CurrentHighmark Blueshield NenyPolicy N/A

Women's Preventive Health Services Addendum (Highmark WV 2026)

Defines covered women's preventive services, screening and counseling guidelines, contraceptive coverage and supplies (including breast pumps), screening schedules for gestational/postpartum diabetes, HIV, HPV, STIs, urinary incontinence, anxiety, breastfeeding counseling, nutritional counseling, and reimbursement process for contraception apps for Highmark West Virginia plans.

Policy Summary

PayerHighmark Blueshield Neny

PolicyWomen's Preventive Health Services Addendum (Highmark WV 2026)

Policy CodePolicy N/A

Change TypeCoding updateClarification

Effective DateN/A

Next Review DateN/A

Key ActionVerify member benefits at each visit and report routine diagnosis codes with E&M (99201-99215) for initial pregnancy determination accompanied by N91.2 and pregnancy diagnosis; ensure breast pumps have a prescription for DME coverage.

SourceLink

POLICY UPDATE CHANGES

Coding update: A4287 effective 2024-01-01 and A4288 effective 2025-10-01 for breast pump supplies.

2022 Clarified language that HIV screening is a benefit and screening recommendations for ages and pregnancy are specified.

Up to 4Wellness visits/year (women)

2Counseling sessions/year (STI/HIV)

3 yrsHPV screening interval (>=30yrs)

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A4287 2024 / A4288 2025Breast pump supply codes effective

Coverage Summary

This document is the Women's Preventive Health Services Addendum to the Highmark West Virginia Preventive Health Guidelines. It enumerates covered women's preventive services (screening, counseling, contraception and sterilization services, breastfeeding counseling and equipment, gestational/postpartum diabetes screening, HPV, HIV and STI screening and counseling, urinary incontinence and anxiety screening, nutritional counseling, and related coding and billing guidance) and aligns with the Women's Preventive Services Initiative and federal preventive coverage expectations. Grandfathered plans may opt out of these benefits; providers should verify member eligibility and benefits for each visit using eligibility and benefits transactions.

Key thresholds: Up to 4 wellness visits annually (2 with a PCP + 2 with an OB/GYN); HIV screening at least once in a lifetime for ages ≥15 with risk assessment beginning at age 13 and rescreening in pregnancy based on risk; HPV screening once every 3 years for women ≥30 with normal Pap; Postpartum diabetes rescreen at least every 3 years for a minimum of 10 years after pregnancy and postpartum testing frequency guidance (initial testing 4–6 weeks and coding frequency notes).

Thresholds

Well Woman Visit FrequencyUp to 4 wellness visits annually (2 PCP + 2 OB/GYN)

HIV screening lifetime recommendationAt least once during lifetime for ages >= 15

HPV screening intervalOnce every 3 years for women ages >= 30 with normal PAP

Postpartum diabetes rescreen intervalRescreen at least every 3 years for a minimum of 10 years after pregnancy

Postpartum diabetes frequency2 annually (coding note for postpartum testing)

Medical Necessity / Coverage Criteria

Well Woman Visits

Covered when ALL of the following are met:

ALL of the following

Well woman preventive care visits annually for adult women to obtain recommended preventive services that are age and developmentally appropriate
Up to four wellness visits annually for women: two visits with a Primary Care Physician (PCP) and two visits with an Obstetrician/Gynecologist Physician with a routine diagnosisUp to 4 visits/year
Initial visit to determine pregnancy defined as E&M procedure codes 99201-99215 when accompanied by diagnosis codes N91.2 (amenorrhea) and a pregnancy diagnosis
Report routine diagnosis codes with E&M (99201-99215) accompanied by N91.2 and pregnancy diagnosis

Coding

Breast Pump DME CodesHCPCSCovered

E0602	Manual breast pump
E0603	Electric breast pump
A4281	Breast pump supply
A4282	Breast pump supply
A4283	Breast pump supply
A4284	Breast pump supply
A4285	Breast pump supply
A4286	Breast pump supply
A4287	Breast pump supply (effective 2024-01-01)
A4288	Breast pump supply (effective 2025-10-01)

Gestational/Postpartum Diabetes Screening CodesCPTCovered

82947	Glucose; quantitative
82950	Glucose tolerance test
82951	Glucose tolerance test
82952	Glucose tolerance test (each additional)
83036	Hemoglobin; glycosylated (A1c)

Gestational Diabetes History ICD-10ICD-10Covered

Z86.32	Personal history of gestational diabetes
Z87.59	Personal history of other endocrine, nutritional and metabolic disease (used per document)

HPV Screening CodesCPTCovered

87623	HPV test
87624	HPV test
87625	HPV test

Provider Actions & Billing Rules

Documentation Required

Well woman visit diagnosis coding

Report routine diagnosis codes with an E&M code (99201-99215) for the initial visit to determine pregnancy when accompanied by diagnosis code N91.2 (amenorrhea) and a pregnancy diagnosis.

E&M: 99201-99215
Diagnosis: N91.2 (amenorrhea)
Pregnancy diagnosis (use appropriate pregnancy DX)

Prior Authorization

Breast pump prescription and DME requirement

Breast pumps are considered durable medical equipment (DME) and require a prescription to be covered. Benefit includes manual (E0602) and electric (E0603) pumps and breast pump supply HCPCS codes. Note coding updates with effective dates for supply codes A4287 and A4288.

Manual breast pump: E0602
Electric breast pump: E0603

Background & Definitions

This addendum supplements the Highmark WV Preventive Health Guidelines to list and clarify women's preventive services in alignment with the Women's Preventive Services Initiative and federal coverage expectations. It details services, coding, effective dates for updated breast pump supply codes, and timing/frequency guidance for screenings.

The document notes that grandfathered plans (plans established before March 23, 2010 that have not changed benefit structure) may opt to exclude these benefits; therefore providers must check member benefits via AVAILITY Eligibility and Benefits or ASC X12 270/271 eligibility transactions each time a member presents for service.

Term	Definition
Grandfathered plans	Health care plans established before March 23, 2010 that have not changed their benefit structure and for which certain PPACA provisions may differ or not apply; grandfathered employers may opt to cover these benefits. Providers should verify member benefits via AVAILITY Eligibility and Benefits or ASC X12 270/271 transactions each time a member presents for service.

FAQs

Frequently Asked Questions

FAQ Takeaways

Revision History

2024-01-01clarified

Supply HCPCS additions with effective dates included.

2025-10-01clarified

Supply HCPCS additions with effective dates included.

clarifiedLatest

Reaffirms screening ages and rescreening in pregnancy based on risk.

Policy Summary

PayerHighmark Blueshield Neny

PolicyWomen's Preventive Health Services Addendum (Highmark WV 2026)

Policy CodePolicy N/A

Change TypeCoding updateClarification

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Covered when ALL of the following are met:

ALL of the following

Counseling on sexually transmitted infections for all sexually active women
Up to two counseling sessions per year for women with code G0445 when accompanied by a routine diagnosisUp to 2 sessions/year
Report G0445 with routine diagnosis

HIV Counseling and Screening

Covered when ALL of the following are met:

ALL of the following

Counseling for HIV infection for all sexually active women
Up to two counseling sessions per year with codes 99401, 99402, 99403, or 99404 when accompanied by HIV counseling diagnosis codeUp to 2 sessions/year
Report 99401-99404 with HIV counseling diagnosis
HIV screening test with a routine diagnosis code
Ages 15 and older: receive a screening test for HIV at least once during their lifetime>=15: at least once in lifetime
2022 clarified language
Risk assessment and prevention education for HIV beginning at age 13>=13 age for risk assessment
Screen for HIV in all pregnant women upon initiation of prenatal care with rescreening during pregnancy based on risk factors

Breastfeeding Counseling and Supplies

Covered when ALL of the following are met:

ALL of the following

Breastfeeding counseling for women with codes 99401, 99402, or 99403 when accompanied by diagnosis Z39.1
Report 99401-99403 with Z39.1
Breastfeeding equipment (breast pumps) in conjunction with each birth; breast pumps are DME items requiring a prescription
Breast pumps are DME requiring prescription
Benefit includes manual E0602 and electric E0603 breast pumps and supplies A4281, A4282, A4283, A4284, A4285, A4286
Coding updates: A4287 effective 2024-01-01; A4288 effective 2025-10-01
Supply code effective dates

Gestational Diabetes Screening

Covered when ALL of the following are met:

ALL of the following

Screen for diabetes in pregnancy at the first prenatal visit or at weeks 24-28
Screen postpartum women with a history of gestational diabetes and no previous diagnosis of diabetes
Use CPT screening codes 82947, 82950, 82951, 82952 or 83036 when accompanied by a pregnancy diagnosis or a postpartum diagnosis with no previous diagnosis of diabetes AND with a diagnosis of gestational diabetes
Use listed CPT codes with appropriate diagnoses
ICD-10 code Z86.32 or Z87.59 used to indicate prior gestational diabetes or history

HPV Screening

Covered when ALL of the following are met:

ALL of the following

HPV screening recommended once every three years for women ages 30 and older with normal PAP cytology resultsOnce every 3 years for ages >=30 with normal PAP
Use codes 87623, 87624, or 87625 when accompanied by a routine diagnosis

Screening for Interpersonal and Domestic Violence

Covered as part of preventive exam:

ALL of the following

Screening and counseling for interpersonal and domestic violence is integral to the physical exam (well woman visit)

Postpartum Diabetes Screening

Covered when ALL of the following are met:

ALL of the following

Women with a history of gestational diabetes mellitus who are not currently pregnant and have not previously been diagnosed with type 2 diabetes mellitus should be screened
Initial testing should ideally occur within the first year postpartum and can be conducted as early as 4-6 weeks postpartum4-6 weeks to 1 year
Women with a negative initial postpartum screening test should be rescreened at least every 3 years for a minimum of 10 years after pregnancyRescreen >= every 3 years for 10 years
For women with a positive postpartum screening test, testing to confirm diagnosis is indicated regardless of initial test (e.g., OGTT, fasting plasma glucose, or A1c)
Repeat testing indicated in women screened with hemoglobin A1c in the first six months postpartum regardless of result
Coding: no pregnancy diagnosis, no diabetes diagnosis: use diagnosis code Z86.32 or Z87.59 and procedure codes 82947, 82950, 82951, 82952, 83036
Frequency: 2 annually; no age limits

Urinary Incontinence Screening

Covered when ALL of the following are met:

ALL of the following

Screening women for urinary incontinence annually as part of Well Woman VisitsAnnual
Screening integral to well woman visits
Screening should assess whether women experience urinary incontinence and whether it impacts activities and quality of life

Screening for Anxiety

Covered when ALL of the following are met:

ALL of the following

Screening for anxiety in adolescent and adult women, including those who are pregnant or postpartum
Refer women for further evaluation and treatment if indicated
Refer women for further evaluation and treatment if indicated

Nutritional Counseling

Covered when ALL of the following are met:

ALL of the following

Nutritional counseling for ages 40-60 years with normal BMI and overweight BMI for prevention of obesity in midlife women (effective 2023-01-01)Ages 40-60
Effective 2023-01-01

Contraceptive and Sterilization Services

Covered when ALL of the following are met:

ALL of the following

FDA-approved contraceptive methods, including sterilization and procedures as prescribed, are covered without cost sharing
One or more forms of contraception in each of the 18 FDA-approved methods, and any particular FDA-approved/cleared contraceptive product that provider determines medically appropriate, are covered without cost share
Provider may request an exception for use of a prescribed nonformulary contraception drug due to medical necessity via online request form; when approved the drug is available with zero-dollar cost share; no initial fail-first required
Exception process: provider-determined medical necessity; no initial fail-first required
Only FDA-approved contraception apps available for download to a cell phone are reimbursable through paper claim with a prescription; members must submit three documents to obtain reimbursement: completed paper claim form with 'contraception app purchase' in diagnosis section, receipt of payment for the app, and provider prescription for the app
Contraception app reimbursement process

Supply codes: A4281, A4282, A4283, A4284, A4285, A4286

Coding updates: A4287 effective 2024-01-01; A4288 effective 2025-10-01

Prior Authorization

Contraception nonformulary exception process

Providers may request a formulary exception for a prescribed nonformulary contraceptive drug for medical necessity via the online request form. When the exception is approved the drug is provided with a zero-dollar cost share. An initial 'fail-first' is not required; provider-determined medical necessity is sufficient.

Billing Rule

Contraception app reimbursement process

Only FDA‑approved contraception apps available for cell phone download are reimbursable through the paper claim process with a prescription. Members must submit three documents to obtain reimbursement and the claim should note 'contraception app purchase' in the diagnosis section.

Completed paper claim form with 'contraception app purchase' noted in diagnosis section
Receipt of payment for the FDA‑approved contraception app
Provider prescription for the FDA‑approved contraception app

Documentation Required

Gestational/postpartum diabetes coding and timing

Use CPT screening codes 82947, 82950, 82951, 82952, or 83036 with an accompanying pregnancy or postpartum diagnosis and indicate history of gestational diabetes when applicable using ICD‑10 codes Z86.32 or Z87.59. Initial postpartum testing can be performed as early as 4–6 weeks; rescreening and frequency guidance apply per postpartum screening recommendations.

CPT: 82947, 82950, 82951, 82952, 83036
ICD‑10 history codes: Z86.32, Z87.59
Timing: initial postpartum testing as early as 4–6 weeks; rescreen negative women at least every 3 years for a minimum of 10 years

Documentation Required

STI and HIV counseling session coding

Report STI and HIV counseling using G0445 and 99401–99404 when accompanied by the appropriate routine or HIV counseling diagnosis codes. Counseling limits apply: up to two counseling sessions per year.

G0445 (STI counseling)
99401, 99402, 99403, 99404 (HIV/preventive counseling)
Limit: up to 2 counseling sessions per year; must be accompanied by appropriate diagnosis code