Women's Preventive Health Services Addendum (West Virginia)
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Defines covered women's preventive services, screening, counseling, and contraceptive benefits for Highmark West Virginia members; applies to providers delivering well-woman, prenatal/postpartum, and contraceptive care under the payer's preventive health guidelines.
No material clinical or coverage changes in this revision.
Coverage Criteria — Women's Preventive Services
Well-woman visits
Covered preventive visits and scope
Initial visit to determine pregnancy defined by E&M procedure codes 99201-99215 when accompanied by appropriate diagnosis codes (e.g., amenorrhea and pregnancy diagnosis).
HIV screening and counseling
Screening and counseling coverage
Use counseling codes 99401-99404 and screening tests with routine diagnosis codes as described in policy.
Breastfeeding counseling and supplies
Counseling and DME coverage
Breast pumps (manual E0602 and electric E0603) and supplies (A4281–A4286; A4287 effective 1/1/2024; A4288 effective 10/1/2025) are covered as durable medical equipment and require a prescription.
Gestational and postpartum diabetes screening
Timing and coding conditions for diabetes screening in pregnancy and postpartum
Use glucose test procedure codes 82947, 82950, 82951, 82952 or 83036 when accompanied by a pregnancy diagnosis.
When no pregnancy and no prior diabetes diagnosis, code with Z86.32 or Z87.59 plus procedure codes 82947, 82950, 82951, 82952, or 83036; policy notes frequency as 2 annually and rescreen interval of at least every 3 years for 10 years.
Urinary incontinence and anxiety screening
Annual screening recommendations
Urinary incontinence is defined as involuntary leakage of urine (e.g., with coughing or sneezing).
Recommendation sourced from the Women's Preventive Services Initiative as noted in the addendum.
Contraceptive methods coverage
Coverage stance for contraceptives
Providers may request an exception for prescribed nonformulary contraceptive drugs via the online request form for medical necessity; an initial 'Fail First' is not required when medical necessity is documented. Only FDA‑approved contraception apps are reimbursable and require a paper claim submission with receipt and provider prescription.
Coverage of non‑FDA‑approved contraception apps is not described in this addendum. Only FDA‑approved contraception apps are eligible for reimbursement, and they must be submitted via the paper claim process. Members must provide three items for reimbursement: (1) the completed paper medical claim form with "contraception app purchase" entered in the diagnosis section, (2) the receipt of payment for the FDA‑approved contraception app, and (3) a provider prescription for the FDA‑approved contraception app. Providers may request an exception for prescribed nonformulary contraceptive drugs due to medical necessity using the online formulary exception request; when approved the prescribed drug will be made available with zero‑dollar cost share. An initial "Fail First" is not required for contraceptive formulary exceptions when medical necessity is documented.
Coding — Procedure and Diagnosis Codes
| 99201-99215 | E&M procedure codes for initial visit to determine pregnancy when accompanied by amenorrhea and pregnancy diagnosis |
| G0445 | STI counseling (up to two sessions per year) when accompanied by a routine diagnosis |
| 99401, 99402, 99403, 99404 | HIV counseling codes when accompanied by HIV counseling diagnosis code |
| Z86.32, Z87.59 | History of gestational diabetes/related diagnosis codes used when no pregnancy diagnosis and no prior diabetes diagnosis |
Provider Actions — Authorization, Documentation, and Billing
Contraceptive formulary exception process
FDA-approved contraceptive methods are covered without cost sharing. Providers may request an exception for prescribed non-formulary contraceptive drugs for medical necessity by completing the online pharmacy exception form: https://providers.highmark.com/resources-and-education/forms/pharmacy-prior-authorization-forms
- Exception requests do NOT require an initial fail‑first or step-therapy attempt — provider-determined medical necessity alone is sufficient.
- If approved, the drug is available to the member with a zero-dollar cost share.
Fail-first not required for contraceptive exception
An initial 'Fail First' (step-therapy) is not required for contraceptive formulary exception requests. Providers may note prior treatment failures on the exception form, but documenting a failed formulary trial is optional and not a condition of approval.
Contraception app reimbursement documentation
Only FDA-approved contraception apps that are downloadable to a mobile device are reimbursable and require a prescription plus documentation submitted by the member via paper claim.
- Member must submit all three documents: 1) Completed Highmark Paper Medical Claim Form with "contraception app purchase" written in the Diagnosis/Nature of Illness or Injury field (https://www.highmarkbcbs.com/redesign/pdfs/mhs/Medical_Claim_Form.pdf).
- 2) Receipt showing payment for the FDA‑approved contraception app.
- 3) Provider prescription for the FDA‑approved contraception app.
- Reimbursement is processed through the paper claim process only.
Coding-linked documentation
Link provider billing and clinical documentation to applicable coding and claim fields to avoid denials. For contraception apps, enter the phrase "contraception app purchase" in the Diagnosis or Nature of Illness or Injury field on the paper claim form; include the receipt and the prescription as supporting documentation.
- Ensure the claim includes the provider prescription and that the member's receipt clearly identifies the app purchase and amount paid.
- For contraceptive drug exceptions, include clinical rationale and any relevant diagnosis codes on the online exception form to support medical necessity.
Potential denial if exception or documentation not provided
Failure to provide the required exception approval or supporting documentation (prescription, receipt, completed paper claim with the required diagnosis text) may result in denial of reimbursement or cost sharing for the service/product.
- For app reimbursement, missing any of the three required documents will delay or deny payment.
- For formulary exceptions, incomplete medical-necessity rationale or missing required information on the online form may delay review or result in denial.
Background
This addendum summarizes Highmark West Virginia's covered women's preventive services, aligning benefits to age, pregnancy status, and visit type. It confirms coverage for FDA‑approved contraceptive methods (including sterilization and procedures) across the 18 FDA‑recognized method categories without cost sharing when medically appropriate, and describes the exception process for prescribed nonformulary contraceptive drugs. It also explains reimbursement requirements specific to FDA‑approved contraception apps and provides instructions for provider and member documentation needed to obtain reimbursement.
Definitions
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