTF insufficiency statements as automatic coverage exclusions.

Consequently, when USPSTF grades indicate insufficient evidence, the policy supports coverage for age- or risk-based screening consistent with AAP/Bright Futures or other specialty guidance rather than endorsing universal population-level screening.

The USPSTF has concluded that current evidence is insufficient to recommend universal screening for primary hypertension in asymptomatic children and adolescents, and similar insufficiency applies to routine lipid screening in asymptomatic pediatric populations. The policy therefore does not support routine population-level screening for primary hypertension or universal lipid screening in children and adolescents without identified risk factors.

Coverage is directed toward targeted, risk-based screening per professional guidance (for example, evaluation and monitoring in children with obesity, family history of premature ASCVD, or other clinical risk indicators) rather than universal screening of asymptomatic pediatric populations.

The citations and literature provided in this section are included to support the policy's coverage rationale and clinical timing recommendations. They do not, within the cited text, define specific conditions as 'not medically necessary'; this section functions as a list of supporting references rather than an explicit not-medically-necessary list.

Applicable Procedure Codes and Clinical Thresholds

Applicable CPT/HCPCS Procedure Codesmixed

80061	Lipid panel
82247	Bilirubin; total
82248	Bilirubin; direct
82465	Cholesterol, serum or whole blood, total
83020	Hemoglobin fractionation and quantitation; electrophoresis
83021	Hemoglobin fractionation and quantitation; chromatography
83655	Lead
83718	Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)
84439	Thyroxine; free
84443	Thyroid stimulating hormone (TSH)

1–10 of 21

1/3

BMI / overweight thresholds

Overweight (BMI percentile)BMI ≥ 85th percentile and < 95th percentile

Obesity (BMI percentile)BMI ≥ 95th percentile

Source guidanceAAP dyslipidemia risk factors define overweight/obesity using BMI percentiles as above

LDL acceptable risk level

Accepted LDL risk levelLDL ≤ 100 mg/dL

Monitoring interval if LDL ≤100 mg/dLRepeat lipid profile every 3 years is reasonable (ADA)

Context

Provider Actions, Documentation, and Billing Notes

Prior Authorization

Prior authorization not specified

No explicit prior authorization statements are present in this section of the document.

Billing Rule

Applicable procedure codes

Use the listed CPT/HCPCS procedure codes when submitting claims for laboratory-based pediatric preventive screening tests; proprietary newborn panel and specific LDT codes are noted and must be billed appropriately.

Examples: 80061, 82247, 82248, 82465, 83020, 83021, 83655, 83718, 84439, 84443, 84478, 85014, 85018, 86480, 86580, 86850, 87555, 87556, 88720, 0257U, S3620
S3620 = Newborn metabolic screening panel (state-specified panel)

Background and Scope

Preventive screening is intended to detect disease in asymptomatic individuals to protect and promote health and well-being. Bright Futures and the American Academy of Pediatrics provide age-based periodicity schedules that inform which laboratory tests are appropriate at specific well-child visits, while newborn screening programs—guided by the Recommended Uniform Screening Panel (RUSP) and implemented at the state level—identify core congenital disorders for early diagnosis and treatment.

The Centers for Disease Control and Prevention estimates approximately 4 million newborn screenings occur annually in the U.S., with newborn screening programs identifying thousands of affected infants each year; these programs and their state-specific panels are separate from the routine preventive laboratory screening coverage described in this policy.

Definitions and Reference Terms

Bright Futures (AAP/HRSA periodicity schedule)

DefinitionBright Futures — national health promotion and prevention initiative led by the AAP with periodicity schedules for pediatric preventive care

ContentDescribes age-based screenings, assessments, examinations, procedures, and timing for each well-child visit

Examples of Bright Futures lab recommendationsNewborn blood and bilirubin; anemia risk assessment at 4 months and testing at 12 months; lead and TB screening schedules as indicated

RUSP (Recommended Uniform Screening Panel)

DefinitionRUSP — Recommended Uniform Screening Panel: federal list of conditions to consider for newborn screening programs

Advisory bodyMaintained by the Advisory Committee on Heritable Disorders in Newborns and Children (HRSA)

Policy Summary

Payerblue cross blue shield - tennessee

PolicyPediatric Preventive Screening Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument beneficiary age and applicable risk factors or indications to support coverage for targeted or age-specific screenings.

SourceLink

On This Page

Coverage follows state-specific newborn screening requirements

Specialty recommendations: Specialty society guidance (e.g., NLA) may recommend targeted testing such as Lp(a) measurement in youth with suspected familial hypercholesterolemia or family history of premature ASCVD; AAFP/AAP risk-based approaches inform coverage for dyslipidemia, iron deficiency, and lead screening.

These recommendations inform coverage in situations of elevated risk or clinical suspicion

Initial testing recommendations and follow-up informed by ADA and AACE/ACE guidance for at-risk children

Blood Lead Reference Value (BLRV)

Current CDC BLRV (2021)3.5 µg/dL

DefinitionMetric identifying children with blood lead levels higher than most (97.5th percentile)

Update noteBLRV lowered from 5 µg/dL to 3.5 µg/dL on May 14, 2021 per CDC

0257U noted as a proprietary VLCAD test performed by a specific lab

Prior Authorization

Prior authorization not specified in references

No prior authorization requirements are provided in the referenced guideline and code entries for these screening tests.

Step Therapy

No step therapy specified

No step therapy requirements for pediatric preventive screening tests are specified in this portion of the policy.

Step Therapy

Step therapy not specified

Step therapy is not applicable for laboratory preventive screening tests in this document; laboratory-developed tests are regulated under CLIA and are not subject to step-therapy requirements here.

LDTs are performed in-house and regulated by CMS under CLIA '88; FDA clearance is not required for clinical use.

Step Therapy

Step therapy absence in citations

No step therapy requirements are included in the cited references for pediatric preventive screening.

Documentation Required

Age and risk-factor documentation

Document the beneficiary's age and any applicable risk factors or indications when ordering and billing screening tests to support coverage for targeted or age-based screenings.

Examples of risk factors: housing built before 1978, low-income household, recent immigrant/refugee/internationally adopted status, household lead exposure via occupation/hobbies (for lead screening).
Document iron deficiency risk factors (e.g., prematurity, prolonged exclusive breastfeeding without iron supplementation) when ordering anemia screening.

Documentation Required

Coding and documentation note

Procedure codes listed in Medical Policy documents are provided as a general reference and may not be all-inclusive; providers must document the exact tests performed and use appropriate CPT/HCPCS codes when submitting claims.

Note

References-only documentation statement

This section provides citations only and does not itself specify the required documentation for claims or authorizations.

Denial Risk

Benefit eligibility and legal compliance determine coverage

Coverage is determined by the member's benefit coverage at the time of the request; newborn screening panels meet coverage when they follow applicable federal and state law recommendations.

Verify benefit eligibility and state-specific newborn screening requirements prior to billing.

Denial Risk

Government policy precedence

If this Policy conflicts with applicable government policy (e.g., LCDs, NCDs, or state Medicaid), government policy takes precedence and will be used to make coverage determinations.

Check CMS and state Medicaid resources for the most current determinations.

Denial Risk

No authorization or denial criteria specified in references

The reference citations do not specify authorization or denial criteria for these screening tests.

Role in policyState newborn screening panels commonly reference the RUSP; coverage follows applicable state mandates and RUSP alignment

Blood Lead Reference Value (BLRV) definition

CDC BLRV definitionA metric used to identify children with blood lead levels higher than most (97.5th percentile)

2021 updateCDC updated the BLRV from 5 µg/dL to 3.5 µg/dL on May 14, 2021

PurposeIdentifies children for public health action and follow-up for lead exposure

RUSP — Advisory Committee on Heritable Disorders in Newborns and Children

Advisory CommitteeAdvisory Committee on Heritable Disorders in Newborns and Children oversees the RUSP

RUSP definitionRecommended Uniform Screening Panel — federal recommendation list for newborn screening conditions

ReferenceRUSP information maintained by HRSA and cited in policy references