harvard pilgrim preventive services Coverage Update

Preventive Services — Coverage Criteria

Abdominal Aortic Aneurysm (AAA) Screening — coverage conditions and preventive diagnosis code billing requirement

Covered when billed with listed preventive diagnosis codes in primary position and when member is eligible by age/condition.

AAA Screening: Covered when billed with one of the listed ICD-10 codes (e.g., F17.210, Z00.00, Z13.6); once-per-lifetime screening for men ages 65-75 with prior history of smokingmen 65-75, prior smoking

Screening ends on the member's 76th birthday

Colorectal Cancer Screening — includes Cologuard frequency/age guidance and setting exclusions

Colorectal cancer screening covered as preventive under listed conditions.

Colonoscopy Screening: Payable as preventive when billed with one of the listed ICD-10 diagnosis codes; excludes inpatient and ER settings; diagnosis must be billed in the primary position; use CPT 00812 for screening colonoscopy and 00811 when a screening colonoscopy converts to diagnosticN/A

Cologuard (81528) and Cologuard Plus (0464U) covered ages 45-75 once every 3 years; prep kits/items require RX coverage

Lung Cancer Screening (LDCT) — eligibility, age and smoking-history criteria

Lung cancer screening coverage conditions.

LDCT Lung Cancer Screening: Covered when billed with one of the listed ICD-10 codes for adults ages 50-80 years with a >=20 pack-year smoking history who currently smoke or have quit within the past 15 yearsages 50-80; >=20 pack-year; quit <=15 years

CPT 71271 (LDCT) requires prior authorization

Contraception — drugs, devices, sterilization coverage guidance

Contraception coverage guidance.

Contraceptive Drugs and Devices: Covered when billed with listed diagnosis/procedure codes; prescription contraceptives require member RX coverage to be covered in full; contraceptive management and device codes (procedure and HCPCS) are listed; voluntary sterilization procedure codes are listedN/A

Natural Cycles app billed under A9293 when billed with Z31.89; refer to member benefit/Rider for RX coverage specifics

Breastfeeding Support and Equipment — coverage and equipment limits (e.g., pumps)

Breastfeeding support coverage.

Breastfeeding Interventions & Equipment: Lactation classes (S9443), lactation visits (99502), breast pump equipment (E0602 manual, E0603 electric, E0604 hospital-grade) and supplies (A4281–A4288) are covered when billed with listed diagnosis codesfrequency limits as noted

99502 limited to one visit every 8 rolling months; E0604 rental limited to 3 months then pump must be returned; E0602/E0603 purchase frequency limits may apply

HIV Screening and PrEP — preventive services and product-level notes

HIV and PrEP preventive services.

HIV Screening and PrEP-related services: HIV screening covered as preventive for ages 15-65 (younger/older if increased risk) and for all pregnant persons when billed with listed ICD-10 codes; includes related services such as adherence counseling, creatinine/eGFR testing, hepatitis B and C testing, and pregnancy testing as appropriateages 15-65 standard

Use the listed ICD-10 diagnosis codes when billing

Lung Cancer Screening — duplicate/alternate lung screening coverage node (document contains multiple references)

Covered when billed with specified diagnosis and age criteria:

Lung Cancer Screening (duplicate entry): Low-dose CT for lung cancer (CPT 71271 / HCPCS G0296) is covered for adults ages 50-80 with >=20 pack-year smoking history who currently smoke or quit within the past 15 yearsage 50-80; >=20 pack-year; quit <=15 years

71271 requires prior authorization

Newborn Screenings — coverage when billed with listed ICD-10 and timing windows

Newborn screenings are covered when billed with listed ICD-10 codes and within specified age windows:

Hearing Screening: Hearing screening (92551, 92552, 92558, 92567, 92587, 92588, 92650) is covered through age 21 when billed with one of the listed ICD-10 codes<=21 years

Hypothyroidism Screening (newborn): Hypothyroidism screening (84437, 84443) is covered when billed with a preventive diagnosis for newborns ages 0-180 days0-180 days

Phenylketonuria Screening: Phenylketonuria screening (84030, 84510) is covered when billed with the listed ICD-10 codes for ages 0-60 days0-60 days

Osteoporosis Screening — bone density screening coverage statement

Bone density screening coverage statement:

Osteoporosis Screening: Covered for all persons age 40 and older when billed with one of the listed CPT or ICD-10 codes (e.g., DXA codes 77078, 77080, vertebral assessment 77081)>=40 years

Obesity Screening — screening and counseling coverage guidance

Obesity screening and counseling coverage:

Obesity Screening and Counseling: Covered for adults, children and adolescents when billed separately or with an E&M service; must append modifier 25 when billed with an E&M visitage varies

Procedure codes include 97802–97804, 99401–99404 and HCPC G0473/S9470

Preventive Immunizations — high-level immunization coverage conditions and exclusions

Preventive immunization coverage conditions:

Preventive Immunizations: Immunizations not excluded by the Certificate of Coverage are covered if FDA-approved and explicitly recommended for routine use by ACIP in the MMWR; implementation typically within 60 days after publicationACIP recommendation

When billing immunizations use ICD-10 code Z23; documentation should include vaccine product and CPT code

HPV Vaccination Coverage — product and age-specific coverage details

HPV vaccine coverage detail:

HPV Vaccination: Gardasil4 (90649) reimbursed for ages 9–26 (series begun by 26 may be completed into 27); Gardasil9 (9vHPV) coverage is limited to ages 9–45ages 9-45 depending on product

Series completion rules apply

Explicit product coverage notes (partial) — product-level coverage nodes (3 top-level nodes)

Gardasil9 coverage: Coverage for Gardasil9 (9vHPV) is limited to ages 9–45age 9-45

Referenced in policy product definitions

MenACWY coverage: Meningococcal conjugate vaccine (MenACWY; Menactra/Menveo) is covered for ages 2 months through 55 yearsage 2 months-55 years

See vaccine-specific CPTs (e.g., 90619, 90734)

Shingrix coverage: Recombinant zoster vaccine (Shingrix) coverage is limited to age 18 years and overage >=18

Policy notes age-based limitation for coverage

Colorectal cancer screening services are payable as preventive only when billed with an appropriate preventive/screening diagnosis code in the primary position. Screening colonoscopy entries exclude inpatient and emergency room settings. Use 00812 for a screening colonoscopy and 00811 if a screening colonoscopy converts to diagnostic. Cologuard (CPT 81528) and Cologuard Plus (CPT 0464U) are covered for members aged 45-75 at a frequency of once every 3 years.

An immunization that is excluded by the member's Certificate of Coverage is not covered even if the product has FDA approval or is recommended by ACIP. Coverage for preventive immunizations requires both FDA approval and an explicit ACIP recommendation for routine use published in the MMWR; implementation typically occurs within 60 days of the MMWR publication.

Some vaccines have explicit age-based coverage limits. For example, HPV vaccine product guidance notes that Gardasil9® coverage is limited to ages 9–45. Age constraints and series-completion rules in the product descriptions must be followed when adjudicating preventive immunization claims.

The recombinant zoster (shingles) vaccine (Shingrix®, CPT references noted) is covered only for members who are age 18 years and over. Billing and coverage should reflect this minimum age requirement.

Preventive services must be billed with the correct preventive diagnosis in the primary position to receive preventive adjudication. For immunizations, providers should document the vaccine product, corresponding CPT code, and the member's age to demonstrate that the immunization meets coverage criteria (including FDA approval and ACIP recommendation when applicable).

No content specified.

Codes and Billing — CPT/HCPCS/ICD-10 Tables

AAA Screening and example diag codesmixedCovered

76706	Abdominal Aortic Aneurysm (AAA) screening
F17.210	ICD-10 diagnosis code listed for AAA screening and smoking-related codes
Z00.00	Preventive visit diagnosis code

AAA Screening - additional ICD-10 examplesmixedCovered

F17.211	ICD-10 diagnosis code listed for AAA screening and smoking-related codes
F17.213	ICD-10 diagnosis code listed for AAA screening and smoking-related codes
F17.218	ICD-10 diagnosis code listed for AAA screening and smoking-related codes
F17.219	ICD-10 diagnosis code listed for AAA screening and smoking-related codes
Z13.6	ICD-10 diagnosis code listed for AAA screening
Z87.891	ICD-10 personal history of nicotine dependence

BRCA Testing and CounselingmixedCovered

81162	BRCA testing (example procedure code list)
96041	Genetic counseling procedure code listed under BRCA counseling
Z12.31	Encounter for screening for BRCA-related cancer

BRCA Testing - additional procedure examplesmixedCovered

81163	BRCA testing (example procedure code list)
81164	BRCA testing (example procedure code list)
81165	BRCA testing (example procedure code list)
81166	BRCA testing (example procedure code list)
81167	BRCA testing (example procedure code list)
81212	BRCA-related testing code example
81215	BRCA-related testing code example
81216	BRCA-related testing code example
81217	BRCA-related testing code example

Colorectal Cancer Screening (Colonoscopy and Cologuard)mixedCovered

00812	Screening colonoscopy code (use when screening turns diagnostic use 00811)
81528	Cologuard
0464U	Cologuard Plus

Colonoscopy - additional procedure examplesmixedCovered

00811	Screening colonoscopy that turns diagnostic (use when screening converts to diagnostic)
45300	Colonoscopy procedure example listed
44388	Colorectal procedure example listed

Lung Cancer ScreeningCPT|HCPCSCovered

71271	Low-dose CT (LDCT) for lung cancer screening
G0296	HCPC for LDCT

Contraception - Drugs, Devices, SterilizationmixedCovered

11976	Contraceptive management procedure code
A4261	Contraceptive device HCPC
Z30.013	ICD-10 diagnosis for contraception

Contraception - additional HCPCS & procedure examplesmixedCovered

11981	Contraceptive procedure example
11982	Contraceptive procedure example
J7300	Intrauterine device HCPC example
J2250	Contraceptive/injectable HCPC example

Voluntary Sterilization - examplesmixedCovered

00851	Voluntary sterilization procedure example
58565	Tubal ligation procedure example
58600	Sterilization procedure example

Newborn ScreeningsCPTCovered

92551	Newborn hearing screening procedure code
84437	Newborn hypothyroidism screening
84030	Phenylketonuria screening

Newborn - additional metabolic/HCPCS exampleCPT|HCPCSCovered

84443	TSH reflex/related (newborn hypothyroidism related)
S3620	Metabolic screening HCPC

Lung/Lead Screening CodesCPT|HCPCS|mixedCovered

71271	Low-dose computed tomography for lung cancer screening
G0296	LDCT lung cancer screening HCPC
83655	Lead screening

Newborn Metabolic & Hemoglobin ScreeningCPT|HCPCS|mixedCovered

84437	TSH
84443	TSH reflex/related
S3620	Metabolic screening HCPC
84030	Phenylketonuria screening
84510	Phenylketonuria screening component
83020	Sickle cell screening
85660	Sickle cell testing

Obesity & Counseling CodesCPT|HCPCSCovered

97802	Medical nutrition therapy
97803	Medical nutrition therapy
97804	Medical nutrition therapy
99401	Preventive counseling, individual
99402	Preventive counseling, individual
99403	Preventive counseling, individual
99404	Preventive counseling, individual
G0473	Intensive behavioral counseling for obesity
S9470	Nutritionist services

Osteoporosis Screening CodesCPT|HCPCSCovered

76977	Bone density (ultrasound)
77078	Dual-energy x-ray absorptiometry (DXA) single
77080	DXA, axial skeleton
77081	DXA, vertebral fracture assessment
77085	Peripheral bone density
77086	Bone density, other
G0130	Bone mass measure, established patient

Tobacco Cessation/Counseling CodesCPT|HCPCSCovered

99406	Tobacco use counseling intermediate
99407	Tobacco use counseling intensive
G0438	Annual wellness visit, Medicare
G0439	Annual wellness visit, subsequent

Immunization & Administration Codes (detailed list)CPT|ICD-10|HCPCS|mixedCovered

Z23	ICD-10 code for immunizations
90460	Immunization administration through age 18 with counseling, first component
90461	Immunization administration through age 18 with counseling, additional component
90471	Immunization administration, one vaccine
90472	Immunization administration, each additional vaccine
90473	Immunization administration by intranasal/oral, one vaccine
90474	Immunization administration by intranasal/oral, additional vaccine
90480	Immunization administration COVID-19, single dose (IM)
90481	Immunization administration COVID-19 additional component
90482	Immunization counseling when vaccine not administered, 3-10 minutes

1–10 of 25

1/3

Tuberculosis Screening CodesCPTCovered

86580	Tuberculin test
86480	TB blood test (IGRA)
86481	TB blood test (IGRA)

Newborn Hearing Screening CodesCPTCovered

92551	Newborn hearing evaluation
92552	Newborn hearing evaluation
92558	Newborn hearing screening
92567	Newborn hearing tests
92587	Auditory brainstem response diagnostic
92588	Auditory brainstem response diagnostic
92650	Hearing services

Examples from preventive immunizations (partial)CPT

90648	Haemophilus influenzae b vaccine (Hib), PRP-T conjugate, 4-dose schedule
90649	Human Papilloma virus vaccine, types 6,11,16,18, quadrivalent (HPV4), 3-dose

HPV codesCPT

90650

HPV2 (bivalent) 3-dose schedule (note: referenced)

Influenza vaccine CPT codes (selected)CPT

90653	Influenza vaccine, inactivated, subunit, adjuvanted (Fluad)
90655	Influenza vaccine, trivalent, split virus, preservative free, 0.25 mL (Fluzone)
90656	Influenza virus vaccine, trivalent, split virus, preservative free, 0.5 mL
90660	Influenza virus vaccine, trivalent, live (LAIV3) (Flumist)
90661	Influenza virus vaccine, trivalent (ccIIV3), derived from cell cultures (Flucelvax)

Pneumococcal and additional influenza codesCPT

90670	Pneumococcal conjugate vaccine, 13 valent (PCV13) (Prevnar 13)
90671	Pneumococcal conjugate vaccine, 15 valent (PCV15)
90677	Pneumococcal conjugate vaccine, 20 valent (PCV20)
90684	Pneumococcal conjugate vaccine, 21 valent (PCV21)
90756	Influenza virus vaccine, quadrivalent (ccIIV4) (Flucelvax) - alternative code listing

DTaP, MMR, IPV, Td/Tdap, Varicella codesCPT

90696	DTaP-IPV for children 4–6 years (Kinrix/Quadracel)
90698	DTaP-containing combination vaccine (Pentacel)
90707	MMR (MMR II)
90710	MMRV (ProQuad)
90713	IPV (Ipol)
90714	Td for individuals 7 years or older
90715	Tdap for individuals 7 years or older
90716	Varicella (Varivax)
90723	DTaP-HepB-IPV (Pediarix)

PPSV23 and meningococcal codesCPT

90732	PPSV23 (pneumococcal polysaccharide vaccine, 23-valent)
90733	Meningococcal polysaccharide vaccine (MPSV4)
90734	Meningococcal conjugate vaccine, quadrivalent (MCV4/MenACWY)

Zoster, COVID-19, hepatitis B codesCPT

90736	Zoster live vaccine (Zostavax)
90748	Zoster recombinant subunit, adjuvanted (Shingrix) - coverage limited to age 18+
91304	Novavax SARS-CoV-2 recombinant nanoparticle vaccine
90759	Hepatitis B 3-antigen vaccine (listed)

Immunization product CPT codes (examples)CPTCovered

90747	4-dose schedule, for intramuscular use (HepB/Hib?) — Comments = 90747
90748	Hepatitis B and Haemophilus influenza b vaccine (HibHepB), intramuscular — Comments = 90748
90756	Influenza virus vaccine, quadrivalent (ccIIV4), Flucelvax® — Comments = 90756

COVID-19 vaccine CPT codesCPTCovered

91304	Novavax COVID-19 vaccine (recombinant spike protein nanoparticle), 3-dose — Comments = 91304
91318	Pfizer-BioNTech COVID-19 vaccine, 3 mcg/0.3 mL — Comments = 91318
91319	Pfizer-BioNTech COVID-19 vaccine, 10 mcg/0.3 mL — Comments = 91319
91320	Pfizer-BioNTech COVID-19 vaccine, 30 mcg/0.3 mL — Comments = 91320
91321	Moderna COVID-19 vaccine, 25 mcg/0.25 mL — Comments = 91321
91322	Moderna COVID-19 vaccine, 50 mcg/0.5 mL — Comments = 91322
91323	COVID-19 vaccine code added under Immunizations (referenced in publication history)

Administration and injection CPT/HCPCS codesmixedCovered

96380	Administration of RSV monoclonal antibody, seasonal dose by intramuscular injection, with counseling
96381	Administration of RSV monoclonal antibody, seasonal dose by intramuscular injection
G0008	Administration of influenza virus vaccine
G0009	Administration of pneumococcal vaccine
G0010	Administration of hepatitis B vaccine
M0201	Administration of pneumococcal, influenza, hepatitis B, and/or COVID-19 vaccine inside a patient's home; reported once per home per date of service

Influenza vaccine HCPCS Q-codesHCPCSCovered

Q2034	Influenza vaccine (Agriflu) — HCPCS Q-code
Q2035	Afluria® influenza vaccine — HCPCS Q-code
Q2036	Flulaval® influenza vaccine — HCPCS Q-code
Q2037	Fluvirin® influenza vaccine — HCPCS Q-code
Q2038	Fluzone® influenza vaccine — HCPCS Q-code
Q2039	Influenza virus vaccine, not otherwise specified — HCPCS Q-code

Lung cancer screening eligibility — key facts

Age rangeAdults ages 50-80 years

Smoking history>=20 pack-year history

Provider Billing, Authorization, and Documentation Requirements

Prior Authorization

Prior Authorization Required for Specific Tests

Prior authorization is required for certain tests and genetic testing to be covered as preventive services. Submit prior authorization before scheduling to avoid denials or delays.

BRCA testing requires prior authorization (see listed procedure codes in policy).
Specific procedure codes may require prior auth as noted elsewhere in this policy.

Prior Authorization

LDCT Prior Authorization

Low-dose computed tomography (LDCT) for lung cancer screening (CPT 71271; HCPCS G0296) requires prior authorization. Verify member eligibility and obtain authorization for adults meeting age and smoking-history criteria before imaging.

71271 requires prior authorization.
Covered when billed with one of the listed ICD-10 codes for adults ages 50-80 with a ≥20 pack-year smoking history, current smokers, or those who quit within 15 years.

Background and Scope

This policy documents preventive services aligned with USPSTF/ACIP guidance and describes how those recommendations are applied for coverage and billing. It specifies that preventive services are adjudicated under the Preventive Care Services benefit when appropriately billed, and it defines requirements such as using an appropriate preventive diagnosis in the primary position and following vaccine-specific coverage conditions (e.g., FDA approval and ACIP recommendation) for immunizations.

Definitions and Interpretation Notes

Modifier 33 — guidance

Modifier descriptionModifier 33 may be reported but is not used to determine preventive benefit applicability unless specifically indicated in the comments section

Use in tableTufts Health Plan considers procedures, diagnosis codes and Preventive Benefit Instructions listed in the table when determining preventive benefits

ExceptionIf comments specifically indicate Modifier 33 use, follow the comments section

Preventive Immunization Coverage Criteria — definition

Coverage ruleImmunizations not excluded by the Certificate of Coverage are considered covered if FDA-approved and explicitly recommended for routine use by ACIP in the MMWR

Implementation timing

Policy Revision History

2026-02-01publicationLatest

Most recent publication entry in the policy history (documented publication window extends through 2026-02-01).

2025-10-01revision

Added A4288 under Breastfeeding Interventions and Z80.44 under Breast Cancer Chemoprevention Counseling.

2025-08-14revision

Removed code 90631 from Immunizations.

OpenPayer

Preventive Care Services Coverage (Preventive/Screens & Immunizations)