DraftBlue Cross Blue Shield - TexasPolicy CPCPOO6

Preventive Services Policy

Defines coverage, coding, and reimbursement rules for preventive services (USPSTF/ACIP/HRSA/Bright Futures) for Blue Cross and Blue Shield of Texas members and provider billing expectations.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyPreventive Services Policy

Policy CodePolicy CPCPOO6

Change TypeCoding and content updates (2025)

Effective DateOctober 1, 2025

Next Review DateN/A

Key ActionInclude a preventive diagnosis code and preventive procedure code on claims to ensure preventive-level processing with no member cost share.

SourceLink

POLICY UPDATE CHANGES

CPT code 96040 removed and replaced with 96041; O500T removed and replaced with 87626; added GO011, GO012, GO013, G0567; removed 90630 and 90654.

Added Influenza vaccine code 90635 and USPSTF syphilis CPT update effective 07/01/2025.

Added codes 91323, 90382, A4288; removed codes 90666, 90667, 90668; Yeztugo added to HIV preexposure prophylaxis section.

Coding and recommendation updates (multiple dates through 02/28/2025).

Verbiage updates for Prep.

1.0policy version

2025-10-01effective date

Numerouspreventive recommendations enumerated

Dozenscode lists present

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

LDCTpreauthorization possible

1 per benefitelectric breast pump limit

Preventive Services Coverage Criteria

Preventive coverage overview

Covered when ALL of the following are met:

Preventive services recommended by the USPSTF (Grade A or B), ACIP, HRSA, or Bright Futures are covered with no member cost-share when provided in-network to members of nongrandfathered plans.

Claim includes a preventive diagnosis code and a preventive procedure code.

Service meets applicable medical policy review criteria and falls within the issuing guideline (USPSTF, ACIP, HRSA, or Bright Futures).

Member uses an in-network provider (out-of-network preventive services are subject to copay, deductible, and coinsurance).

Exceptions

Grandfathered plans are exempt from the no cost-share requirement (grandfathered plans may elect coverage but are not required to do so).

Colorectal screening specifics

Colorectal cancer screening coverage and coding rules:

Screening recommended per USPSTF: adults 50–75 (A) and adults 45–49 (B) as specified by USPSTF guidance; multiple screening methods and CPT/HCPCS codes are listed for those age ranges.

Certain colorectal screening services may be subject to medical policy criteria and may require authorization; Modifier 33 or PT may be applied as noted.

Preventive colonoscopy with polypectomy: if a polyp is removed during a preventive colonoscopy, the colonoscopy, polyp removal, labs, and related services are reimbursable at the preventive level when billed appropriately.

Sedation procedure codes (99152, 99153, 99156, 99157, G0500) will process at the preventive level when billed with diagnosis Z12.11 or Z12.12.

Procedure code 74263 is reimbursable at the preventive level only when billed with the specified diagnosis codes listed in the policy.

Preventive service criteria and billing notes

Selected preventive services with billing notes and conditions:

Gestational diabetes screening: screen at 24 weeks or later per USPSTF/related guidance; listed CPTs apply and services are payable with a pregnancy diagnosis.

Hepatitis B screening in pregnant women: screen at the first prenatal visit per USPSTF A; listed lab and procedure codes apply and are payable with a pregnancy diagnosis or a Diagnosis List 1 code.

High blood pressure screening in adults: screen adults age 18+; certain out-of-clinic measurement procedure codes (93784, 93786, 93788, 93790, 99473, 99474) are reimbursable at the preventive level when billed with specified diagnosis codes.

Lung cancer LDCT screening: annual LDCT for adults 50–80 with a 20 pack-year history who currently smoke or quit within the past 15 years; codes include G0296 and 71271.

71271 is reimbursable at the preventive level only if it meets medical policy criteria and is billed with one of the specified diagnosis codes; the service is subject to medical policy criteria and may require preauthorization.

Coverage criteria for referenced preventive services

Coverage criteria for referenced preventive services (highlights):

Syphilis screening in pregnant women: early, universal screening recommended; listed codes (80055, 80081, 86592, 86593, 86780, 0065U, 36415, 0210U, 87285) are payable with a pregnancy diagnosis or a Diagnosis List 1 code.

Tobacco cessation: clinicians should ask all adults and pregnant women about tobacco use, advise cessation, provide behavioral interventions and FDA‑approved pharmacotherapy; coverage includes behavioral codes and pharmacotherapy with limits of two 90‑day regimens per benefit period and prescription requirements for OTC/Rx products.

Breastfeeding support and equipment: comprehensive lactation support and supplies are recommended; electric breast pumps limited to one per benefit period and hospital‑grade pumps limited to rental only as specified in the policy.

Contraceptive care: full range of FDA‑approved contraceptives and related services covered; certain procedures may be reimbursable at the preventive level only when billed with specific modifiers or diagnosis codes.

Preventive service reimbursement criteria (partial)

Reimbursement conditions and operational notes (selected):

Many preventive services (vaccines, screenings, counseling, preventive visits) are payable at the preventive level when billed with an appropriate diagnosis code from Diagnosis List 1.

Breast pump coverage specifics: manual pumps (E0602) may be purchased in- or out-of-network or retail; electric pumps (E0603) must be rented or purchased from an in-network provider or contracted DME supplier; one electric pump allowed per benefit period; hospital‑grade pumps (E0604) are covered only when rented in-network or from an in-network DME supplier up to $1,000 or 12 months and must be returned at the end of coverage.

Distinction between preventive and diagnostic: services intended to prevent illness or detect issues before symptoms are preventive; services for diagnosis, treatment, or ongoing care are diagnostic and may be covered under other plan provisions and subject to cost sharing.

Laboratory tests administered as part of routine pregnancy care are reimbursable at the preventive level when billed with a pregnancy diagnosis.

Limitations and exclusions

Limitations, exclusions, and member responsibilities:

Breastfeeding equipment and supplies not listed in the Breastfeeding Equipment & Supplies section are excluded (examples include batteries, breastfeeding ointments/creams, pump cleaning supplies, milk storage supplies, pump travel cases, infant scales, nursing bras, nursing covers/scarves).

Immunizations that are not published in CDC MMWR and/or not on the FDA 'Vaccines Licensed for Use in the United States' list are excluded from coverage.

Prescription and pharmacy coverage may vary by plan; a prescription may be required for pharmacy reimbursement of OTC items, generic-first requirements, age limits, and other plan-specific restrictions may apply; members should verify pharmacy benefits with customer service.

Each member's benefit plan, summary plan description, or contract governs coverage; if there is a discrepancy between a medical policy and a member's contract, the contract governs. Members and providers are responsible for consulting the member's benefit plan to confirm coverage and any applicable limitations or exclusions.

Procedure and Diagnosis Coding

Covered CPT and HCPCS CodesmixedCovered

99387	Preventive medicine, established patient; age 18-39 (example)
99395	Periodic comprehensive preventive medicine re-evaluation and management of an individual; established patient; 18-39 years
99396	Periodic comprehensive preventive medicine re-evaluation and management of an individual; established patient; 40-64 years
99397	Periodic comprehensive preventive medicine re-evaluation and management of an individual; established patient; 65 years and over
G0438	Annual wellness visit, includes a personalized prevention plan of service (PPPS), initial visit
G0439	Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit
G0446	Annual, standardized, brief depression screening
S9452	Smoking cessation; less than 8 minutes, individual
S9470	Intensive behavioral counseling for obesity, per session
97802	Medical nutrition therapy; initial assessment and intervention, individual

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Provider Billing Requirements and Actions

Prior Authorization

Preauthorization May Be Required for Lung Cancer Screening

Lung cancer screening with low-dose CT (LDCT) is subject to medical policy criteria and may require preauthorization. When medical policy criteria are met and the service is eligible as preventive, LDCT (e.g., CPT 71271, G0296) may be reimbursed at the preventive level.

Subject to medical policy criteria and may require preauthorization
Procedure codes: G0296, 71271 — reimbursable at preventive level when criteria met and billed with appropriate diagnosis codes (e.g., tobacco use or screening diagnosis)

Billing Rule

Smoking Cessation Pharmacy Authorization Notes

Two 90‑day pharmacotherapy regimens per benefit period are allowed for smoking cessation; the 90‑day regimens are at the discretion of the provider working with the member. A prescription is required for both over‑the‑counter and prescription medications used for smoking cessation. Contact the phone number on the member's BCBSTX ID card for pharmacy‑benefit details (the pharmacy benefit may be managed by a separate vendor).

Definitions and Terms

ACIP definition

ACIP acronymACIP = Advisory Committee on Immunization Practices

Context useAcronym used throughout the reimbursement policy to reference immunization recommendations

Authority relevanceACIP recommendations are among the referenced guidance for preventive‑level coverage under PPACA

USPSTF definition

USPSTF acronymUSPSTF = United States Preventive Services Task Force

RoleSource of preventive service recommendations (A/B) used to determine no cost‑share coverage for nongrandfathered plans

Policy Revision History

2017-06-23policy_created

New policy created, replacing medical policy ADM1001.030.

2017-07-14coding_update

Removed codes 99174 and 99177.

2017-12-06coding_recommendation_update

Coding and USPSTF recommendation updates recorded.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyPreventive Services Policy

Policy CodePolicy CPCPOO6

Change TypeCoding and content updates (2025)

Effective DateOctober 1, 2025

Next Review DateN/A

Key ActionInclude a preventive diagnosis code and preventive procedure code on claims to ensure preventive-level processing with no member cost share.

SourceLink

On This Page

Two 90‑day treatment regimens per benefit period
Prescription required for both OTC and prescription smoking cessation medications
Examples of covered therapies include generic bupropion SR, nicotine gum/lozenge/patch, varenicline; coverage specifics determined by the member's pharmacy benefit manager

Billing Rule

Breast Pump Procurement and Network Requirements

Electric breast pumps (HCPCS E0603) must be rented or purchased from an in‑network provider or a contracted durable medical equipment (DME) supplier to be covered at the preventive level. Members are allowed one electric breast pump per benefit period. Hospital‑grade breast pumps (E0604) are covered only as rentals from in‑network providers or contracted DME suppliers and are limited to rental coverage (coverage up to purchase price or 12 months, whichever comes first). Manual breast pumps (E0602) are covered when obtained in‑network, out‑of‑network, or from retail providers; however retail sales tax is excluded and out‑of‑network preventive reimbursement may include cost‑sharing.

E0603 (electric) — must be rented/purchased from in‑network or contracted DME supplier; one per benefit period
E0604 (hospital‑grade) — rental only, in‑network DME supplier; coverage up to purchase price or 12 months
E0602 (manual) — available from in‑network, out‑of‑network, or retail providers (retail purchases exclude sales tax)
Upgraded models may result in member balance billing for the difference beyond standard model allowance

Documentation Required

Diagnosis Coding Requirement for Preventive‑Level Payment

Many preventive services are payable at the preventive level only when billed with a preventive diagnosis from Diagnosis List 1. Services performed for symptomatic or diagnostic reasons should be billed with the appropriate diagnostic code and may be subject to applicable cost sharing.

Preventive claims must include a preventive diagnosis code (Diagnosis List 1) and a preventive procedure code to process with no member cost‑share
If the service is provided for symptomatic/diagnostic indications, bill with the symptom/diagnosis code — the service may be covered under another benefit provision and subject to cost sharing

Note

Prescription Requirement for OTC Items

Some over‑the‑counter (OTC) items and breastfeeding supplies may require a provider prescription to be covered under the pharmacy benefit. Members should obtain a prescription from their provider and present it to the pharmacy; coverage and any prior authorization or generic‑first requirements depend on the member's pharmacy plan.

OTC purchases require a prescription to be filled under the pharmacy benefit
Prescription may be required and the plan may require trying a generic before a brand; pharmacy benefit details vary by plan and may be managed by another vendor
Members should verify pharmacy coverage by calling the customer service number on their ID card

Multiple USPSTF recommendations are cited throughout the policy (screenings, counseling, medications)

HRSA definition

HRSA acronymHRSA = Health Resources and Services Administration

RoleHRSA (and Women's Preventive Services Initiative) recommendations referenced for women's services and breastfeeding equipment coverage

Document referencesHRSA recommendations appear in breastfeeding and women's preventive sections

Preventive‑level reimbursement (definition and notes)

Preventive‑level reimbursement definitionServices intended to prevent illness or identify issues before symptoms are preventive and may be reimbursed at the preventive level when billed with appropriate diagnosis codes

Diagnostic distinctionDiagnostic services treat existing symptoms or ongoing conditions and may be subject to different benefit provisions and cost‑sharing

Billing implicationMany preventive services are payable at preventive level only when billed with a Diagnosis List 1 code or pregnancy diagnosis as specified

PrEP (HIV prevention) — preventive services covered

PrEP preventive coveragePre‑exposure prophylaxis (PrEP) and related baseline and monitoring services are reimbursable at the preventive level consistent with USPSTF recommendations

Covered productsIncludes oral agents (e.g., generic Truvada) and injectable agents (e.g., cabotegravir/Apretude) and newer agents referenced in the policy

Pharmacy benefit notePharmacy benefit coverage may be managed by an external pharmacy benefit manager; contact member card number for pharmacy benefit details

Diagnosis List 1 — payable condition reference

Diagnosis List 1 usageMany preventive services are payable when billed with a diagnosis code from Diagnosis List 1

LocationDiagnosis List 1 is present in the document and contains numerous ICD codes (used for preventive billing)

ImplicationServices performed for non‑preventive indications may be covered under other plan provisions and subject to cost sharing

Breastfeeding equipment limits — quantities and limits

Electric pump quantity limitOne electric breast pump (E0603) allowed per benefit period

Hospital‑grade pump rental onlyHospital‑grade pumps (E0604) limited to rental and covered only when rented in‑network or from an in‑network DME supplier

Coverage capHospital‑grade pump coverage limited to up to $1,000.00 or 12 months (whichever comes first) and must be returned at end of coverage

Preventive services — definition and examples

Preventive services definitionServices intended to prevent illness or identify issues before symptoms are considered preventive (e.g., screenings, counseling interventions)

ExamplesBiennial mammogram for screening, counseling for CVD risk factors, colonoscopy for colorectal cancer screening

Billing notePreventive services may be reimbursable at the preventive level when billed with specified diagnosis codes

Diagnostic services — definition and examples

Diagnostic services definitionServices for diagnosis of existing symptoms, treatment, ongoing care, or tests to manage a health condition are diagnostic

ExamplesMammogram after noticing a lump; nutritional counseling to manage diagnosed diabetes; tests to manage an established condition

Coverage implicationDiagnostic care may be covered under other benefit provisions and is generally subject to cost sharing

Cross‑reference — other portions of the medical plan

Cross‑reference to other plan sectionsBreastfeeding equipment coverage and limits are described in the Breastfeeding Equipment & Supplies section; members should consult their benefit plan/contract for plan‑specific terms

Out‑of‑network noteRetail vendors are considered out‑of‑network; out‑of‑network preventive coverage follows plan out‑of‑network benefit level and may include cost sharing and sales tax exclusions

Governing clauseIf discrepancies exist between medical policy and the member's benefit plan/contract, the benefit plan governs

Excluded breastfeeding supplies — examples and member note

Examples of excluded breastfeeding suppliesBatteries; breastfeeding ointments/creams; breast pump cleaning supplies; breast milk storage supplies (bags, freezer packs); breast pump travel cases; infant scales; nursing bras; nursing covers/scarves

Coverage noteBreastfeeding equipment and supplies not listed under the Breastfeeding Equipment & Supplies section are excluded; members should verify benefits with customer service

Prescription/pharmacy notePrescription coverage may vary; OTC purchases may require a prescription to be filled at a pharmacy to obtain coverage

2018-04-30coding_recommendation_update

Coding and USPSTF recommendation updates recorded.

2018-07-12coding_recommendation_update

Coding and USPSTF recommendation updates recorded.

2018-12-27coding_recommendation_update

Coding and USPSTF recommendation updates recorded.

2019-09-26coding_recommendation_update

Coding and USPSTF recommendation updates recorded.

2019-10-14vaccine_update

HPV vaccine update recorded.

2019-12-30coding_recommendation_update

Disclaimer, coding and USPSTF updates recorded.

2020-04-20recommendation_update

Recommendation updates recorded.

2020-06-08coding_recommendation_update

Disclaimer, coding links, and recommendation updates recorded.

2020-09-09coding_recommendation_update

Coding and recommendation updates recorded.

2020-12-21coding_recommendation_drug_update

Coding and recommendation updates plus drug information updates and disclaimers recorded.

2021-01-12coding_update

Coding updates recorded.

2021-09-22coding_recommendation_drug_update

Coding and recommendation updates and drug information updates recorded.

2021-12-16coding_recommendation_update

Coding and USPSTF updates recorded.

2022-03-23coding_recommendation_update

Coding and recommendation updates recorded.

2022-06-01coding_recommendation_update

Coding and recommendation updates recorded.

2022-07-29diagnosis_list_update

Diagnosis List updates recorded.

2022-09-09coding_recommendation_update

Coding and recommendation updates recorded.

2023-02-20coding_update

Coding updates recorded.

2023-03-16coding_recommendation_update

Coding and recommendation updates and hyperlink updates recorded.

2023-05-24coding_recommendation_update

Coding and recommendation updates recorded.

2023-06-01coding_recommendation_update

Coding and recommendation updates recorded.

2023-09-25coding_recommendation_update

Coding and recommendation updates recorded.

2023-09-27coding_recommendation_update

Coding and recommendation updates recorded.

2023-12-18coding_recommendation_update

Coding and recommendation updates recorded.

2024-03-22coding_recommendation_update

Coding and recommendation updates recorded.

2024-06-01coding_recommendation_update

Coding and recommendation updates recorded.

2024-08-29coding_recommendation_update

Coding and recommendation updates recorded.

2025-02-01verbiage_update

Verbiage updates for PrEP recorded.

2025-02-28coding_recommendation_update

Coding and recommendation updates recorded.

2025-04-01material_coding_changes

Coding and recommendation updates: CPT 96040 removed and replaced with 96041; O500T removed and replaced with 87626; added GO011, GO012, GO013, G0567; removed 90630 and 90654.

2025-07-01coding_recommendation_update

Added influenza vaccine code 90635 and USPSTF syphilis CPT update recorded.

2025-08-29coding_recommendation_updateLatest

Added codes 91323, 90382, A4288; removed codes 90666, 90667, 90668; Yeztugo added to HIV PrEP section.