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    v1.0.28
    OpenPayerPolicy UpdatesPreventive Services & ScreeningEmblemHealth preventive services — Coverage Update…
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    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.

    ModifiedEmblemHealthPolicy N/A

    Preventive Care and Screening Services — Coverage Criteria

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    Governs coverage, frequency, and coding for preventive screenings, counseling, immunizations, breastfeeding equipment and related services for members under ConnectiCare/EmblemHealth plans, with distinctions for non‑grandfathered and grandfathered plans and network vs out‑of‑network providers.

    Policy Summary
    PayerEmblemHealth
    PolicyPreventive Care and Screening Services — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeCode additions, deletions, and age/frequency guidance revisions (material)
    Effective DateN/A
    Next Review DateN/A
    Key ActionBill using the current valid CPT codes listed in the policy and follow FDA/CDC/ACIP age and frequency guidance when administering vaccines.
    SourceLink
    POLICY UPDATE CHANGES

    Added Respiratory Syncytial Virus (RSV) Vaccine code 90683 effective 5/31/2024.

    Added Pneumococcal Conjugate code 90684 effective 6/17/2024.

    Removed age requirements for Dengue vaccine CPT code 90587; provider must adhere to FDA/CDC age/frequency guidelines.

    Addition of CPT code 87626 for Human Papillomavirus (HPV) screening (DNA) effective 1/1/2025.

    Deleted CPT code 0500T indicated for HPV screening.

    Updated BRCA genetic testing counseling/evaluation codes to include CPT 99401–99404 and deletion of CPT 96040 effective 1/1/2025.

    No member cost-sharingNon-grandfathered plans
    1x/yearGeneral preventive visit frequency (adult)
    1x/pregnancy
    Breast pump coverage frequency
    12x/yearBehavioral interventions (adult)
    90683RSV vaccine code added
    90684Pneumococcal conjugate code added

    Coverage Criteria and Preventive Services

    PPACA Preventive Services Coverage

    Covered when ALL of the following are met

    PPACA preventive services: Service is an evidence-based item rated A or B by USPSTF, an ACIP routine immunization, or included in HRSA/AAP Bright Futures or other HRSA-supported comprehensive guidelines

    Per PPACA requirements for non-grandfathered plans

    Network provider: Service is provided by a Network provider for non-grandfathered plans to be covered without member cost-sharing

    Out-of-network preventive services may be subject to member cost-sharing; refer to member benefit plan document

    Specific Covered Preventive Services and Frequencies

    Covered preventive services with specified frequencies

    General preventive visits: Preventive screening examination and counseling codes (e.g., 99383–99397, 96160–96161, 99401–99404) are covered, typically one procedure code/member/year for adults; well child visit frequencies vary by age band as listedOne procedure code/member/year (adults); see well child age bands for pediatric frequencies

    See CPT listings for age bands and exact frequencies

    Breast imaging: Mammography and adjuncts (including tomosynthesis, ultrasound, MRI) are covered with stated frequencies and age bands (mammography screening generally 1x/year for ages 40+)1x/year for mammography ages 40+ (subject to state mandates)

    Breast MRI screening requires authorization per Pre-Authorization policy

    Breastfeeding equipment: Personal-use electric breast pumps (E0602/E0603) and supplies (A4281–A4287) are covered1x/pregnancy

    Replacement supplies and new HCPCS codes effective dates are listed in coding section

    Obesity counseling: Intensive behavioral interventions for adults with BMI >=30 and pediatric obesity screening/counseling are covered per USPSTF guidanceAdults: up to 12 visits/year; Children/adolescents: 4x/year

    ICD-10 codes for BMI/obesity apply and code updates effective 10/1/2024 are noted

    AAA screening: Abdominal aortic aneurysm (AAA) ultrasound screening (76706) is covered one time in a lifetime for ages 65–751x/lifetime ages 65-75

    See imaging code group for CPTs

    Breast screening

    Breast imaging preventive coverage rules

    Breast tomosynthesis screening is listed with procedure codes 77061, 77062, 77063 (use in addition to mammography codes) and ICD-10 Z12.31/Z12.39; preventive benefit instructions vary by mandateFrequency: 1x/year ages 40+ (some state mandates indicate unlimited/all ages effective 1/01/2023)

    Breast MRI screening (77046–77049) requires prior authorization per NIA; see Pre-Authorization policy

    Chlamydia and colonoscopy screening

    Chlamydia and colonoscopy screening rules

    Chlamydia screening procedure codes (86631, 86632, 87110, 87270, 87320, 87490–87492, 87801, 87810) are coveredFrequency: screening 1x/year; pregnancy 3x/year

    ICD-10 screening diagnosis codes for adults and children are provided; see Appendix II for additional mappings

    Colonoscopy pre-procedure screening: Pre-procedure gastroenterology evaluation codes (99202–99215) and related ICD-10 codes are covered for colonoscopy screeningFrequency: 1x/year ages 45–75

    ICD-10 code Z01.818 removed effective 6/1/2024; other ICD-10 updates effective 6/1/2024 are listed

    Colorectal screening

    Colorectal cancer screening methods and frequencies

    Colorectal screening options: Covered options include colonoscopy procedures, CT colonography (74263), stool-based tests (82270, 82274), Cologuard (81528) and Cologuard Plus (0464U effective 9/01/2025)Frequency: generally 1x/year; age ranges commonly 45–75 or 45–85 depending on test

    ICD-10 codes and anesthesia/ancillary CPTs for screening procedures are listed; see coding section for additions/deletions

    Contraceptive services

    Contraceptive services coverage

    Contraceptive counseling and management: Contraceptive counseling (99401–99404) and contraceptive management (office visit and ED codes as listed) are covered; counseling is unlimitedCounseling: Unlimited; Methods frequency varies by method (see method-specific entries)

    Multiple HCPCS/J-codes for IUDs, implants, injections, and contraceptive supplies are enumerated; frequency directives vary from 1x/year to up to 12x/year depending on service

    Pediatric and diabetes screening

    Pediatric and metabolic screening

    Oral fluoride varnish (99188) is covered for ages 0–5 when performed by a pediatrician or PCP2x/year ages 0–5

    Provider limitation: pediatricians or PCPs only

    Diabetes screening procedure codes (e.g., 82947–82952, 83036) are coveredAdults: 1x/year ages 18+; Children: 1x/year ages 0–17; Gestational: 2x/year generally, effective 1/01/2024 gestational frequency updated to 3x/year

    Guidance aligned to USPSTF; effective date changes noted for gestational testing

    Infectious disease, hearing, lead, lung

    Infectious disease and other screenings

    Gonorrhea and HIV screening: Gonorrhea screening (87590–87592, 87801, 87850) and HIV screening (86689, 86701–86703, 87389–87391, 87806) are coveredGonorrhea: up to 4x/year; HIV: unlimited frequency

    Hepatitis B and C screening are covered 1x/year for ages 18–79; HPV DNA screening CPTs updated and code 0500T deleted effective 1/01/2025

    Hearing and lead screening: Hearing screening (92551–92558, 92587–92588, 92650–92651) and lead screening (83655) are coveredHearing: 1x/year ages 0–21 (PCP only); Lead: 1x/year ages 0–6 (PCP only)

    Refer to OAE Medical Policy for hearing age limitations

    Lung cancer screening: Low-dose CT lung cancer screening (71271) is covered with tobacco-related ICD-10 criteriaFrequency: 1x/year ages 50–80

    HPV screening (DNA)

    Covered when ALL of the following are met

    Age and frequency: Member age between 30 and 65 AND screening frequency 1x/yearAges 30-65; Frequency 1x/year

    Procedure codes 87624–87626 listed for HPV DNA screening; relevant ICD-10 screening codes include Z00.00, Z00.01, Z01.411, Z01.419, Z11.51, Z12.4

    Mental Health Wellness Exams (CT/MA mandates)

    Covered when ALL of the following are met

    Codes and frequency: Procedure codes 96127, 96130, 96131 are covered for Mental Health Wellness Exams where mandated (CT/MA); frequency is 2x/yearFrequency: 2x/year

    ICD-10 diagnosis codes include Z13.31, Z13.32, Z13.39; state mandates (CT, MA) may apply

    Osteoporosis screening

    Coverage varies by effective date and patient history

    General screening until 12/31/2025: Osteoporosis screening with procedure codes 76977, 77080, 77081 is covered every 23 months for ages 60+ until 12/31/2025Every 23 months; Ages 60+ (until 12/31/2025)

    Effective until 12/31/2025 per policy text

    Screening effective 1/1/2026: Osteoporosis screening with procedure codes 76977, 77080, 77081 is covered every 23 months for ages 65+ effective 1/1/2026Every 23 months; Ages 65+ (effective 1/1/2026)

    Policy change effective 1/1/2026

    Individuals with history of fragility fractures: Osteoporosis screening with codes 76977, 77080, 77081 is covered every 23 months for ages 40–65 when ICD-10 Z87.310 AND Z13.820 are presentEvery 23 months; Ages 40–65 with fragility fracture history

    Pregnancy screening panel and obstetric panel

    Covered when ALL of the following are met

    Panel coverage: Pregnancy screening panel (80055) and obstetric panel (80081) are covered; frequency 1x/yearFrequency: 1x/year

    Panels include Hepatitis B, CBC, Rh(D), syphilis, HIV testing; see Appendix I/II for ICD-10 pairings

    PrEP counseling, administration, monitoring

    Covered when ALL of the following are met

    Counseling and administration: PrEP counseling codes (G0011, G0013), administration (G0012), and cabotegravir product (J0739) are covered; ICD-10 Z29.81 must be appended to PrEP visits on/after 10/01/2023Frequency: Unlimited; Cost-share waived per USPSTF schedule

    Providers must append Z29.81 to PrEP visits on/after 10/01/2023 to ensure correct benefit processing

    Monitoring labs and frequency: PrEP monitoring labs (creatinine 82565/82575) and STI/HIV screening codes are covered as specified for monitoringCreatinine up to 3x/year; STI screening up to 4x/year; HIV screening unlimited

    Cost share waived for USPSTF schedule; pregnancy testing and urinalysis frequencies specified where applicable

    Immunizations

    Covered when ALL of the following are met

    Administration and product guidance: Immunization administration CPTs for adult and pediatric (e.g., 90460–90474, 90471–90474) and vaccine CPTs (including COVID-19 vaccines) are covered when administered per FDA/CDC guidanceAge and frequency per FDA/CDC/ACIP guidance and CPT-specific listings

    Providers must adhere to FDA/CDC age/frequency guidelines; ICD-10 pairing Z23 for COVID-19 administration

    Preventive vaccine coverage

    Preventive immunizations are covered when administered according to the listed age/frequency instructions and applicable CDC/ACIP or FDA guidance

    General preventive coverage: Vaccine administration and product CPT must match the listed vaccine and be given to a member in the age group specified under Preventive Benefit Instructions or per CDC/FDA/ACIP guidanceAge/frequency per CPT entry and CDC/FDA/ACIP guidance

    Policy notes removal of age requirement for Dengue (90587) — providers must follow FDA/CDC; RSV and pneumococcal conjugate codes added with effective dates noted

    General alignment to guideline bodies

    Policy alignment and revision notes

    Policy alignment: Policy is updated to align with USPSTF, CDC, Bright Futures and HRSA recommendations and includes noted code additions, deletions, and effective dates

    Revision history documents additions such as CPT 87626 (HPV DNA) and RSV CPT 90683, deletions such as 0500T, and vaccine age guidance changes (e.g., Dengue) — consult revision entries for effective dates

    Examinations, screenings, tests, or vaccines that are performed solely to meet non‑clinical requirements are not eligible for coverage under the preventive benefit. This includes services required exclusively for employment, school/education, sports or camp participation, travel (including travel vaccines), insurance, marriage or adoption, as well as services related to judicial or administrative proceedings, those conducted for medical research, or those required to obtain or maintain any type of license. Such services may be covered under other portions of the member’s medical benefit plan, but they do not qualify as preventive services for the purposes of no cost‑sharing preventive coverage.

    A vaccine (immunization) will not be covered as a preventive benefit if it does not meet the company’s vaccine policy requirements for FDA labeling or if it lacks an explicit ACIP recommendation for routine use published in the CDC Morbidity and Mortality Weekly Report (MMWR). Providers should confirm both FDA licensure status and ACIP routine‑use guidance before submitting a preventive vaccine claim to avoid denial.

    The policy reflects ICD‑10 coding updates for colorectal screening services. In particular, the ICD‑10 code entry list for colon cancer screening annotated that ICD‑10 Code Z86.010 was deleted effective 10/1/2024. Providers should reference the updated ICD‑10 set when billing anesthesia and ancillary services associated with colon cancer screening to ensure correct diagnosis coding.

    Within the excerpted vaccine and preventive guidance, there are no additional explicit categorical exclusions beyond the general limitations already stated (for example, exclusions tied to services required solely for employment/school/travel). The revision history does note operational changes—such as removal of age requirements for certain vaccines—and otherwise directs providers to follow FDA/CDC/ACIP guidance for any vaccine‑specific age or frequency determinations.

    Services described in the policy that are investigational, experimental, unproven, or not medically necessary are not covered. This exclusion applies to preventive benefit determinations and aligns with the policy’s Correct Coding Guidelines and medical necessity framework.

    No explicit statements labeled 'Not Medically Necessary' are present in the provided excerpt. The document ties coverage decisions primarily to alignment with guideline‑based age and frequency instructions rather than listing discrete NMN conditions in this section.

    Coverage under this policy is predicated on alignment with recognized guideline bodies: services are covered when they meet PPACA criteria (USPSTF A/B recommendations), are listed as routine immunizations by ACIP, or are included in HRSA/AAP Bright Futures pediatric recommendations. For non‑grandfathered plans, preventive services provided by network physicians are covered without member cost‑sharing when these guideline conditions are met.

    The policy does not present standalone 'Not Medically Necessary' declarations within the excerpted sections; instead, coverage is governed by age and frequency criteria and by compliance with the specified effective dates and coding changes (for example, HPV testing code updates and deleted codes). Where codes are removed or added, providers must use current valid CPT/ICD entries consistent with the policy effective dates.

    Procedure, Vaccine, and Diagnosis Codes

    General Preventive/Counseling CPT CodesCPTCovered
    99383Preventive Screening Examination and Counseling Services
    99384Preventive Screening Examination and Counseling Services
    99385Preventive Screening Examination and Counseling Services
    99386Preventive Screening Examination and Counseling Services
    99387Preventive Screening Examination and Counseling Services
    99393Preventive Screening Examination and Counseling Services
    99394Preventive Screening Examination and Counseling Services
    99395Preventive Screening Examination and Counseling Services
    99396Preventive Screening Examination and Counseling Services
    99397Preventive Screening Examination and Counseling Services
    1–10 of 22
    1/3
    Obesity/Weight Management CodesCPTCovered
    97802Medical Nutrition Therapy
    97803Medical Nutrition Therapy
    97804Medical Nutrition Therapy
    Breast & AAA Screening Imaging CodesCPTCovered
    76706Abdominal Aortic Aneurysm (AAA) screening
    77063Breast tomosynthesis screening (in addition to mammography)
    77065Mammography, screening
    77066Mammography, screening
    77067Mammography, screening
    76641Breast Ultrasound - Screening
    76642Breast Ultrasound - Screening
    77046Breast MRI screening
    77047Breast MRI screening
    77048Breast MRI screening
    1–10 of 11
    1/2
    Breast Pumps and Supplies (HCPCS)HCPCSCovered
    E0603Personal-use electric breast pump
    E0602Breast pump
    A4281Breast pump supply
    A4282Breast pump supply
    A4283Breast pump supply
    A4284Breast pump supply
    A4285Breast pump supply
    A4286Breast pump supply
    A4287New breast pump supply code effective 1/1/2024
    Preventive ICD-10 Codes (examples)ICD-10
    Z12.31Encounter for screening mammogram for malignant neoplasm of breast
    Z12.39Encounter for other screening for malignant neoplasm
    Z92.3Personal history of irradiation
    Z33.2Pregnancy (used for abortion services listings)
    Z15.01Genetic susceptibility to malignant neoplasm of breast
    Z15.02Genetic susceptibility to other malignant neoplasm
    Z80.3Family history of malignant neoplasm of breast
    Z80.41Family history of malignant neoplasm of ovary
    Z85.3Personal history of malignant neoplasm of breast
    Z85.43Personal history of malignant neoplasm of ovary
    Breast tomosynthesis / ultrasound / relatedCPTCovered
    77063Breast tomosynthesis screening (use in addition to mammography codes)
    77061Breast tomosynthesis screening
    77062Breast tomosynthesis screening
    76641Breast Ultrasound- Screening
    76642Breast Ultrasound- Screening
    MammographyCPTCovered
    77065Mammography, screening
    77066Mammography, screening
    77067Mammography, screening
    Chlamydia screeningCPTCovered
    86631Chlamydia Screening
    86632Chlamydia Screening
    87110Chlamydia Screening
    87270Chlamydia Screening
    87320Chlamydia Screening
    87490Chlamydia Screening
    87491Chlamydia Screening
    87492Chlamydia Screening
    87801Chlamydia Screening
    87810Chlamydia Screening
    Colorectal / colonoscopy relatedmixedCovered
    99202Colonoscopy pre-procedure screening with gastroenterologist
    99203Colonoscopy pre-procedure screening with gastroenterologist
    99204Colonoscopy pre-procedure screening with gastroenterologist
    99205Colonoscopy pre-procedure screening with gastroenterologist
    00811Anesthesia & Ancillary for colon cancer screening
    00812Anesthesia & Ancillary for colon cancer screening
    88305Anesthesia & Ancillary for colon cancer screening
    44388Colon cancer screening procedures (list)
    74263CT Colonography (screening)
    81528Cologuard stool test
    Cologuard PlusCPTCovered
    0464UCologuard Plus Lab Test (effective 9/01/2025)
    Contraceptive counseling and IUDsmixedCovered
    99401Contraceptive counseling (Group 1)
    99402Contraceptive counseling
    99403Contraceptive counseling
    99404Contraceptive counseling
    J7306IUD (unspecified)
    J7307IUD
    J7300IUD (copper)
    J7301IUD (Skyla)
    J7297IUD (Liletta)
    J7296IUD (Kyleena)
    1–10 of 11
    1/2
    Contraceptive methods (implants, injections, pills)CPT|HCPCSCovered
    J1050Contraceptive injection
    96372Administration
    S4993Contraceptive pills (for plans with pharmacy benefits)
    11976Implant capsule removal
    11981Implant insertion
    11982Implant removal
    11983Removal with reinsertion
    58300IUD insertion
    S4981IUD insertion supply
    58301IUD removal
    Pediatric preventive / mental health screeningCPTCovered
    99188Oral Fluoride Varnish
    96127Depression/Anxiety screening
    Diabetes screeningCPTCovered
    82947Diabetes screening (glucose)
    82948Diabetes screening
    82950Diabetes screening
    82951Diabetes screening
    82952Diabetes screening
    83036Hemoglobin A1c / diabetes screening
    Various infectious disease, screening, hearing, lead, lipid, lung, maternitymixedCovered
    87590Gonorrhea screening
    87591Gonorrhea screening
    87592Gonorrhea screening
    87801Gonorrhea/chlamydia NAAT
    87850Gonorrhea screening
    92551Hearing screening
    92552Hearing screening
    92553Hearing screening
    92558Hearing screening
    92587Hearing screening
    1–10 of 40
    1/4
    HPV screening CPTsCPTCovered
    87624Human Papillomavirus (HPV) screening (DNA)
    87625Human Papillomavirus (HPV) screening (DNA)
    87626Human Papillomavirus (HPV) screening (DNA)
    0500TDeleted code effective 1/01/2025
    Selected screening CPTsCPTCovered
    83655Lead Screening
    80061Lipid panel
    82465Lipid screening
    83718Lipid testing
    71271Lung Cancer Screening CT Low Dose
    Pregnancy and cervical screening CPTsCPTCovered
    88141Pap smear codes (collection/interpretation group)
    88142Pap smear
    81007Urinalysis (pregnancy bacteriuria screening)
    80055Pregnancy screening panel
    80081Pregnancy/Obstetric panel (includes HIV testing)
    PrEP counseling and administrationHCPCSCovered
    G0012Antiretroviral Therapy Injection: Administration Code (PrEP cabotegravir)
    J0739Injection cabotegravir, 1mg
    G0011Counseling for PrEP to Prevent HIV
    G0013Counseling for PrEP to Prevent HIV
    PrEP monitoring labs (creatinine)CPTCovered
    82565Creatinine test
    82575Creatinine test
    HIV screening codesCPTCovered
    86689HIV screening
    86701HIV 1/2 antibodies
    86702HIV test
    86703HIV 1/2 antigen/antibody
    STI and syphilis screeningCPTCovered
    86592Syphilis screening (treponemal/nontreponemal)
    86593Syphilis screening
    Immunizations and administration codesCPTCovered
    90460Immunization administration (pediatric)
    90461Immunization administration (pediatric)
    90471Immunization administration (adult/pediatric)
    90472Immunization administration (adult/pediatric)
    90473Immunization administration (adult/pediatric)
    90474Immunization administration (adult/pediatric)
    90480COVID-19 vaccine administration code
    91304COVID-19 vaccine (Novavax)
    91318COVID-19 vaccine (Pfizer-BioNTech)
    91319COVID-19 vaccine (Pfizer-BioNTech)
    1–10 of 20
    1/2
    DengueCPTCovered
    90587Dengue (Dengvaxia®)
    Diphtheria / DTaP and combination vaccinesCPTCovered
    90702Diptheria
    90700DTaP
    90723DtaP-HepB-IPV
    90696DTaP-IPV
    90697DTaP-IPV-Hib-HepB (Vaxelis®)
    90698DTaP-HIB-IPV
    Td / TdapCPTCovered
    90714Td (diptheria preservative free, tetanus)
    90715Tdap
    Hepatitis A / B vaccinesCPTCovered
    90632Hepatitis A (Havrix®, VAQTA®)
    90636Hepatitis A (Twinrix®)
    90633Hepatitis A (pediatric)
    90739Hepatitis B (HEPLISAV-B®)
    90740Hepatitis B (Recombivax HB®)
    90743Hepatitis B (Recombivax HB®) adolescent
    90744Hepatitis B (Recombivax HB®, Engerix-B®)
    90746Hepatitis B (Recombivax HB®, Engerix-B®) adult
    90747Hepatitis B (Engerix-B®)
    90748Hepatitis B (unspecified)
    HIB and HPV vaccinesCPTCovered
    90647HIB (PedvaxHIB®)
    90648HIB (ActHIB®)
    90649HPV (Gardasil®)
    90650HPV (unspecified)
    90651HPV (Gardasil9®) *coverage note through age 45 with cost share
    Influenza vaccines (season-specific listings)CPTCovered
    90653Influenza vaccine (seasonal listings)
    90656Influenza vaccine (Afluria/Fluarix/FluLaval/Fluzone variants)
    90657Influenza vaccine (pediatric 6-35 months)
    90658Influenza vaccine (Afluria/Fluzone variants)
    90660Flumist® (LAIV3)
    90661Flucelvax (ccIIV3)
    90662Fluzone High-Dose
    90672Flumist (LAIV4)
    90674Flucelvax Quadrivalent
    90682Flublok Quadrivalent
    1–10 of 15
    1/2
    MMR and Meningococcal vaccinesCPTCovered
    90707MMR (MMR II®)
    90710MMRV (ProQuad®)
    90619Meningococcal (MenQuadfi®)
    90620Meningococcal (Bexsero®)
    90621Meningococcal (Trumenba®)
    90644MenHibrix®
    90733Menomune®
    90734Menactra®, Menveo®
    Pneumococcal vaccinesCPTCovered
    90670Pneumococcal (PPSV23) / Prevnar 13®
    90671Pneumococcal conjugate (Vaxneuvance®)
    90677Pneumococcal conjugate (Prevnar20®)
    90684Pneumococcal conjugate (CAPVAXIVE™) effective 6/17/2024
    90732Pneumococcal (Pneumovax®)
    Polio, Rotavirus, and RSV vaccines / administrationmixedCovered
    90713Polio (IPV) (Ipol®)
    90680Rotavirus (Rotateq®)
    90681Rotavirus (Rotarix®)
    96380RSV administration code
    96381RSV administration code
    90380RSV vaccine (Beyfortus™ 0.5ml)
    90381RSV vaccine (Beyfortus™ 1ml)
    90678RSV vaccine (Abrysvo™)
    90679RSV vaccine (Arexvy™)
    90683RSV vaccine (mRESVIA®) effective 5/31/2024
    Varicella and ZosterCPTCovered
    90716Varicella (Varivax®)
    90750Zoster (Shingrix®)
    Notable code additions and deletions in this chunkCPT
    87626HPV screening (DNA) — added
    0500THPV screening (DNA) — deleted/indicated removed
    96040BRCA genetic testing counseling/evaluation — deleted
    99401BRCA genetic testing counseling/evaluation — added
    99402BRCA genetic testing counseling/evaluation — added
    99403BRCA genetic testing counseling/evaluation — added
    99404BRCA genetic testing counseling/evaluation — added
    90587Dengue vaccine (Dengvaxia®) — age requirements removed; follow FDA/CDC
    90661Influenza vaccine — age range corrected to Ages 6 months and older
    Adult BMI — Eligibility for Intensive Behavioral Interventions

    Prior Authorization, Documentation, and Billing Guidance

    Prior Authorization

    Prior Authorization Required for MRI

    MRIs used for preventive breast screening and other MRI services must be prior authorized through NIA. Refer to the Pre-Authorization policy on the provider website for criteria and submission instructions.

    • MRIs for preventive breast screening require NIA authorization.
    • See Pre-Authorization policy on provider website for MRI documentation and criteria.
    Prior Authorization

    Potential Prior Authorization for BRCA Services

    Breast cancer (BRCA) genetic testing counseling/evaluation and BRCA genetic testing procedure codes may be subject to prior authorization. Providers should verify prior authorization requirements before scheduling or submitting claims.

    • BRCA counseling procedure codes: 99401, 99402, 99403, 99404 (effective 1/1/2025).
    • BRCA genetic testing codes: 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217.

    Policy Background and Guiding Authorities

    Background: This preventive services policy implements federal PPACA requirements by covering services consistent with USPSTF A/B recommendations, ACIP routine immunizations, and HRSA/AAP Bright Futures pediatric preventive services. The policy has been revised periodically to add or remove codes and to clarify age/frequency guidance (for example, additions of RSV and pneumococcal conjugate codes and updates to HPV screening codes). It is intended to align benefit coverage with major preventive guideline bodies and applicable effective dates.

    Definitions and Key Terms

    Preventive service
    DefinitionService performed on asymptomatic persons who have not had the screening before, had prior normal screening within the recommended interval, or normal diagnostic results followed by preventive interval screening
    Preventive vs diagnosticWhen a service is done for diagnostic purposes it will be considered under the applicable nonpreventive medical benefit
    Documentation implicationPreventive designation requires documentation showing asymptomatic status and eligibility within recommended interval
    Diagnostic service
    DefinitionService performed due to abnormal prior findings, symptoms, or when outside the recommended screening population or interval; billed under nonpreventive benefit
    Examples

    Policy Revisions and Material Changes

    2025-06-09update

    ACIP link updated and clarified procedure codes and age/frequency limitations for Preventive Screening Examination and Well Child Visits.

    2025-04-01addition

    Added Cologuard Plus lab test code 0464U to Colorectal Cancer Screening effective 2025-09-01.

    2025-04-01addition

    Added CPT code 87626 for HPV screening (DNA) effective 2025-01-01 and indicated deletion of CPT code 0500T.

    Policy Summary
    PayerEmblemHealth
    PolicyPreventive Care and Screening Services — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeCode additions, deletions, and age/frequency guidance revisions (material)
    Effective DateN/A
    Next Review DateN/A
    Key ActionBill using the current valid CPT codes listed in the policy and follow FDA/CDC/ACIP age and frequency guidance when administering vaccines.
    SourceLink
    On This Page
    Coverage Criteria and Preventive ServicesProcedure, Vaccine, and Diagnosis CodesPrior Authorization, Documentation, and Billing GuidancePolicy Background and Guiding AuthoritiesDefinitions and Key TermsPolicy Revisions and Material Changes

    Procedure code effective 1/01/2021; see smoking-related diagnosis codes listed

    Effective 1/1/2026; specific ICD-10 pairings required

    Threshold
    BMI >= 30.0 indicates eligibility for intensive multicomponent behavioral interventions
    FrequencyPreventive benefits instruction: 12x/year for behavioral interventions
    Relevant CPT codes99401, 99402, 99403, 99404 (Preventive Medicine, Individual Counseling)
    AAA screening age
    Age bandAges 65-75 years
    FrequencyOne-time (1x/lifetime)
    Procedure code76706 (Abdominal Aortic Aneurysm screening)
    Mammography screening frequency
    Frequency1x/year
    Age bandAges 40 years and older
    Procedure codes77065, 77066, 77067 (mammography screening); 77063 (use in addition to mammography for baseline/tomosynthesis)
    Colorectal screening age
    Age bandAges 45-85 years for stool-based tests (Cologuard) and Cologuard Plus
    Frequency1x/year
    Procedure codes81528 (Cologuard); 0464U (Cologuard Plus effective 9/01/2025)
    Hearing screening frequency
    Frequency1x/year
    Age bandAges 0-21 years (ends on 21st birthday)
    Provider limitationPCP only
    Oral fluoride varnish frequency (pediatrics)
    Frequency2x/year
    Age bandAges 0-5 years
    Provider limitationPediatrician(s) or PCP providers only; Procedure code 99188
    Mental Health Wellness Exams frequency
    Frequency2x/year
    Procedure codes96127, 96130, 96131 (Mental Health/Behavioral screening/wellness exams)
    MandatesCT and MA mandates referenced for 2x/year frequency
    HPV screening frequency
    Frequency1x/year
    Age bandAges 30-65 years
    Procedure codesHPV DNA screening CPTs (e.g., 87624-87626; 0500T deleted effective 1/01/2025)
    Osteoporosis screening (effective 1/1/2026)
    FrequencyEvery 23 months
    Age bandsGeneral: Ages 65+ effective 1/1/2026; Individuals with history of fragility fractures: Ages 40-65 (every 23 months)
    Procedure codes76977, 77080, 77081 (osteoporosis screening modalities)
    HPV coverage age limit
    Age band (preventive coverage)Ages 9-26 years (coverage ends on 27th birthday)
    ExceptionCPT 90651 (Gardasil9) coverage allowed through age 45 (ends on 46th birthday) but with cost share
    Procedure codes90650, 90651 (HPV vaccine CPTs listed)
    RSV pediatric age
    Age bandAges 0-24 months (ends on 2nd birthday) for certain RSV products (e.g., Beyfortus 90380/90381)
    Products and codes90380, 90381 (Beyfortus); 90678 (Abrysvo), 90679 (Arexvy), 90683 effective 5/31/2024 (mRESVIA®); administration codes 96380/96381
    GuidanceProviders must adhere to CDC/ACIP guidance for RSV vaccines
    Influenza age thresholds
    General instructionInfluenza vaccines preventive benefit generally for ages 6 months and older
    Age-specific codesSpecific influenza CPT entries designate age bands (e.g., pediatric 6-35 months, older adult 65+); see listed CPTs such as 90662, 90673, 90694
    Provider guidanceImmunizations must follow FDA/CDC/ACIP age and frequency guidelines
  1. Prior authorization requirements may apply — confirm per plan.
    2. Billing Rule

    Use Current CPT/Code Sets

    Providers must bill using current, valid CPT/HCPCS/NDC codes. Coding updates in this policy (added and removed CPT codes and vaccine codes) must be adopted to avoid processing errors or denials.

    • Use the updated CPT codes added in revisions (e.g., 87626 for HPV DNA screening; removal of deleted codes such as 96040, 0500T, 88154).
    • Include newly added vaccine CPTs (e.g., RSV 90683, pneumococcal conjugate 90684) where applicable.
    • Do not submit deleted/removed CPT codes.
    Denial Risk

    Vaccine Coverage Trigger and Guideline Adherence

    Vaccines are covered only when they meet FDA licensure and have explicit ACIP routine-use recommendations published in the CDC MMWR. Vaccines failing to meet these criteria may be denied under the preventive benefit.

    • Vaccines must meet FDA labeling and explicit ACIP routine-use recommendation in MMWR to be covered.
    • Providers must follow FDA/CDC and CDC/ACIP age and frequency guidelines; failure to adhere may result in non-preventive benefit determination.
    • Examples: Dengvaxia (90587) age/frequency adherence required; RSV vaccines (90679, 90683) follow CDC/ACIP guidance.
    Billing Rule

    PrEP Visit Coding Requirement

    All PrEP visits on or after 10/01/2023 must be appended with ICD-10 code Z29.81. Failure to append this code may cause incorrect benefit processing or denial.

    • PrEP visit CPTs: 99202-99215.
    • Append ICD-10 Z29.81 to all PrEP visits on or after 10/01/2023.
    Documentation Required

    Age and Frequency Guideline Adherence

    Providers must adhere to FDA/CDC and CDC/ACIP age and frequency guidelines for immunizations and preventive services. Document adherence to these guidelines to support preventive benefit coverage.

    • Follow CDC Child, Adolescent & Catch-up and Adult Immunization schedules.
    • Document the patient age, vaccine, and interval to demonstrate guideline adherence.
    • Failure to follow age/frequency guidance (e.g., Dengue, RSV vaccines) may result in non-preventive determination.
    Denial Risk

    Coding-Related Denial Risk

    Coding updates and misuse of codes can lead to incorrect processing or claim denials. Verify code lists in Appendix I/II and the policy revision history before submission.

    • Review recent revisions for added/removed CPT and ICD-10 codes to avoid using deleted codes.
    • Incorrect or outdated coding may trigger denials or processing under non-preventive benefits.
    Documentation Required

    Appendix Code Pairings for Pregnancy and Maternity

    Reference Appendix I and II for pregnancy and maternity ICD-10 code pairings to ensure correct diagnosis-code pairing on claims. Use the appendices when billing related screenings to prevent rejected or misprocessed claims.

    • Appendix I: Pregnancy Screenings and Gestational Diabetes ICD-10 code pairings.
    • Appendix II: Maternity Screening ICD-10 code pairings.
    • Download the policy and access appendices via the paperclip icon to obtain full code lists.
    Abnormal prior studies requiring further diagnostic evaluation or symptoms prompting diagnostic testing
    Billing implicationDocument diagnostic intent/abnormal findings to bill under nonpreventive benefit
    Breast tomosynthesis screening
    RoleBreast tomosynthesis is a screening adjunct to mammography
    Procedure codes77061, 77062, 77063 (tomosynthesis); 77063 noted as 'use in addition to mammography codes'
    ICD-10 pairingsZ12.31, Z12.39
    Cologuard / lab stool test
    Test descriptionStool-based colorectal cancer screening (Cologuard) and Cologuard Plus lab test
    Procedure codes81528 (Cologuard); 0464U (Cologuard Plus effective 9/01/2025)
    Age/frequencyPreventive benefit instructions: 1x/year; Ages 45-85 for stool tests
    Immunization administration
    Administration codesAdult: 90471-90474; Pediatric: 90460-90461; (both groups share 90471-90474)
    GuidanceProviders must adhere to FDA/CDC age and frequency guidelines when administering immunizations
    DocumentationICD-10 pairing Z23 used for vaccine administration in some entries (e.g., COVID-19) and follow-up coding guidance applies
    PrEP services
    Included servicesPrEP services include counseling (G0011, G0013), administration (G0012, J0739), monitoring visits (99202-99215) and labs
    Cost-shareCost share waived for monitoring per USPSTF schedule of testing
    Monitoring frequencyCreatinine testing (82565/82575) up to 3x/year; STI screening up to 4x/year
    Age/frequency guidance
    AuthorityPreventive coverage applicability is determined by CDC/FDA/ACIP age and frequency guidance
    Provider requirementProviders must follow and document adherence to FDA/CDC and CDC/ACIP age and frequency guidelines where indicated (e.g., Dengue, RSV)
    Operational noteSome vaccine age requirements were removed and providers must follow current FDA/CDC guidance (see dengue 90587 revision)
    Indications for Coverage
    PurposeIndications for Coverage content expanded to align coverage with major guideline bodies (USPSTF, CDC, Bright Futures, HRSA)
    AlignmentPolicy updated to align with USPSTF A/B recommendations, ACIP routine immunizations, and HRSA/AAP guidelines
    Effective noteComprehensive review performed; effective 10/01/2021 with subsequent updates noted in revision history
    2025-01-29revision

    Updated BRCA genetic testing counseling/evaluation codes: deleted CPT code 96040 and added CPT codes 99401–99404 effective 2025-01-01.

    2024-12-19revision

    Removed age requirements for Dengue vaccine CPT code 90587; providers must follow FDA/CDC age and frequency guidelines.

    2024-10-28correction

    Corrected age range for Influenza vaccine CPT 90661 to ages 6 months and older and updated colon cancer screening ICD-10 codes effective 2024-10-01.

    2024-08-13addition

    Added RSV vaccine CPT code 90683 effective 2024-05-31 and added pneumococcal conjugate CPT code 90684 effective 2024-06-17.

    2024-03-05removal

    Removed deleted Pap smear code 88154 from the code set.

    The policy and its revision history explicitly state alignment to external guideline bodies. Revision notes document multiple updates and clarify that the policy is maintained to reflect recommendations and coding changes from USPSTF, CDC/ACIP, Bright Futures, and HRSA; providers should reference the policy’s revision history for recent code additions, deletions, and effective dates.