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ModifiedEmblemHealthPolicy N/A

Preventive Services & Screening — Coverage Criteria

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Defines EmblemHealth coverage, coding, frequencies and limitations for preventive services and screenings (including immunizations, counseling, breastfeeding equipment and specific screening tests) for commercial and Medicaid members; applies to network providers and non-grandfathered plans unless otherwise noted.

Policy Summary

PayerEmblemHealth

PolicyPreventive Services & Screening — Coverage Criteria

Policy CodePolicy N/A

Change TypeMaterial code additions and immunization updates

Effective DateN/A

Next Review DateN/A

Key ActionDocument patient age and append the appropriate preventive ICD-10 diagnosis codes when billing vaccines and preventive services.

SourceLink

POLICY UPDATE CHANGES

Addition of new CPT code 87494 to Chlamydia Screening, Gonorrhea Screening, and PrEP Monitoring and Ongoing Laboratory Testing.

Addition of new CPT code 90481 to COVID-19 vaccine and administration.

Addition of Immunization Counseling (without vaccine administration on same date of service) and new CPT codes 90482, 90483, 90484.

Addition of new CPT code 90683 for RSV vaccine administration (previously added earlier revisions noted).

Clarified procedure codes and age/frequency limitations for Preventive Screening Examination and Counseling Services Well Child Visits.

No member cost sharingNon-grandfathered plans coverage

1 per birthBreast pump limit

1x/yearPreventive visit frequency

5yColorectal screening interval

3yStool DNA testing frequency

IncludedRSV vaccine codes

Coverage Criteria and Preventive Benefit Rules

PPACA-defined preventive services

Covered when ALL of the following are met

PPACA preventive service mandate: Service is an evidence-based item/service rated A or B by the USPSTF, an ACIP-recommended immunization, or an HRSA/AAP Bright Futures pediatric preventive service

Applies to non-grandfathered plans when provided by network physicians

Determining preventive vs diagnostic coverage

Classification rule

Preventive vs Diagnostic determination: Service must be performed for preventive screening (asymptomatic, prior normal within interval, or routine screening recommendation) and reported as preventive to be considered under the preventive benefit; services performed for diagnostic reasons (prior abnormality, symptoms, or shortened interval repeats) are considered non-preventive/diagnostic

If reported/used for diagnostic purposes the non-preventive medical benefit applies

Breast pumps and supplies

Breast pump coverage

Personal-use electric breast pump: Purchase of one personal-use electric breast pump (HCPCS E0603/E0602) per birth is covered; includes necessary pump supplies and replacement supplies to operate the pump1 per birth

One pump per birth; multiple infants from same birth do not increase quantity

Breast pump supplies frequency: Breast pump supply codes (A4281, A4282, A4283, A4284, A4285, A4286, A4288 and A4287 where listed) are covered per preventive benefit1x/pregnancy; A4287: 200 units per 30 days

Effective dates noted for supply codes (see coding module)

Colorectal cancer screening frequencies and modalities

Colorectal cancer screening

Age and frequency: Screening colonoscopy, CT colonography, and listed colon/colorectal modalities are covered per preventive benefitOnce every 5 years; Ages 45-75

Includes anesthesia, pathology, and pre-procedure consultation codes as listed

Stool-based tests: Fecal occult blood tests (82270, 82274) and stool DNA options (e.g., 81528) are covered as preventive optionsOnce every 3 years; Ages 45-85 (Shield: 45+)

See coding for Cologuard/Cologuard Plus/Shield effective dates and codes

Colon Cancer Screening (CT Colonography)

Covered when meeting listed age and frequency limits with specified diagnosis codes

CT Colonography: Procedure code 74263 with listed preventive ICD-10 diagnosis codes (e.g., Z00.00, Z12.12, Z12.10, Z12.11, Z80.0, Z83.*) is covered as CT colonography for screeningFrequency: once every 5 years; Ages: 45-75 years

Billing must use the preventive diagnosis codes to receive preventive benefit

Stool-based Colorectal Cancer Screening

Covered preventive stool-based colorectal tests with age- and frequency-based limits

Stool occult blood tests: Procedure codes 82270 and 82274 with listed preventive ICD-10 diagnosis codes are covered for colorectal cancer screeningOnce every 3 years; Ages: 45-85 years

Must bill with preventive diagnosis codes

Cologuard and stool DNA tests: Cologuard (81528), Cologuard Plus (0464U effective 9/01/2025) and Shield (0537U effective 1/1/2026) with listed preventive ICD-10 codes are coveredOnce every 3 years; Ages: 45-85 years (Shield: 45+)

Observe effective dates for new codes

Contraceptive Services

Contraceptive counseling, management, and methods coverage rules

Contraceptive counseling: Procedure codes 99401-99404 (counseling) with ICD-10 Z30.02/Z30.09 are covered; frequency: unlimited; ages: allunlimited

Counseling included in wellness visits

Contraceptive management visits: Evaluation/management office visit codes (e.g., 99202-99205, 99211-99215 and ED/urgent codes 99281-99285 as listed) with Group diagnosis codes are coveredunlimited

Use listed ICD-10 Z30.* codes

Contraceptive methods and supplies: Contraceptive methods (IUDs, implants, injections, pills, diaphragms) and associated J-codes/CPTs (examples: J7300-J7307, J7296-J7298, J1050, 11976-11983, 58300/S4981) are covered per method-specific frequency limitsmethod-specific (e.g., implants 1x/year, pills up to 12x/year)

Behavioral and Diabetes Screening

Behavioral and diabetes screening coverage

Depression/Anxiety screening: Procedure code 96127 (depression/anxiety screening) with ICD-10 Z13.31/Z13.32/Z13.39 is coveredFrequency: 1x/year for ages 12+; 2x/year ages 8–<12

Includes postpartum individuals

Diabetes screening (adults and children): Glucose and HbA1c procedure codes (82947-82952, 83036) with ICD-10 Z00.00/Z00.01/Z13.1/Z86.32 (adults) or Z13.1 (children) are covered1x/year for adults and children; gestational screening per pregnancy guidance

Gestational diabetes frequency: up to 3x/year as listed

Dietary Counseling and STI Screening

Dietary counseling and STI screening coverage

Dietary counseling for overweight/obese with CVD risk: Procedure codes 97802-97804 and S9470 for medical nutrition therapy are covered for individuals who are overweight/obese with additional cardiovascular risk factorsFrequency: 4x/year

Use listed ICD-10 diagnostic groups (E08–E13, E66.*, I10, etc.)

Gonorrhea and chlamydia screening: NAAT and related STI testing codes (e.g., 87494, 87590-87592, 87801, 87850, 0455U) are covered for screening with appropriate ICD-10 screening diagnosis codesFrequency: screening up to 4x/year; pregnancy screening up to 3x/year

New codes effective 1/1/2026 (87494, 0455U)

Routine Preventive Screenings

Various routine preventive screens with age/frequency constraints

Hearing screening: Procedure codes 92551–92651 with preventive ICD-10 codes are covered for pediatric hearing screeningFrequency: 1x/year; Ages: 0–21 (PCP only)

See OAE policy for age limits

Hepatitis B and C screening: Hepatitis B (87340–87341) covered 1x/year ages 18–79; Hepatitis C (86803–86804) covered 1x/year with indicated ICD-10s1x/year

Follow listed diagnosis codes

HIV screening codes (86689, 86701–86703, 87389–87391, 87806) are covered as preventive screeningFrequency: unlimited; Ages: all

Use appropriate preventive diagnosis codes

Osteoporosis Screening (effective dates noted)

Osteoporosis screening coverage with effective dates

Osteoporosis Screening (through 12/31/2025): Procedure codes 76977, 77080, 77081 with preventive ICD-10 codes are coveredFrequency: every 23 months; Ages: 60+ (through 12/31/2025)

Effective until 12/31/2025

Osteoporosis Screening (effective 1/1/2026): Procedure codes 76977, 77080, 77081 with indicated ICD-10 codes are coveredFrequency: every 24 months; Ages: 65+ (from 1/1/2026). Individuals with prior fragility fractures (Z87.310 AND Z13.820) follow same frequency

Effective 1/1/2026

Pregnancy & Pap screening - Covered when service-specific conditions met

Covered preventive pregnancy and Pap screening when meeting service-specific instructions:

Pap Smear: Pap smear cytology codes (e.g., 88155, 88164–88167, 88174–88175) with ICD-10 Z00.00/Z01.411/Z12.4 are coveredFrequency: once every 3 years; Ages: 21–65

Bill with preventive diagnosis codes

Pregnancy Bacteriuria Screening: Urinalysis and urine culture codes (81007, 87086, 87088) for bacteriuria screening in pregnancy are coveredFrequency: unlimited; Ages: all

See Appendix I for pregnancy ICD-10 codes

Pregnancy Blood Count: Pregnancy CBC codes (85025, 85027) are covered for pregnancy screeningFrequency: unlimited; Ages: all

PrEP - Covered with specified codes and frequencies

PrEP counseling, administration, and monitoring coverage

PrEP Counseling & Administration: PrEP counseling and administration codes (G0012, J0739, G0011, G0013) are covered for prevention of HIV; preventive ICD-10 Z29.81 required for visits on/after 10/01/2023Frequency: unlimited; Ages: all

Effective 1/01/2024 for listed administration codes

PrEP Monitoring & Laboratory Testing: Monitoring labs (creatinine 82565/82575 up to 3x/year), pregnancy screening (81025/84702/84703 unlimited for those of childbearing potential), HIV screening (86689,86701–86703,87389–87391,87806 unlimited), and STI testing (listed codes up to 4x/year) are covered with PrEP visits (99202–99215)See item-specific frequencies (e.g., creatinine 3x/year, STI testing 4x/year)

Cost share waived for USPSTF schedule of testing; append appropriate ICD-10 codes per date of service

PrEP ICD-10 appending rules:

Behavioral and infectious disease screening - Covered

Behavioral and infectious disease screening coverage

Smoking Cessation: Smoking cessation counseling codes (99401, 99402, 99403, 99406, 99407) are coveredFrequency: 8x/year; Ages: all

Use listed ICD-10 tobacco dependence and history codes

Syphilis Screening: Syphilis screening codes (86592, 86593) are covered for preventive screeningFrequency: 4x/year; Ages: all

Use appropriate ICD-10 screening diagnosis codes

TB Testing: TB testing codes (86480, 86481, 86580) are coveredFrequency: 1x/year; Ages: all

Use listed ICD-10 codes (R76.11, R76.12, Z11.1, etc.)

Immunizations & vision screening - Covered per CDC/FDA schedules

Immunizations and vision screening coverage (FDA/CDC-aligned)

Immunization administration codes (90460–90474, 90480–90481 etc.) and vaccine product codes are covered when provided per FDA/CDC age and frequency guidanceProvider must follow FDA/CDC age/frequency guidelines

Adult: 21+; Pediatric: 0–21 (ends on 21st birthday)

COVID-19 vaccines: COVID-19 vaccine product and administration codes (e.g., 91304, 91318–91323, 90480/90481) are covered when given per FDA/CDC guidance

90481 is a new admin code effective 1/1/2026; bill with Z23 when applicable

HPV vaccine codes (90649–90651) are covered for ages 9–26 under preventive benefit; coverage is allowed through age 45 but cost share applies beyond age 26Preventive ages 9–26 (ends on 27th birthday); coverage allowed through 45 with cost share

Bill with preventive ICD-10 codes

Preventive Vaccination Coverage

Covered when ALL of the following are met

Age and code match: Patient age must match the Preventive Benefit Instructions for the vaccine CPT/HCPCS code being administeredSee code-specific age bands in coding module (examples: 90653 for ages 65+; 90661 for ages 6 months+; 90660 for ages 2–49)

Providers must document patient age and use appropriate preventive diagnosis code when billing

RSV Vaccine Coverage

Covered when ALL of the following are met

Guideline adherence: RSV vaccines and related administration codes are covered when provider administration and patient selection adhere to current CDC/ACIP guidelines and the vaccine-specific age indicationsCDC/ACIP

Specific RSV product age bands noted in coding (e.g., 90380/90381 for ages 0–24 months; 90683 for ages 60+); providers must follow ACIP guidance

Examinations, screenings, testing, or vaccines are not covered under the preventive benefit when they are required solely for non‑medical administrative reasons such as employment, school/education, sports or camp participation, travel (including travel vaccines), insurance, marriage or adoption, judicial or administrative proceedings/orders, medical research, or to obtain or maintain any type of license. These services may still be covered under another portion of the medical benefit; providers should review the member’s plan and bill under the appropriate benefit if clinically indicated.

A vaccine (immunization) will not be covered under the 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 must adhere to FDA/CDC/ACIP guidance when administering and billing vaccines to ensure preventive benefit coverage.

Preventive benefits apply only when services are billed with the appropriate preventive ICD‑10 diagnosis codes and corresponding procedure codes specified in this guideline. Examples include using the listed preventive diagnosis codes for CT colonography and Cologuard (see the colorectal screening entries). If a service is reported as diagnostic rather than preventive (for example because of symptoms, prior abnormal findings, or shortened interval repeat testing), it will be adjudicated under the non‑preventive medical benefit.

HPV vaccine preventive coverage is defined for ages 9–26 years (ends on the 27th birthday). Vaccination is allowed through age 45 (until the 46th birthday), but such doses are subject to member cost sharing (i.e., not fully preventive without cost share).

For EmblemHealth Medicaid plans, reimbursement is limited to procedure codes that appear on the applicable Medicaid fee schedule. Codes not included on the Medicaid fee schedule(s) will be denied, so providers should confirm Medicaid fee schedule inclusion before billing.

Services that are investigational, experimental, unproven, or not medically necessary are not covered under the preventive benefit. Such determinations should follow applicable medical necessity and coverage policies; services meeting those descriptions should not be billed as preventive.

Preventive screening tests performed outside the stated age ranges or more frequently than the frequencies listed in this guideline may not be covered as preventive services. Examples include CT colonography performed outside ages 45–75 years or more often than once every 5 years, and Pap smear cytology performed more frequently than once every 3 years for ages 21–65 years.

The referenced policy chunks do not include any additional explicit statements labeled as 'not medically necessary' beyond the general exclusions and frequency/age‑based limitations already documented elsewhere in the guideline.

CPT/HCPCS Codes and Frequency Summaries

General preventive visit CPT codesCPTCovered

99383	Preventive Screening Examination and Counseling Services
99384	Preventive Screening Examination and Counseling Services
99385	Preventive Screening Examination and Counseling Services
99386	Preventive Screening Examination and Counseling Services
99387	Preventive Screening Examination and Counseling Services
99393	Preventive Screening Examination and Counseling Services
99394	Preventive Screening Examination and Counseling Services
99395	Preventive Screening Examination and Counseling Services
99396	Preventive Screening Examination and Counseling Services
99397	Preventive Screening Examination and Counseling Services

1–10 of 16

1/2

Breast pump and suppliesHCPCSCovered

E0603	Personal-use electric breast pump
E0602	Breast pump (unspecified)
A4281	Breast pump supply
A4282	Breast pump supply
A4283	Breast pump supply
A4284	Breast pump supply
A4285	Breast pump supply
A4286	Breast pump supply
A4288	Breast pump supply
A4287	Breast pump supply (Z39.1) optional

Behavioral counseling for weight managementCPTCovered

99401	Preventive Medicine, Individual Counseling
99402	Preventive Medicine, Individual Counseling
99403	Preventive Medicine, Individual Counseling
99404	Preventive Medicine, Individual Counseling

Selected specific screening codesmixedCovered

96110	Autism / Formal Developmental Screening
85014	Anemia screening (blood)
85018	Anemia screening (blood)
99401	Breast cancer (BRCA) Genetic testing Counseling/evaluation
99402	Breast cancer (BRCA) Genetic testing Counseling/evaluation
99403	Breast cancer (BRCA) Genetic testing Counseling/evaluation
99404	Breast cancer (BRCA) Genetic testing Counseling/evaluation
81162	BRCA testing
81163	BRCA testing
81164	BRCA testing

1–10 of 17

1/2

Breast imaging and chlamydia testingCPTCovered

77061	Breast tomosynthesis
77062	Breast tomosynthesis
77063	Mammography/tomosynthesis/mammography code (use with mammography)
77065	Diagnostic mammography
77066	Diagnostic mammography bilateral
77067	Screening mammography
76641	Breast ultrasound unilateral
76642	Breast ultrasound bilateral
77048	Additional breast imaging
0455U	Chlamydia/Gonorrhea combined testing (new)

1–10 of 14

1/2

Colon and colorectal cancer screening codesCPT|HCPCS|mixedCovered

00811	Anesthesia for lower intestinal endoscopic procedures
00812	Anesthesia for lower intestinal endoscopic procedures
88305	Pathology, gross and microscopic examination
44388	Colonoscopy
44389	Colonoscopy
44391	Colonoscopy
44392	Colonoscopy
74263	CT colonography
45378	Diagnostic colonoscopy
45380	Colonoscopy with biopsy

1–10 of 12

1/2

Colon Cancer Screening (CT Colonography)CPTCovered

74263

CT Colonography

Screening colonoscopy pre-procedure consultationsCPTCovered

99202	Office/outpatient visit, new patient
99203	Office/outpatient visit, new patient
99204	Office/outpatient visit, new patient
99205	Office/outpatient visit, new patient
99211	Office/outpatient visit, established patient
99212	Office/outpatient visit, established patient
99213	Office/outpatient visit, established patient
99214	Office/outpatient visit, established patient
99215	Office/outpatient visit, established patient

Colon Cancer Screening (Pathology)CPTCovered

88305

Pathology, surgical pathology, colon cancer screening pathology

Colon and Colorectal Cancer Screening (stool occult blood)CPTCovered

82270	Occult blood, qualitative
82274	Occult blood, immunoassay

Colorectal Cancer Screening (stool DNA tests)CPT|HCPCS|OtherCovered

81528	Cologuard stool DNA test
0464U	Cologuard Plus lab test (effective 9/01/2025)
0537U	Shield™ Guardant Health stool DNA test (effective 1/1/2026)

Contraceptive counseling, management, and methodsCPT|HCPCS|J-codesCovered

99401	Preventive medicine counseling
99402	Preventive medicine counseling
99403	Preventive medicine counseling
99404	Preventive medicine counseling
99202	Maternity initial visit (see grouping)
J7306	IUD device code example
J7307	IUD device code example
J7300	IUD (copper)
J7301	IUD (Skyla®)
J7297	IUD (Liletta®)

1–10 of 16

1/2

Implantable contraceptive device proceduresCPTCovered

11976	Capsule removal (implantable contraceptive)
11981	Implant insertion
11982	Implant removal
11983	Removal with reinsertion

Dental Caries Prevention (Oral Fluoride Varnish)CPTCovered

99188

Oral fluoride varnish

Depression/Anxiety ScreeningCPTCovered

96127

Brief emotional/behavioral assessment screening

Diabetes Screening (Adults, Children, Gestational)CPT|LaboratoryCovered

82947	Glucose; quantitative
82948	Glucose; quantitative, reagent strip
82950	Glucose tolerance test
82951	Glucose tolerance test
82952	Glucose tolerance test
83036	Hemoglobin A1c

Dietary Counseling for overweight/obese with CVD riskCPT|HCPCSCovered

97802	Medical nutrition therapy, initial
97803	Medical nutrition therapy, re-assessment
97804	Medical nutrition therapy, group
S9470	Nutrition counseling

Gonorrhea ScreeningCPT|HCPCS|OtherCovered

87494	Gonorrhea NAAT (new code effective 1/1/2026)
87590	Chlamydia/Gonorrhea testing
87591	Chlamydia/Gonorrhea testing
87592	Chlamydia/Gonorrhea testing
87801	Gonorrhea test
87850	Chlamydia/Gonorrhea antigen
0455U

Hearing ScreeningCPTCovered

92551	Screening test, puretone
92552	Pure-tone audiometry
92553	Comprehensive audiometry
92558	Speech recognition threshold
92587	Auditory evoked potentials
92588	Auditory evoked potentials
92650	Assessment of cochlear implant
92651	Evaluation of cochlear implant

Hepatitis B ScreeningCPTCovered

87340	Hepatitis B surface antigen
87341	Hepatitis B surface antibody

Hepatitis C ScreeningCPTCovered

86803	Hepatitis C antibody
86804	Hepatitis C testing

HIV Screening for Adolescents and AdultsCPTCovered

86689	HIV antibody
86701	HIV confirmatory
86702	HIV confirmatory
86703	HIV test
87389	HIV antigen/antibody
87390	HIV antigen/antibody
87391	HIV testing
87806	HIV viral detection

HPV Screening (DNA)CPTCovered

87624	HPV DNA testing
87625	HPV DNA testing
87626	HPV DNA testing
0500T	Deleted code effective 1/01/2025

Lead ScreeningCPTCovered

83655

Lead testing

Lipid ScreeningCPTCovered

80061	Lipid panel
82465	Lipoprotein
83718	Lipoprotein, direct
83719	Lipoprotein, direct
83721	Lipids
83722	Lipoprotein, direct
84478	Triglycerides

Lung Cancer ScreeningCPTCovered

71271

Low dose CT for lung cancer screening

Maternity/Antepartum/Global careCPTCovered

59425	Antepartum care only
59426	Antepartum care with delivery
59400	Global maternity
59510	Global maternity, VBAC
59610	Global maternity, repeat cesarean
59618	Global maternity

Newborn Screening: HypothyroidismCPTCovered

84437	Thyroid stimulating hormone (TSH)
84443	Thyroxine (T4)

Newborn Screening: PKUCPT|HCPCSCovered

84030	Phenylketonuria (PKU) testing
S3620	Newborn metabolic screening

Newborn Screening: Sickle Cell DiseaseCPTCovered

83020	Sickle cell screening
83021	Sickle cell screening
83051	Sickle cell testing

Osteoporosis Screening (codes and effective dates noted)CPTCovered

76977	Ultrasound bone density (portable)
77080	Dual-energy X-ray absorptiometry (DEXA)
77081	Bone density study

Pap Smear (Cytology)CPTCovered

88141	Pap smear cytology
88142	Pap smear cytology
88143	Pap smear cytology
88147	Pap smear cytology
88148	Pap smear cytology
88150	Pap smear cytology
88152	Pap smear cytology
88153	Pap smear cytology
88155	Pap smear cytology
88164	Pap smear cytology

1–10 of 15

1/2

Pregnancy Bacteriuria ScreeningCPTCovered

81007	Urinalysis, pregnancy bacteriuria screening
87086	Urine culture
87088	Culture, bacterial

Pregnancy screening panels and Rh typingCPTCovered

80081	Obstetric panel (includes HIV testing)
86901	Rh (D) typing
80055	Pregnancy screening panel (Hep B, CBC, Rh D, Syphilis)

Pap smear and pregnancy basic screensmixedCovered

88155	Pap smear-related CPT
88164	Pap smear-related CPT
88165	Pap smear-related CPT
88166	Pap smear-related CPT
88167	Pap smear-related CPT
88174	Pap smear-related CPT
88175	Pap smear-related CPT
81007	Pregnancy bacteriuria screening
87086	Pregnancy bacteriuria screening
87088	Pregnancy bacteriuria screening

1–10 of 12

1/2

Pregnancy panels and specific pregnancy testsCPTCovered

80081	Pregnancy obstetric panel (includes HIV testing)
87340	Hepatitis B screening
87341	Hepatitis B screening
86901	Rh (D) typing
80055	Pregnancy screening panel (HepB, CBC, Rh(D), Syphilis)

PrEP counseling and administration codesHCPCSCovered

G0012	Administration code (PrEP-related injection)
J0739	Injection cabotegravir, 1mg
G0011	Counseling for PrEP
G0013	Counseling for PrEP

PrEP monitoring, HIV/STI/pregnancy testing, and related labs/visitsmixedCovered

82565	Creatinine
82575	Creatinine
81025	Pregnancy screening urine test
84702	Pregnancy screening
84703	Pregnancy screening
86689	HIV screening
86701	HIV screening
86702	HIV screening
86703	HIV screening
87389	HIV screening

1–10 of 48

1/5

Behavioral, sterilization, TB, vision, venipuncturemixedCovered

99401	Smoking cessation counseling
99402	Smoking cessation counseling
99403	Smoking cessation counseling
99406	Smoking cessation counseling
99407	Smoking cessation counseling
58340	Sterilization procedure
58565	Sterilization procedure
58600	Sterilization procedure
58605	Sterilization procedure
58611	Sterilization procedure

1–10 of 30

1/3

Immunizations and administration codesmixedCovered

90471	Immunization administration (adult/pediatric variants listed)
90472	Immunization administration
90473	Immunization administration
90474	Immunization administration
90460	Pediatric immunization admin
90480	COVID-19 vaccine administration (admin code)
90481	COVID-19 vaccine administration (in conjunction with 90480) - new code effective 1/1/2026
91304	COVID-19 vaccine product
91318	COVID-19 vaccine - Novavax
91319	COVID-19 vaccine - Pfizer-BioNTech

1–10 of 45

1/5

Influenza vaccinesCPTCovered

90653	Fluad (aIIV3) (0.5ml SDS) - Adult: Ages 65 and older
90656	Afluria (IIV3) (0.5ml SDS) - Pediatric: Ages 3 years and older / Adult and Pediatric: Ages 2-49 years (where indicated)
90657	Afluria (IIV3) (5ml MDV) / Fluzone (IIV3) (5ml MDV) - Pediatric: Ages 6-35 months
90658	Afluria (IIV3) (5ml MDV) - Pediatric: Ages 3 years and older
90660	Flumist® (LAIV3) (0.2 ml nasal) - Ages 2-49 years
90661	Flucelvax (ccIIV3) (0.5ml SDS / 5ml MDV) - Ages 6 months and older
90662	Fluzone High-Dose (HD-IIV3) (0.5ml SDS) - Ages 65 and older
90673	Flublok (RIV3) (0.5ml SDS) - Ages 9 and older
Q2039	Influenza virus vaccine, not otherwise specified - Ages 18 and older (where indicated)

Provider Billing, Documentation, and Authorization Guidance

Prior Authorization

Prior authorization may be required for BRCA genetic testing

BRCA genetic testing counseling/evaluation may require prior authorization. Verify PA requirements before ordering genetic testing to avoid delays.

Affected codes: 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217
Preventive frequency: once per lifetime; ICD-10: Z15.01, Z15.02, Z80.3, Z80.41, Z85.3, Z85.43

Prior Authorization

Confirm prior authorization for imaging and maternity-related services

Confirm whether prior authorization is required for imaging or maternity-related preventive services per member plan — check plan-specific PA rules prior to scheduling.

Examples: screening colonoscopy pre-procedure consults (99202-99215 series) and newborn/specialty screens may have plan-level PA rules
Verify PA for services effective dates noted in code lists (e.g., codes with future effective dates)

Policy Background and Scope

This policy implements the Patient Protection and Affordable Care Act (PPACA) preventive service mandates for non‑grandfathered plans and aligns coverage with authoritative recommendations. Covered preventive services include items rated A or B by the USPSTF, immunizations recommended by ACIP/CDC, and HRSA/AAP Bright Futures pediatric preventive services. The guideline distinguishes preventive services (performed for asymptomatic individuals within recommended intervals and billed as preventive) from diagnostic services (performed for symptoms, prior abnormal findings, or shortened‑interval testing), and requires appropriate preventive coding and adherence to the applicable age and frequency criteria to qualify for the no cost‑sharing preventive benefit.

Key Definitions

inv-101: Preventive service definition

DefinitionServices performed on an asymptomatic person within recommended intervals, or routine screening with prior normal findings, and reported as preventive to be covered under the preventive benefit

Coverage linkagePreventive services include USPSTF A/B recommendations, ACIP-recommended immunizations, and HRSA/AAP Bright Futures pediatric preventive services

Billing requirementService must be reported as preventive (use applicable preventive ICD-10 codes) to be considered under the preventive benefit; otherwise treated as diagnostic

inv-102: Diagnostic service definition

DefinitionService performed to evaluate symptoms, prior abnormal findings, or when repeat testing is indicated at intervals shorter than recommended preventive intervals — considered diagnostic and billed under non-preventive benefit

Examples

Revision History and Material Changes

2026-02-09code additionsLatest

Added CPT 87494 to Chlamydia/Gonorrhea screening and PrEP monitoring; added CPT 90481 to COVID-19 vaccine administration; added immunization counseling codes 90482, 90483, 90484.

2025-10-14code addition

Added HCPCS code A4288 to Breast Pump Supplies effective 10/01/2025.

2025-09-18code addition

Policy Summary

PayerEmblemHealth

PolicyPreventive Services & Screening — Coverage Criteria

Policy CodePolicy N/A

Change TypeMaterial code additions and immunization updates

Effective DateN/A

Next Review DateN/A

Key ActionDocument patient age and append the appropriate preventive ICD-10 diagnosis codes when billing vaccines and preventive services.

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Bill with Z30.x diagnosis codes; frequencies vary by method as listed

HPV DNA screening: HPV DNA testing codes (87624–87626 effective 1/01/2025) are coveredFrequency: 1x/year; Ages: 30–65

Observe code changes effective 1/01/2025

Lung cancer screening: Low-dose CT (71271) is covered for lung cancer screening with smoking-related ICD-10 codesFrequency: 1x/year; Ages: 50–80

See diagnostic linkage for eligibility

Pap smear cytology codes (88141–88175) with listed ICD-10 screening codes are coveredFrequency: once every 3 years; Ages: 21–65

Bill with preventive diagnosis codes

Pregnancy labs and screening panels: Pregnancy-related screening tests and panels (e.g., 81007, 87086, 87088, 80081, 80055, 87340–87341, 86901) are covered per service-specific instructionsFrequency: test-specific (ranges from unlimited to 1x/year)

Refer to pregnancy preventive instructions and Appendix I for ICD-10 codes

Use pregnancy screening ICD-10s

Pregnancy Obstetric Panel: Obstetric panel (80081, includes HIV testing) is covered for pregnancy screeningFrequency: 1x/year; Ages: all

Bill with appropriate pregnancy ICD-10 codes

Pregnancy Screening Panel: Pregnancy screening panel (80055 includes Hep B, CBC, Rh(D), Syphilis) is coveredFrequency: 1x/year; Ages: all

Use pregnancy ICD-10 codes as listed

For visits before 10/01/2023 use Z20.6 (and related codes) as described; for visits on/after 10/01/2023 append Z29.81 to all PrEP visits

Append additional testing diagnosis codes as applicable (Z01.812, Z11.* etc.)

Influenza vaccines: Influenza vaccine product codes by age group (e.g., 90653, 90656, 90657, 90658, 90660, 90661, 90662, 90673) are covered per seasonal/FDA/CDC indicationsAge-specific as listed per vaccine product

Follow seasonal effective dates and age bands in coding module

Vision screening in children: Visual acuity and instrument-based vision screening (99173, 99174, 99177) are covered per preventive instructionsFrequency: 1x/year (instrument based 1–4 years where noted); Ages: 0–21

PCP-only for specified ages

MMR and Meningococcal vaccinesCPTCovered

90707	MMR II®
90710	ProQuad® (MMRV)
90619	MenQuadfi®
90620	Bexsero®
90621	Trumenba®
90644	MenHibrix®
90733	Menomune®
90734	Menactra®, Menveo®

Pneumococcal vaccinesCPTCovered

90670	Pneumococcal (PPSV23) / Prevnar 13®
90671	Pneumococcal conjugate / Vaxneuvance®
90677	Pneumococcal conjugate / Prevnar20®
90684	Pneumococcal conjugate / CAPVAXIVE™ - Adult (19 years+)
90732	Pneumovax®

Polio and Rotavirus vaccinesCPTCovered

90713	Polio (IPV) / Ipol®
90680	Rotavirus (RV1, RV5) / Rotateq®
90681	Rotavirus (RV1, RV5) / Rotarix®

RSV vaccines and administrationCPTCovered

96380	RSV vaccine administration
96381	RSV vaccine administration
90380	Beyfortus™ (RSV)
90381	Beyfortus™ (RSV)
90678	Abrysvo™ (RSV) - follow CDC/ACIP
90679	Arexvy™ (RSV) - follow CDC/ACIP
90683	mRESVIA® (RSV) - Ages 60 and older

Varicella and ZosterCPTCovered

90716	Varivax® (Varicella vaccine)
90750	Shingrix® (Zoster/Shingles)

inv-72: BMI threshold for intensive behavioral interventions

BMI thresholdAdults BMI ≥ 30 — refer to intensive multicomponent behavioral interventions (USPSTF recommendation); associated counseling codes: 99401–99404

Severe obesity thresholdBMI ≥ 40 — ICD-10 examples: Z68.41–Z68.45 (documentation and appropriate counseling/services)

Frequency for adult behavioral interventionsPreventive behavioral intervention frequency (adults with BMI ≥30): up to 12x/year for intensive programs as noted in preventive instructions

inv-73: Colorectal screening age and interval summary

Primary age rangeAges 45–75 years for colonoscopy, CT colonography and other listed colorectal screening modalities

Colonoscopy/CT colonography intervalFrequency: once every 5 years for screening colonoscopy, CT colonography and related pre-procedure consultations

Stool DNA test interval and ageStool DNA tests (Cologuard 81528, Cologuard Plus 0464U, Shield 0537U): once every 3 years; ages 45–85 (Shield: ages 45+)

inv-74: Colon Cancer Screening (CT Colonography) Age

CT colonography age bandAges 45–75 years

CT colonography frequencyOnce every 5 years

Preventive diagnosis linkageUse preventive ICD-10 codes listed (e.g., Z12.12, Z12.10) when billing to ensure preventive benefit

inv-75: Stool-based colorectal screening frequency

Stool-based screening frequencyOnce every 3 years for fecal occult blood (82270, 82274) and stool DNA tests (81528, 0464U, 0537U)

Age limits for stool occult blood testsAges 45–85 years for fecal occult blood tests (82270, 82274)

Age limits for stool DNA testsCologuard (81528, 0464U) ages 45–85; Shield (0537U) preventive instructions: ages 45 and older

inv-76: Pap smear frequency

Pap smear frequency (cytology)Once every 3 years for cytology (CPT codes 88141–88175) for ages 21–65

Applicable CPT codesCytology codes listed include 88141–88175 (select codes 88155, 88164–88167, 88174, 88175 referenced)

Diagnostic vs preventiveReport as preventive (use preventive ICD-10 codes such as Z12.4 or Z00.00/Z00.01) to receive preventive benefit; more frequent testing for diagnostic indications is considered non-preventive

inv-77: Lung cancer screening age and frequency

Lung cancer screening age bandAges 50–80 years

Lung cancer screening frequencyLow-dose CT (procedure code 71271) — once per year

ICD-10 and risk linkageScreening tied to smoking-related diagnosis codes as listed in the lung cancer screening entry

inv-78: Pap smear frequency (alternate reference)

Pap smear frequency (alternate ref)Once every 3 years (1x/3 years) for ages 21–65 using cytology CPT codes 88141–88175

Preventive diagnosis codesTypical preventive ICD-10 codes include Z00.00, Z00.01, Z01.411, Z01.419, Z12.4

Frequency noteTesting more frequently than 1x/3 years for ages 21–65 is considered diagnostic and billed under the non-preventive benefit

inv-79: Pregnancy obstetric panel frequency

Pregnancy obstetric panel frequencyObstetric panel (CPT 80081, includes HIV testing): once per year during pregnancy (Preventive Benefit Instructions)

Pregnancy screening panel frequencyPregnancy screening panel (CPT 80055, includes Hep B, CBC, Rh(D), Syphilis): once per year

Pregnancy bacteriuria and CBCBacteriuria screening (81007, 87086, 87088) and pregnancy blood counts (85025, 85027): frequency unlimited as clinically indicated

inv-80: Smoking cessation visits frequency

Smoking cessation visit allowanceUp to 8 visits per year for smoking cessation counseling (CPT 99401–99404, 99406, 99407)

Applicable CPT codesSmoking cessation codes include 99401, 99402, 99403, 99406, 99407

DocumentationUse appropriate smoking-related ICD-10 codes (e.g., F17.x, Z87.891) when billing preventive smoking cessation services

inv-81: Syphilis screening frequency

Syphilis screening frequencyUp to 4 times per year for syphilis screening (CPT 86592, 86593)

Applicable agesFrequency applies to all ages as listed in preventive instructions

Associated ICD-10 codesUse Z00.00/Z00.01 for adult screening and pediatric codes Z00.121/Z00.129 as applicable

inv-82: Vision screening in children frequency

Vision screening frequency (children)Once per year for children ages 0–21 (visual acuity CPT 99173)

Instrument-based screeningInstrument-based vision screening (CPT 99174, 99177): frequency 1x/year for ages 1–4 years as noted

Provider limitationPreventive vision screening for children 0–21 is PCP-only per the preventive benefit instructions

inv-83: Age limits for vaccines (age bands referenced)

Vaccine age bands vary by codeAge limits are specified per vaccine CPT/HCPCS code (examples: influenza high-dose 90653 for ages 65+; influenza 90661 for ages ≥6 months; rotavirus 90681 for ages 0–8 months; RSV product codes with specific pediatric/adult ages)

RSV age examplesRSV vaccine entries (CPT/HCPCS 90380, 90381, 90678, 90679, 90683) include ages 0–24 months for some products and age 60+ for others (see coding entries) — follow Preventive Benefit Instructions

Influenza age examplesInfluenza product codes listed with age-specific guidance (e.g., 90656 pediatric 3+; 90657 pediatric 6–35 months; 90660 ages 2–49)

Billing Rule

PrEP counseling and administration — coding and diagnosis requirements

PrEP counseling and administration is a covered preventive service (effective 1/01/2024). Use required administration and counseling codes and append mandated diagnosis codes on visits on/after 10/01/2023.

Counseling/admin codes: G0011, G0013, G0012; Injection cabotegravir: J0739
PrEP visits: 99202-99215
Required diagnosis: Z29.81 (must be appended for visits on/after 10/01/2023); earlier visits use Z20.6 and Z20.2 as specified
Append additional testing/visit codes as applicable: Z01.812, Z11.3, Z11.4, Z11.59, Z20.2, Z20.5, Z20.6, Z77.21

Prior Authorization

Prior authorization summary for vaccines and administration

Prior authorization may be required for certain vaccines and vaccine administration depending on plan rules and FDA/ACIP recommendations. Document age and applicable preventive diagnosis when administering vaccines.

Follow CDC/ACIP and FDA licensure guidance for age and frequency (e.g., RSV vaccine age limits, pneumococcal, polio, rotavirus)
Document patient age and preventive diagnosis code when billing vaccine administration
Check PA for non-routine or off-label vaccine use

Documentation Required

Preventive vs Diagnostic reporting guidance

Distinguish preventive versus diagnostic intent when reporting services. Use preventive diagnosis codes and intervals when the service meets preventive criteria; otherwise bill under the non-preventive medical benefit.

Preventive: asymptomatic, within recommended interval, or prior normal diagnostic result leading to routine screening
Diagnostic: symptoms, prior abnormal results requiring follow-up, shortened-interval repeats, or outside guideline population

Denial Risk

Medicaid fee schedule denial risk

EmblemHealth Medicaid plans reimburse only codes listed on the Medicaid fee schedule — codes not on the fee schedule will be denied.

Verify code inclusion on the member's Medicaid fee schedule before billing
Risk of denial for codes absent from Medicaid fee schedules

Denial Risk

Frequency limits and denial risk for out-of-interval services

Frequency limits apply to many preventive services; billing for services outside stated intervals risks denial. Confirm the allowed frequency and patient age prior to performing the service.

Examples: screening colonoscopy consults and stool occult blood testing have specified frequencies (see code lists)
Services billed outside the listed frequency or age ranges may be denied

Documentation Required

Immunization guideline adherence requirement

When administering immunizations, providers must adhere to FDA/CDC age and interval guidance (ACIP). Non-adherence may result in coverage denial.

Follow CDC Child, Adolescent & Catch-up and Adult Immunization Schedules
Document adherence to age/frequency rules in the medical record

Documentation Required

Adhere to CDC/ACIP guidance (RSV and influenza specific note)

For RSV and other vaccines, adhere to CDC/ACIP recommendations and document patient age; follow specified age limits for administration.

RSV vaccine example: Beyfortus (90380/90381) indicated for ages 0–24 months (ends on 2nd birthday); Abrysvo (90678) per CDC guidance
Document preventive diagnosis and patient age when billing

Diagnostic reasons include prior abnormal studies requiring follow-up, symptoms requiring further evaluation, or not meeting preventive population criteria

ConsequenceServices performed for diagnostic purposes are not eligible for the preventive benefit and should be billed under the applicable medical benefit

inv-103: Colorectal cancer screening (stool DNA/Cologuard/Shield) definition

DefinitionNoninvasive stool-based DNA tests used for colorectal cancer screening (e.g., Cologuard CPT 81528; Cologuard Plus 0464U effective 9/01/2025; Shield 0537U effective 1/01/2026)

Interval and agesUsed for screening once every 3 years for ages 45–85 (Shield: ages 45 and older)

Preventive codingBill with preventive ICD-10 codes Z12.10/Z12.11/Z12.12 and procedure codes listed to apply the preventive benefit

inv-104: Pap smear definition

DefinitionPap smear refers to cytology testing using CPT codes 88141–88175 for cervical cancer screening

Recommended interval and agesRecommended once every 3 years for ages 21–65 when billed as preventive

Billing noteUse preventive ICD-10 codes (e.g., Z12.4, Z00.00/Z00.01) to ensure preventive benefit; more frequent testing for abnormal results is diagnostic

inv-105: PrEP Monitoring and Testing definition

DefinitionPrEP Monitoring and Testing includes counseling/administration (G0011, G0012, G0013, J0739) and associated periodic lab testing and visits for persons receiving PrEP

Typical monitoring tests & frequencyCreatinine (82565, 82575) up to 3x/year; pregnancy screening (81025, 84702, 84703) unlimited for those of childbearing potential; HIV screening and STI testing per sections (many tests unlimited or up to 4x/year)

Coding & ICD-10 appendingPrEP visits before 10/01/2023 used Z20.6/Z20.2; for visits on/after 10/01/2023 append Z29.81 to all PrEP visits as specified

inv-106: Preventive Benefit Instructions (vaccine age groups)

DefinitionPreventive Benefit Instructions: age-group and preventive-use guidance associated with each vaccine CPT/HCPCS code as listed in the policy (follow code-specific age/frequency guidance)

Provider responsibilityProviders must document patient age and use the Preventive Benefit Instructions when administering vaccines to determine preventive coverage

AlignmentInstructions align with FDA licensure and CDC/ACIP recommendations as detailed in the immunization sections

inv-107: ACIP/CDC adherence definition

DefinitionACIP/CDC adherence means providers must follow current CDC/ACIP vaccine age and frequency guidelines (e.g., RSV, certain influenza codes) to qualify for preventive coverage

Policy implicationFailure to adhere to FDA/CDC/ACIP age or frequency guidance may affect preventive billing or result in coverage restrictions

ExamplesRSV vaccine entries explicitly require adherence to CDC/ACIP; influenza vaccine product codes include age-specific preventive instructions

Added COVID-19 vaccine product code 91323 effective 08/27/2025.

2025-09-04code additions and vaccine update

Added 0455U to Chlamydia/Gonorrhea screening and PrEP monitoring; added colorectal stool DNA code 0537U (Shield™); updated 2025-2026 influenza vaccine listings.

2025-06-09clarification

Clarified procedure codes and age/frequency limitations for Preventive Screening Examination and Well Child visit services; updated ACIP link in Introduction.

2025-04-28clarification

Clarified that EmblemHealth Medicaid plans reimburse codes only if found on the Medicaid fee schedules.

2022-06-14vaccine and age-limit updates

Added dengue vaccine CPT 90587 and pneumococcal conjugate codes 90671 and 90677 with associated age/benefit limits; updated zoster age limit and removed CPT 90736.

2022-01-24frequency update

Updated medical nutrition CPT codes 97802/97803/97804 frequency to 4 times per year effective 01/01/2020.

2021-10-15contraceptive code updates

Added two new contraceptive codes effective 10/01/2021 and noted deletion of J7303 effective 09/30/2021.

2021-10-01screening ICD-10 updates

Updated Chlamydia and HIV screening ICD-10 code lists to include additional Z-codes for screening.