CurrentHighmark Blueshield NenyPolicy N/A

Pediatric obesity preventive services coverage

Defines covered preventive benefits, required billing codes, and laboratory testing for children aged 2–18 with BMI ≥85th percentile. Applies to Highmark BlueShield Neny members meeting the BMI criteria.

Policy Summary

PayerHighmark Blueshield Neny

PolicyPediatric obesity preventive services coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionBill pediatric preventive office visit and nutritional counseling codes and include an obesity diagnosis code (268.53 or 268.54) when billing these services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4preventive health office visits (includes annual + 3 follow-ups)

Unlimitednutritional counseling visits per year

1/yearrecommended laboratory work annually

2–18eligible pediatric age range

BMI ≥85theligibility threshold

Policy Summary

PayerHighmark Blueshield Neny

PolicyPediatric obesity preventive services coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionBill pediatric preventive office visit and nutritional counseling codes and include an obesity diagnosis code (268.53 or 268.54) when billing these services.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Eligibility and covered services

Covered when ALL of the following are met:

Member is age 2–18 years

Member has body mass index (BMI) at or above the 85th percentile for age

ALL of the following

Preventive office visits
- Annual preventive health office visit (use appropriate pediatric preventive CPT code)
- Up to three additional follow-up visits per year specifically for obesity, including a blood pressure check
Nutritional counseling
- Unlimited nutritional counseling visits per year specifically for obesity (bill with listed counseling codes)
Laboratory screening (one set per calendar year)
- Cholesterol screening (lipid panel or components) — codes: 80061, 82465, 83718, 84478, 83721
- AST (code 84450) and ALT (code 84460)
- Glycemic testing
  - Hemoglobin A1c (codes 83036 or 83037)
  - OR fasting glucose (code 82985)

ALL of the following

Use an obesity diagnosis code (268.53 or 268.54) when billing for the listed services
Exception: cholesterol screening services are eligible with any routine diagnosis code

Relevant Billing Codes and Lab Guidance

Covered CPT/HCPCS CodesCPTCovered

80061	Lipid panel
82465	Total cholesterol
83718	HDL cholesterol
84478	Triglycerides
83721	LDL cholesterol
83036	Hemoglobin A1c
82985	Fasting glucose
84450	AST (aspartate aminotransferase)
84460	ALT (alanine aminotransferase)
99381	Initial comprehensive preventive medicine, ages 0-4

1–10 of 25

1/3

Lab frequency

Lab frequencyOne set of the recommended laboratory tests (lipid panel or individual cholesterol tests, plus AST/ALT and either hemoglobin A1c OR fasting glucose) per calendar year.

A1c vs fasting glucose

A1c vs fasting glucoseEligible for either one hemoglobin A1c (CPT 83036/83037) OR one fasting glucose (CPT 82985) per calendar year.

Billing and Diagnosis Guidance for Providers

Billing Rule

Billing and Diagnosis Guidance — Provider Action

Annually, children ages 2–18 with BMI ≥ 85th percentile are eligible for covered obesity-related services. When billing, providers must include the appropriate pediatric obesity diagnosis code (see items) on claims for the covered services to avoid denials. Documentation should support BMI percentile, date of measurement, and services provided (e.g., preventive visit, nutritional counseling, labs).

Covered services: Four preventive health office visits per year (one annual preventive exam plus three follow-up visits specifically for obesity and blood pressure monitoring).
Labs: One set of recommended lab work annually — cholesterol screening, AST, ALT, and Hemoglobin A1c OR fasting glucose.
Counseling: Unlimited nutritional counseling visits per year specifically for obesity.
Required diagnosis codes: Use an obesity diagnosis code on claims for the listed services (except cholesterol screening): ICD-10: 268.53 — BMI pediatric, 85th to <95th percentile; ICD-10: 268.54 — BMI pediatric, ≥95th percentile.
Documentation expectations: Record BMI percentile, date/age at measurement, rationale for services, visit notes for counseling or follow-up, and ordered/performed lab results.
Claiming note: Include the obesity diagnosis code on the same claim line(s) for the obesity-specific visits and counseling to support medical necessity and payment.

BMI Percentile Definitions

268.53 — Pediatric BMI (85th–<95th pct)

ICD-10-CM code268.53

DefinitionBody Mass Index (BMI) Pediatric, 85th percentile to less than 95th percentile for age.

Billing requirementUse an obesity diagnosis code (268.53 or 268.54) when billing for the listed services except cholesterol screening.

Eligible age rangeApplies to children ages 2–18 with BMI at or above the 85th percentile (policy eligibility).

268.54 — Pediatric BMI (≥95th pct)

ICD-10-CM code268.54

DefinitionBody Mass Index (BMI) Pediatric, greater than or equal to 95th percentile for age.