CurrentCignaPolicy N/A

Preventive Care Administrative Policy

Defines administration and coverage handling of preventive services for Cigna standard benefit plans, including which preventive services are covered, coding guidance, frequency, and reasonable medical management; applies to in-network preventive services and related claim submission practices.

Policy Summary

PayerCigna

PolicyPreventive Care Administrative Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionWhen ACA sources lack specifics, use reasonable medical management (precertification, concurrent review, claim review) to determine coverage limitations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

USPSTF A/B, ACIP, HRSADesignated ACA sources for required preventive services

Ages 0-5; annual ≥5Wellness exam frequency summarized

Reasonable medical managementUse of management tools

SDOH sectionHealth equity

Many codesCoding lists present

Preventive Services Coverage Criteria

inv-01: Preventive services coverage criteria

Covered when all applicable plan terms and ACA requirements are met:

ALL of the following

Preventive care services designated by ACA sources (USPSTF grade A/B, ACIP recommendations adopted by CDC Director, HRSA-supported guidelines) are covered in-network without cost sharing when applicable.
Wellness examination frequency: ages 0–5 per AAP Bright Futures periodicity schedule; ages 5 and above—annual wellness examination or well-woman exam (use listed preventive E/M and HCPCS codes).
Colorectal cancer screening for asymptomatic average-risk adults age 45–75 is allowed using accepted modalities and intervals (FIT/FOBT annually; Stool DNA-FIT annually; flexible sigmoidoscopy every 5–10 years with/without annual FIT; colonoscopy every 10 years; CT colonography every 5 years; DCBE every 5 years).

All ICD-10, CPT and HCPCS codes billed for a preventive service must follow standard coding guidelines and identify the service as preventive (services billed with treatment diagnosis codes will be paid under medical benefits). Modifier 33 alone is not sufficient to identify a claim as preventive.

Reasonable medical management (eg, precertification, concurrent review, claim review) may be used to determine frequency, method, treatment or setting when guidelines do not specify such details.

inv-02: Preventive services coverage criteria and billing rules

Coverage and billing rules vary by service type and population; follow allowed diagnosis contexts and designated wellness codes when specified:

Hepatitis screening

Hepatitis B screening: pregnant persons at first prenatal visit and adolescents/adults at high risk — use G0499; allowed with a maternity diagnosis code as specified.
Hepatitis C screening: adults age 18–79 — use 86803, 87520, 87521, 87522, G0567 or G0472 as indicated; follow designated wellness code selection rules.

HIV screening

HIV screening: pregnant persons; adolescents and adults 15–65 (younger with risk factors); annually for sexually active women — use listed laboratory and G-codes (eg, 80081, 86701-86703, 87389-87391, 87534-87539, 87806, S3645, G0432, G0433, G0435, G0475); select designated wellness code from Code Group 1 or allow with maternity diagnosis as specified.

inv-03: Preventive service coverage and coding requirements

Preventive services are identified and paid as preventive only when billed with appropriate preventive diagnosis and procedure codes:

All ICD-10, CPT and HCPCS codes billed for preventive services must follow standard coding guidelines; claims submitted with diagnosis codes for treatment of illness or injury will be processed under medical benefits rather than as preventive care.

Modifier 33 alone is insufficient — Cigna will not process a claim as preventive based solely on modifier 33; preventive identification requires use of preventive diagnosis and procedure codes.

Select designated wellness codes from the relevant code groups when required (eg, Code Group 1) and use maternity diagnosis codes where the policy specifies allowance with a maternity diagnosis.

inv-04: Covered codes for preventive services

The following CPT/HCPCS codes are covered when billed for preventive screenings and interventions (selection shown — refer to full code lists in policy):

Infectious disease and antigen tests: Examples: 87389-87391, 87490-87492, 87516, 87520-87522, 87534-87539, 87624-87626, 87800-87806.

Immunizations and administration: Examples: administration codes 90460-90474, 90480, vaccine product codes 90611, 90632, 90651, 90670, 90680, 90694, 90696-90698, 90707, 90710, and multiple 906xx/907xx series and newer vaccine product codes (91304, 91318+).

Screening imaging and procedures: Examples: 71271 (low-dose CT), 76977 (bone density ultrasound), 77078-77086 (DXA/mammography series), 45330-45390 series (colonoscopy/sigmoidoscopy), S0285 (colonoscopy consult), 0813 and Cologuard 81528, 0464U.

Screening and behavioral assessment: Examples: 96110, 96127, 96156-96161, 96164-96168, 99401-99404, 99406-99407, 99408-99409, G0442-G0446, G0473.

inv-05: Preventive services coverage criteria (partial)

Conditions and usage limits for listed preventive codes:

Preventive use only: Codes in the policy code lists are covered only when billed to report preventive screenings and interventions and not for treatment of illness or injury.

Vaccine funding exclusion: The cost of government-provided and funded vaccinations is not covered; vaccine administration codes are covered and should be billed separately for administration (see administration codes and notes).

Self-measured blood pressure monitoring (eg, code 99474) requires a minimum of 12 readings over 30 days per the code description.

Physical therapy evaluation complexity/time: When reporting PT evaluation codes (97161-97163) and re-evaluation (97164), use the CPT descriptions for complexity and typical face-to-face time (eg, 97161 ~20 minutes, 97162 ~30 minutes, 97163 ~45 minutes, 97164 ~20 minutes) as applicable.

inv-06: Code combination requirements

Certain diagnosis codes must be used in combination with specified procedure codes:

Fall prevention diagnosis codes (eg, M62.81, R26.81, R54, Z91.81) must be used only in combination with specified CPT/HCPCS procedure codes (eg, 97110, 97112, 97113, 97116, 97150, 97161-97164, 97530, G0159, S8990, S9131) as listed in Code Group 2.

inv-07: Vaccine funding exclusion

Funding and billing note for vaccines:

The cost of government-provided and funded vaccinations is excluded from coverage; however, vaccine administration is covered and should be billed using the appropriate administration codes (eg, G0008, G0009, G0010 or 90460-90474) as applicable.

inv-08: Osteoporosis screening coding requirement

Required diagnosis-procedure pairing for osteoporosis screening claims:

When the encounter is for osteoporosis screening, report diagnosis code Z13.820 in combination with CPT codes 76977, 77078, 77080, 77081, 77085, 77086 or HCPCS code G0130.

Coding Tables and Frequency Guidance

Covered CPT Codes - Flexible Sigmoidoscopy / Barium EnemaCPTCovered

45330	Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure).
45331	Sigmoidoscopy, flexible; with biopsy, single or multiple.
45333	Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps.
45338	Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.
45346	Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed).
74270	Radiologic examination, colon, single-contrast (eg, barium) study.
74280	Radiologic examination, colon, double-contrast (eg, high density barium and air).
G0104	Flexible sigmoidoscopy screening (HCPCS) - select designated code from Code Group 11.

Covered CPT Codes - ColonoscopyCPTCovered

45378	Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure).
45380	Colonoscopy, flexible; with biopsy, single or multiple.
45381	Colonoscopy, flexible; with directed submucosal injection(s), any substance.
45384	Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps.
45385	Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.
45388	Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed).
45390	Colonoscopy, flexible; with endoscopic mucosal resection.
G0105	Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk (HCPCS).
G0121	Colorectal cancer screening; colonoscopy on individual meeting criteria for high risk (HCPCS).

Colonoscopy Code Group (Use with designated diagnosis codes)mixedCovered

45378-45390 series	Colonoscopy CPT range included for preventive screening and related therapeutic maneuvers when reported as preventive (see individual codes listed elsewhere).
45331	Flexible sigmoidoscopy with biopsy - listed for preventive flexible sigmoidoscopy group.
45333	Flexible sigmoidoscopy with removal by hot biopsy forceps - listed for preventive flexible sigmoidoscopy group.
45338	Flexible sigmoidoscopy with snare technique - listed for preventive flexible sigmoidoscopy group.
45346	Flexible sigmoidoscopy with ablation - listed for preventive flexible sigmoidoscopy group.

Preventive Screening Procedures and Laboratory Codes (selected)mixedCovered

00812	Anesthesia for lower intestinal endoscopic procedures; screening colonoscopy.
00813	Anesthesia for combined upper and lower gastrointestinal endoscopic procedures; preventive when performed as part of screening colonoscopy.
00840	Anesthesia for intraperitoneal procedures in lower abdomen; preventive coverage when applicable.
36415	Collection of venous blood by venipuncture.
82270	Fecal occult blood test (guaiac), qualitative; colorectal neoplasm screening - consecutive specimens.
82274	Fecal immunochemical test (FIT), qualitative - feces, 1-3 simultaneous determinations.

Provider Billing and Operational Actions

Prior Authorization

Precertification and medical management

The ACA allows reasonable medical management techniques to determine coverage limits when a recommendation or guideline does not specify frequency, method, treatment, or setting for a recommended preventive service. Reasonable medical management techniques may include precertification, concurrent review, claim review, or similar practices to determine coverage limitations under the plan. Providers should follow prior authorization and claim review processes as established by the plan.

Note

Reasonable Medical Management

If a guideline lacks specifics about frequency, method, treatment, or setting for a recommended preventive service, the plan may use reasonable medical management (precertification, concurrent review, claim review or similar practices) to determine coverage limits. Providers should be prepared to support the medical necessity and preventive intent of billed services during review.

Definitions and Reference Concepts

Administrative Policies — Definition & Scope

DefinitionAdministrative Policies provide information about administration of standard Cigna benefit plans and are not treatment recommendations.

Plan document precedenceIn the event of a conflict, a customer's benefit plan document supersedes the Administrative Policy.

Purpose of coverage determinationsCoverage determinations require consideration of plan terms, applicable laws/regulations, relevant collateral materials including Administrative Policies, and the specific facts of the situation.

ACA-Designated Preventive Service Sources

ACA-designated sourcesUSPSTF recommendations graded A or B; ACIP recommendations adopted by the CDC Director; HRSA-supported guidelines for pediatric and women's preventive services.

Coverage implication

Policy Summary

PayerCigna

PolicyPreventive Care Administrative Policy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionWhen ACA sources lack specifics, use reasonable medical management (precertification, concurrent review, claim review) to determine coverage limitations.

SourceLink

On This Page

Lung cancer screening:

Adults age 50–80 with ≥20 pack-year smoking history who currently smoke or quit within 15 years — use low-dose CT codes (eg, 71271) or G0296 and select Code Group 8 codes as indicated.

Nutrition/Physical activity counseling: Behavioral nutrition/physical activity counseling for adults with CVD risk factors, obese children ≥6, pregnant adolescents/adults: use S3620, 97802-97804, S9470, G0446/G0447/G0473; subject to a 3-visit limitation where noted.

Osteoporosis screening: Screening per criteria: women ≥65 (without specified conditions) and select <65 with elevated risk by formal clinical risk tool; screening every 2 years per policy — use listed DXA/ultrasound codes as indicated.

Vaccinations: Vaccines recommended per ACIP for children, adolescents and adults are covered when billed for preventive care; vaccine administration codes are covered but the cost of government-provided/funded vaccines is not covered (bill administration separately).

Vision screening and contraceptive services: Vision screening (age 3–15) and women's contraceptive services/supplies are allowed per listed codes; follow rules for maternity or any-diagnosis contexts as specified.

Reporting and ancillary services: Report preventive services with diagnosis and procedure codes that identify the service as preventive; ancillary services directly related to a preventive procedure (eg, pre-procedure visit, facility fee, anesthesia, pathology for screening colonoscopy) are considered part of the preventive service as described.

Physical therapy and nutrition (preventive use): Examples: PT evaluation codes 97161-97164, therapeutic activities 97530, medical nutrition therapy 97802-97804 when used for preventive counseling/intervention.

Billing Rule

Preventive medicine and counseling billing

The following preventive medicine, counseling, screening, and brief intervention codes are covered when used to report preventive care screenings and interventions (not for treatment of illness or injury): 99401-99404 (preventive medicine counseling, 15–60 minutes), 99406-99407 (smoking/tobacco cessation counseling), 99408 (alcohol/substance abuse structured screening and brief intervention), 99473-99474 (self-measured blood pressure monitoring training and device), and other listed screening/intervention CPT/HCPCS codes (eg, 0403T, 97161-97164 for PT evaluation/re-evaluation, 97530, 97802-97804 for nutrition therapy, 99173-99174 ocular/vision screening, 99188 topical fluoride). Report the appropriate preventive counseling, screening, evaluation, or re-evaluation code when the service is rendered as a preventive service.

Billing Rule

Vaccine administration billing note

Vaccine administration codes (for example G0008, G0009, G0010 and the applicable CPT/HCPCS administration codes) are covered for administration of recommended vaccines. Note: the cost of government-provided or government-funded vaccines is not covered by the plan; providers should bill only the vaccine administration when the vaccine itself is provided by a government program. Ensure administration is billed with appropriate administration codes and linkage to the preventive intent.

Services recommended by these sources are required to be covered in-network without cost sharing under the ACA (subject to plan exceptions like grandfathered plans).

USPSTF grade descriptionsUSPSTF grades describe recommendation strength (A, B, C, D, I) and inform coverage under ACA requirements.

Definition — Preventive Care Services

Preventive care services — definitionScreenings, tests, and services performed for symptom-free or disease-free individuals, including routine immunizations and wellness screening services for asymptomatic individuals at increased risk.

Distinction from diagnostic/monitoringDiagnostic tests evaluate abnormalities; monitoring/surveillance apply to individuals with known conditions or history and are no longer considered screening.

Impact of positive screenA positive preventive screening does not change the service classification at the time but may change future services to non-preventive if a diagnosis is established.

USPSTF Grades — Descriptions

USPSTF Grade AThe USPSTF recommends the service. There is high certainty that the net benefit is substantial.

USPSTF Grade BThe USPSTF recommends the service. There is high certainty that the net benefit is moderate or moderate certainty that the net benefit is moderate to substantial.

USPSTF Grades C/D/IGrade C: selectively offer based on professional judgment; Grade D: recommends against; Grade I: insufficient evidence.

Health Equity & Social Determinants of Health

Health equity definitionHealth equity is the highest level of health for all people; health inequity refers to avoidable differences due to social conditions (SDOH).

Examples of SDOHIncludes housing, transportation, neighborhood safety, racism, education, job opportunities, income, access to nutritious foods, and language/literacy.

Access implicationThe ACA's requirement to provide preventive services without cost share may enhance access and help address disparities in preventive care.

Reasonable Medical Management — Definition & Examples

DefinitionReasonable medical management refers to techniques used when guidelines lack specifics to determine coverage limitations (e.g., frequency, method, setting).

ExamplesMay include precertification, concurrent review, claim review or similar practices to determine coverage limitations under the plan.

Use caseApplied when a recommendation or guideline does not specify frequency, method, treatment, or setting for a preventive service.

Preventive Service Identification & Coding

Identification requirementPreventive services are identified and covered when submitted with preventive diagnosis and procedure codes that indicate the service is preventive.

Modifier 33 limitationModifier 33 alone will not cause Cigna to process a claim as preventive; appropriate preventive coding must be used.

Coding practiceAll ICD-10, CPT and HCPCS codes billed for preventive services should follow standard coding guidelines, including primary/principal diagnosis rules.

Preventive Use Restriction

Preventive-use restrictionCodes listed in the preventive sections are covered only when used to report preventive screenings and interventions, not for treatment of illness or injury.

Billing implicationWhen the same code is used for treatment of illness or injury, it will be processed under medical benefits rather than preventive coverage.

Example categoryIncludes infectious agent detection, screening imaging, therapy and nutrition CPT codes when used for preventive purposes.

Physical Therapy Evaluation (97161-97164) — Definitions

97161-97164 definitionsPhysical therapy evaluation complexity levels defined by history, exam elements, clinical presentation and clinical decision making (97161 low, 97162 moderate, 97163 high, 97164 re-evaluation).

Typical face-to-face timesTypical face-to-face times: 97161 ~20 minutes; 97162 ~30 minutes; 97163 ~45 minutes; 97164 re-evaluation ~20 minutes.

ComponentsEvaluations include standardized tests and measures and require documentation of clinical decision making consistent with CPT descriptions.

Medical Nutrition Therapy (97802-97804)

97802-97804 descriptions97802: initial assessment and intervention, individual, per 15 minutes; 97803: re-assessment and intervention, individual, per 15 minutes; 97804: group, per 30 minutes.

Preventive billing contextMedical nutrition therapy codes may be used for preventive nutrition/physical activity counseling and are subject to the 3-visit limitation where specified.

Allowed diagnosisAllowed with any diagnosis or designated wellness code; pregnant persons may require a maternity diagnosis code when specified.

Vaccine Cost Coverage Exception

Government-provided vaccine cost exclusionThe cost of government-provided and funded vaccinations is not covered; only vaccine administration is covered.

Billing action for providersProviders should bill vaccine administration codes separately (e.g., G0008, G0009, G0010) when vaccine cost is government-funded.

Repeated policy noteThis note regarding vaccine cost vs administration is repeated in multiple sections of the policy for emphasis.

Vaccine Cost vs Administration — Restatement

Restatement of vaccine cost guidanceThe cost of government-provided and funded vaccinations is not covered; the administration of the vaccine is covered.

Administration codes examplesExamples of administration codes include G0008 (influenza), G0009 (pneumococcal), G0010 (hepatitis B) and other listed administration codes.

Provider billing considerationWhen vaccines are government-provided, bill only for administration; vaccine product cost should not be billed for coverage under this policy.

Osteoporosis Screening — Z13.820

Z13.820 codeZ13.820 — Encounter for screening for osteoporosis.

Pairing requirementReport Z13.820 in combination with CPT codes 76977, 77078, 77080, 77081, 77085, 77086 or HCPCS G0130 when the encounter is for osteoporosis screening.

PurposeEnsures osteoporosis screening procedures are identified and processed as preventive services when billed with the screening diagnosis code.