Kaiser Permanente Preventive Services Coverage | OpenPayer
CurrentKaiser PermanentePolicy N/A
Preventive Care & Screening Services (Commercial)
Defines Kaiser Permanente Washington coverage, codes, and billing guidance for commercial preventive services (non‑Medicare, non‑grandfathered plans) including screening tests, counseling, and related procedures when rendered in‑network.
Policy Summary
PayerKaiser Permanente
PolicyPreventive Care & Screening Services (Commercial)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionBill preventive services with the listed procedure and diagnosis codes and add modifier 33 when applicable to indicate ACA preventive coverage; ensure documentation supports both preventive and any concurrent medical services.
No material clinical or coverage changes in this revision.
100%In‑network preventive coverage
Grade A/BUSPSTF basis
45-75Colorectal screening age
≥65Osteoporosis screening age
PayablePayable regardless of diagnosis
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Mar 10, 2026
Last revised
Coverage Criteria — Preventive Services
General Preventive Coverage
Covered when services are preventive per listed authorities and rendered in-network
In‑network preventive coverage: Preventive services designated by USPSTF Grade A/B, Bright Futures, ACIP, HRSA, state/federal law, and Kaiser WA are covered at 100% when provided by an in‑network provider
Members should check Evidence of Coverage; grandfathered/PPACA-exempt groups may differ
Coding & Billing Criteria
Billing and modifier guidance for visits combining preventive and medical services
Documentation & coding: When preventive services are provided on the same day as medical services, those services may be included in the office visit code (if minor additional work) or billed separately using appropriate preventive service codes; documentation must clearly support both services if both are billed and modifier 33 may be used when ACA preventive coverage applies
Certain procedure/diagnosis pairings listed in the code tables must be billed with modifier 33 or PT as indicated
Selected Screening Recommendations
Specific USPSTF screening recommendations called out in document
Colorectal cancer screening: USPSTF recommends screening adults aged 45-75 years (Grade B); selectively screen 76–85 years; multiple modalities listed including colonoscopy, FIT/FOBT, stool DNA, sigmoidoscopyAge 45-75
Billed with specified colorectal screening CPT/HCPCS and diagnosis codes; modifier 33 or PT as indicated
Prediabetes/Type 2 diabetes screening: USPSTF recommends screening adults aged 35-70 years with overweight or obesity and offer/referral to effective preventive interventionsAge 35-70 with overweight/obesity
Procedure codes include glucose and HbA1c (82947, 82948, 82950, 83036)
HIV screening: USPSTF recommends screening adolescents and adults aged 15-65 years and others at increased risk
Prediabetes and Type 2 Diabetes Screening
Covered when aligned with USPSTF recommendations
Prediabetes/Type 2 Diabetes Screening: USPSTF recommends screening adults aged 35–70 years who have overweight or obesity; clinicians should offer or refer patients with prediabetes to effective preventive interventionsage 35-70 + overweight/obesity
Covered preventive screenings with accompanying procedure codes
Depression and Anxiety Screening: USPSTF recommends screening for depression and anxiety in adults, including pregnant and postpartum persons; implement with systems for diagnosis, treatment, and follow-upgeneral adult population, pregnant/postpartum
Procedure codes include G0444, 96127, 96160, 96161; G0444 payable as preventive regardless of diagnosis
Vision Screening in Children: Bright Futures and USPSTF recommend vision screening in children (procedures such as 99172) and listed child vision screening CPTschildren ages 3-5 (at least once)
Procedure codes include 99172 and related pediatric vision screening codes
Pregnancy and Newborn Screening/Prophylaxis
Maternity and newborn preventive services
Asymptomatic Bacteriuria Screening in Pregnancy: USPSTF recommends screening pregnant women with urine culture at 12–16 weeks' gestation or at their first prenatal visit; payable as preventive with any pregnancy/maternity diagnosispregnant women at 12-16 weeks or first prenatal visit
Procedure codes include 87086, 87088, 81007
Hepatitis B Screening in Pregnancy: USPSTF recommends screening for HBV infection at the first prenatal visit; procedure codes 87340/87341 listed and payable as preventive with any pregnancy/maternity diagnosisfirst prenatal visit
(July 2019)
Gonococcal ocular prophylaxis for newborns: USPSTF recommends prophylactic ocular topical medication for all newborns to prevent gonococcal ophthalmia neonatorum
Aspirin for Primary Prevention
Aspirin for Primary Prevention: USPSTF recommends initiating low-dose aspirin for adults aged 50–59 years with >=10% 10-year CVD risk who are not at increased bleeding risk, have a life expectancy ≥10 years, and are willing to take aspirin for ≥10 yearsage 50-59 + >=10% 10-year CVD risk
(April 2016)
Preventive services payable as preventive
Covered as preventive when billed with listed procedure codes and appropriate preventive visit/diagnosis codes:
General preventive coverage: Services are payable as preventive regardless of medical diagnosis code when the procedure codes listed for each topic are used
Examples include depression screening (G0444), obesity screening, STI screening, and immunizations; follow diagnosis/pairing guidance in code lists
Guideline recommendations
Services recommended by USPSTF, Bright Futures, ACIP, or Women's Preventive Services Initiative:
Rh(D) testing: Rh(D) blood typing and antibody testing for all pregnant women at first prenatal visit; repeat antibody testing at 24–28 weeks for unsensitized Rh(D)-negative women
Procedure codes include 86900, 86850
Cervical cancer screening intervals: Cytology every 3 years for ages 21–29; ages 30–65: cytology every 3 years or hrHPV testing alone or co-testing every 5 years
Follow WPSI/USPSTF guidance; do not screen average-risk women more than once every 3 years
Obesity referral: Offer or refer adults with BMI ≥30 to intensive, multicomponent behavioral interventionsBMI ≥ 30
Procedure codes such as G0447, G0473 and behavior intervention CPTs listed
Cervical cancer screening
Covered when following age-based recommendations are met:
Cervical screening ages 21-29: Average-risk women aged 21–29: cervical cytology (Pap) every 3 yearsage 21-29
Cotesting with HPV not recommended for women <30; follow listed cervical cytology CPTs
Cervical screening ages 30-65: Average-risk women aged 30–65: high-risk HPV testing alone every 5 years, or cotesting (cytology + hrHPV) every 5 years, or cytology alone every 3 yearsage 30-65
Do not screen average-risk women more than once every 3 years
Gestational diabetes screening
Covered when performed in pregnancy as recommended:
Routine GDM screening: Screen asymptomatic pregnant persons for gestational diabetes at 24 weeks' gestation or after (preferably 24–28 weeks); WPSI recommends earlier screening for those with risk factors>=24 weeks gestation
Procedure codes include 82947–82952 and 83036; payable as preventive with pregnancy diagnosis
Hypertensive disorders of pregnancy screening
Covered as preventive in pregnancy:
BP monitoring in pregnancy: Screen for hypertensive disorders with blood pressure measurements throughout pregnancyongoing during pregnancy
Payable as preventive with any pregnancy/maternity diagnosis; formerly titled Preeclampsia: Screening
Behavioral interventions for high BMI (youth)
Covered when ALL of the following are met:
Age and BMI criteria: Children and adolescents aged ≥6 years with BMI ≥95th percentile for age and sex>=95th percentile
Refer to comprehensive, intensive behavioral interventions; USPSTF June 2024
Breastfeeding services and supplies
Covered services and supplies include:
Lactation counseling and services: Comprehensive lactation support (counseling, education) during antenatal, perinatal, and postpartum periodsas clinically indicated
Procedure codes include 98960–98962, 99393–99396, 99401–99404; HRSA/WPSI and USPSTF support
Breastfeeding supplies/services: Breastfeeding supplies and related services payable as preventive (e.g., S9443, E0602, E0603 where applicable)N/A
When older preventive CPTs or G0318 submitted, use diagnosis Z39.1 as indicated
Mobile contraceptive application
Covered as follows
Mobile contraceptive app coverage: A9293 (mobile application) is payable as preventive when billed with the preventive diagnosis Z30.8; FDA-approved/cleared contraceptive mobile apps are noted—if prescribed as medically indicated, members pay out of pocket and may submit for reimbursement per plan guidance
Member OOP then possible reimbursement; follow plan evidence of coverage
Breastfeeding services and supplies
Covered when billed with listed procedure and diagnosis codes
Breastfeeding services: Procedure codes 98960–98962 and preventive visit codes 99393–99396 and counseling codes 99401–99404 are listed; older CPTs (99341–99350) and G0318 are payable as preventive when billed with diagnosis Z39.1; S9443, E0602, E0603 payable as preventive regardless of diagnosis
Supports HRSA and USPSTF recommendations for lactation support
Hepatitis C screening
Covered per USPSTF recommendations
Hepatitis C screening: Procedure codes 86803 and 87521 listed; USPSTF recommends screening adults age 18–79 and persons at high risk (and one-time for those born 1945–1965)age 18–79 per USPSTF
Diagnosis codes and pregnancy encounter codes included for billing as preventive
Lung cancer screening (LDCT)
Covered per USPSTF criteria
Lung cancer LDCT eligibility: Documents both earlier USPSTF language (adults 55–80 with 30 pack-year) and updated recommendation effective 03/09/2021 (adults 50–80 with 20 pack-year); current smokers or quit within past 15 years; discontinue after 15 years abstinence or if limited life expectancypack-year and quit-time thresholds as stated
Procedure codes 71271 and G0296 listed; payable as preventive regardless of diagnosis
Preexposure prophylaxis (PrEP)
Covered consistent with USPSTF 'A' recommendation
PrEP coverage: PrEP initiation, monitoring, and related laboratory and venipuncture services are covered consistent with USPSTF A rating and CDC guidance; listed procedure and lab CPTs include 86632, G0499 and multiple infectious disease tests
Venipuncture and office visit codes for monitoring are payable as preventive regardless of medical diagnosis code where indicated
Post-pregnancy diabetes and perinatal depression screening
Covered per HRSA/WPSI and USPSTF
Screening after GDM and perinatal depression: Post-pregnancy diabetes screening using glucose codes 82947–82952 and A1C 83036 is covered for women with prior GDM; perinatal depression screening codes include 96127, 96160–96161 and G0444 (G0444 payable as preventive regardless of diagnosis)
Follow HRSA/WPSI and USPSTF guidance for timing and follow-up
Retinopathy screening for diabetes
Covered with listed CPTs for diabetic retinopathy screening
Diabetic retinopathy screening: Retinopathy screening for diabetes is listed with CPTs 92227, 92228, 92229, 92250 and extensive diabetes-related ICD-10 diagnosis codes; IRS Expanded Preventive Services Notice 2019-45 referenced
Providers should document preventive service visits using the listed CPT codes and appropriate diagnosis codes
Covered preventive services (code lists)
Covered preventive services and associated codes (as listed):
Retinopathy screening coverage: Retinopathy screening CPTs 92227–92250 are listed with extensive diabetes-related ICD-10 codes; IRS EPS Notice 2019-45 applies
A1C testing coverage: A1C testing (CPT 83036) is listed for diabetes-related diagnosis codes and preventive screening encounters
IRS EPS Notice 2019-45 referenced
INR testing coverage: INR testing CPTs 85610 and 85611 are listed for liver disease or bleeding disorder diagnosis codes
LDL testing coverage: LDL testing CPTs (83695–83722 range) are listed for heart disease-related ICD codes
Preventive service coverage
Covered when billed as commercial preventive care services and linked to the listed diagnosis codes/CPTs
Preventive billing linkage: CPTs such as 84152–84154 (PSA) and 36415 (venipuncture) are payable as preventive when associated with covered preventive services listed in this document
Venipuncture (CPT 36415) is payable as preventive when required for any covered preventive service; document linkage to the preventive service
Risk assessment age: Risk assessment for sudden cardiac applies to ages 11–21 to align with AAP/Bright Futures guidance11-21 years
Use CPTs 96160/96161 and relevant diagnosis codes
Many preventive services are covered at 100% in‑network when delivered by an in‑network provider per the ACA; members should check their Evidence of Coverage for plan‑specific details. Except for mammography, many POS and PPO plans do not cover preventive care out‑of‑network, so out‑of‑network preventive benefit levels may not apply for those plans. Non‑preventive services provided during a preventive visit may be subject to member cost shares and plan authorization requirements still apply.
The USPSTF concluded that current evidence is insufficient to determine whether screening pregnant women for iron deficiency anemia prevents adverse maternal or birth outcomes; therefore routine screening for this purpose is not supported by USPSTF evidence (September 2015).
Consistent with the USPSTF statement, the policy notes there is insufficient evidence to assess the balance of benefits and harms of screening for iron deficiency anemia in pregnant women, and the guideline does not recommend routine screening for that preventive purpose.
For average‑risk women, cervical cancer screening intervals should follow WPSI/USPSTF guidance: ages 21–29 receive cytology (Pap) every 3 years, and ages 30–65 receive either cotesting (cytology + hrHPV) every 5 years or cytology alone every 3 years. The policy explicitly states: do not screen average‑risk women more than once every 3 years.
The policy lists HCPCS A9293 — Mobile Application for contraceptive applications and notes Kaiser WA identifies FDA‑approved/cleared apps (Natural Cycles, Clue Plus). If a provider prescribes an FDA‑approved/cleared contraceptive mobile medical app as medically indicated, members will pay out of pocket and may submit for reimbursement rather than the plan directly covering the app at point of prescription.
The extracted document segments in this window do not enumerate specific explicit exclusions for the services listed elsewhere in the policy fragment.
Within the provided chunks there are no additional explicit exclusions stated for the preventive services shown in this excerpt.
No statements labeled 'not medically necessary' appear in the provided document chunks; the excerpt focuses on services designated as preventive and their billing/coding guidance.
In these fragments there are no explicit 'not medically necessary' determinations recorded; content emphasizes preventive coverage and applicable coding/diagnosis pairings.
Coding — Procedure and Diagnosis Codes
Provider Actions — Billing, Documentation, and Authorization
Billing Rule
Provider action: Billing, documentation, and authorization
When billing preventive services, follow these provider actions and coding rules to avoid denials and ensure proper benefit application.
Prior authorization: Plan authorization requirements must still be met for services that require prior authorization; check member Evidence of Coverage for plan-specific rules and out‑of‑network preventive benefit limits.
BRCA risk assessment: When submitting BRCA/Genetic risk assessment and related counseling, use the listed evaluation and counseling procedure codes (e.g., 99202–99205, 99211–99215, 99241–99245, S0265, 99417, G2212, 81212, 81215–81217, 81162–81167). Bill with diagnosis Z71.89 where indicated and ensure documentation supports genetic counseling and any subsequent testing.
Contraceptive procedures — coding note: Contraceptive method and counseling codes listed (e.g., 11976, 11981–11983, 58300–58301, 58600 series, 76830, 99383–99396, J7300–J7307, A4261–A4269, J7294–J7298, S4993, S4981, S4989) must be paired with the appropriate Z30.* diagnosis codes as specified (see list). Some contraception codes are payable as preventive regardless of medical diagnosis code; others require specific Z30.x codes — submit the correct diagnosis to ensure preventive benefit.
Injection — preventive billing: Injection and vaccine administration codes (e.g., J0739, G0012, J0750, J0751, J0799, 96372 and the listed immunization CPTs/HCPCS) are payable as preventive regardless of medical diagnosis code when submitted as part of a covered preventive service.
Background & Policy Basis
This policy aligns Kaiser Foundation Health Plan of Washington coverage with national preventive authorities including the USPSTF (Grade A/B), Bright Futures, ACIP, HRSA/WPSI, and applicable state and federal laws. It clarifies that recommended preventive services are covered at 100% in‑network when provided by an in‑network provider, lists procedure and diagnosis code mappings to support preventive billing, and provides documentation and modifier guidance (e.g., use of modifier 33 when ACA preventive coverage criteria apply). Members and providers should confirm plan details in the member's Evidence of Coverage; grandfathered and PPACA‑exempt groups may differ and plan authorization requirements still apply where indicated.
Definitions & Key Criteria
Preventive services — Services designated by USPSTF Grade A/B, Bright Futures, ACIP, HRSA, and state/federal laws considered preventive for covered populations.
DefinitionServices designated by USPSTF Grade A/B, Bright Futures, ACIP, HRSA, and state/federal laws considered preventive for covered populations.
Coverage contextCovered at 100% when provided in‑network and aligned with listed authorities (members should check Evidence of Coverage)
USPSTF: screen adults aged 35–70 years with overweight or obesity; offer/referral to preventive interventions — Prediabetes and Type 2 Diabetes screening recommendation
USPSTF recommendationScreen adults aged 35–70 years with overweight or obesity for prediabetes and type 2 diabetes; offer or refer to preventive interventions.
Revision History
2026-03-10revisionLatest
Policy text and code lists updated (document shows 'Last Revised: March 10, 2026') — multiple sections including breastfeeding services, PrEP lab guidance, and post‑pregnancy diabetes screening reference the revision.
2021-07-19guideline_effective_date
PrEP baseline and monitoring testing guidance updated to reflect USPSTF/CDC combination of baseline and monitoring tests effective 07/19/2021, as noted in PrEP section.
2021-01-01
Policy Summary
PayerKaiser Permanente
PolicyPreventive Care & Screening Services (Commercial)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateN/A
Next Review DateN/A
Key ActionBill preventive services with the listed procedure and diagnosis codes and add modifier 33 when applicable to indicate ACA preventive coverage; ensure documentation supports both preventive and any concurrent medical services.
Bright Futures notes adolescent screening; listed HIV procedure codes apply
all newborns
Prophylaxis is included in the preventive office visit coding
Prostate cancer screening coverage: PSA CPTs 84152–84154 listed with preventive exam diagnosis codes (Z00.00, Z00.01, Z12.5, Z80.42) and payable as preventive when billed appropriately
Providers should link CPTs to listed diagnosis codes for preventive payment
Preventive-service CPT billing: Routine preventive office visit and related E/M codes (e.g., 99202–99215, 99417, G2212; well visit codes 99385–99387, 99395–99397; adolescent/adult preventive codes) may be billed with modifier 33 where appropriate or with the preventive diagnosis codes (Z00.0x, Z71.89, Z76.89) as indicated. Documentation must clearly support preventive services when modifier 33 is used.
If G0444 is submitted: Payable as preventive regardless of medical diagnosis code.
Diagnosis code pairing for preventive claims: Many procedures require specific accompanying diagnosis codes to qualify as preventive (examples: venipuncture CPT 36415 — applicable to any covered preventive service requiring blood draw; breastfeeding visit codes 99341–99350 or G0318 — use Z39.1; contraceptive procedure codes — use indicated Z30.* codes). Review the procedure-to-diagnosis pairings in the preventive code lists and bill accordingly.
Required diagnosis codes for preventive billing: Some services are explicitly marked payable as preventive regardless of medical diagnosis code; others require pregnancy/maternity or Z30.* family planning codes, or other specified Z codes (e.g., hepatitis B screening in pregnancy payable with any pregnancy/maternity diagnosis). Use the exact diagnosis codes listed for each procedure group.
Breastfeeding services coding/documentation: When billing breastfeeding-related visit codes (99341–99350 or G0318) or breastfeeding counseling/education codes (98960–98962, 99393–99396, 99401–99404), include diagnosis Z39.1 (or the listed postpartum/lactation diagnosis codes) to ensure preventive benefit.
Perinatal depression coding note: If G0444 is submitted for perinatal depression screening it is payable as preventive regardless of medical diagnosis code.
Documentation & modifier guidance: When preventive and non‑preventive services are provided the same day, documentation should clearly support both services if both are billed. Apply modifier 33 only when the service is mandated as preventive by ACA or other regulation and when no other code set designates the service as preventive.
Venipuncture documentation: CPT 36415 is payable as preventive when required for any covered preventive service — document the connection to the preventive service.
PrEP and related labs: Preexposure prophylaxis (PrEP) initiation, monitoring, and associated lab/procedure codes are covered consistent with USPSTF recommendations; many PrEP-related procedure codes and venipuncture and visit codes are payable as preventive regardless of diagnosis.
No explicit prior authorization requirements specified: For the preventive CPTs and codes listed in this section, no additional prior authorization requirements are specified in these fragments. However, plan authorization rules still apply for services that otherwise require prior authorization.
No explicit denial triggers stated: The source fragments do not list explicit denial triggers for the listed preventive services — denials are most likely to result from incorrect procedure/diagnosis pairings, missing documentation, or out‑of‑network billing on plans that limit out‑of‑network preventive coverage.
Provider action — general: Providers should bill the listed procedure codes with the associated diagnosis codes indicated in the preventive code lists; follow the specific pairings to obtain preventive benefit and avoid patient cost share.
Note
Provider action: Code group examples and pairing guidance
These are the specific code groups and common code examples referenced in the provider actions above. Use these pairings when submitting preventive claims and apply the preventive diagnosis or modifier as required by the listing.
BRCA risk assessment / genetic counseling examples: 99202–99205, 99211–99215, 99241–99245, S0265, 99417, G2212; BRCA test panels 81212, 81215–81217, 81162–81167. Diagnosis: Z71.89 (genetic counseling) or as specified.
Contraception examples and diagnosis pairing: 11981–11983 (implant insertion/removal) — submit Z30.017, Z30.018, Z30.019 or appropriate Z30.*; 11976, 57170, J7304/J7306/J7307, A4261/A4266 — many are payable as preventive regardless of medical diagnosis code or with specified Z30 codes; 96372 (contraceptive injection) — submit Z30.012–Z30.019 or Z30.02 as applicable.
Injection / immunization examples: J0739, G0012, J0750, J0751, J0799, 96372 and immunization CPTs/HCPCS (90460–90474, 90620–90759, Q2035–Q2037, G0008–G0010) — payable as preventive regardless of diagnosis when part of covered preventive services.
G0444 (depression screening): G0444 is payable as preventive regardless of medical diagnosis code when submitted for depression screening.
Breastfeeding and lactation support codes: 98960–98962, 99341–99350, 99393–99396, 99401–99404, G0318. When 99341–99350 or G0318 are submitted use diagnosis Z39.1.
Venipuncture and related lab codes: CPT 36415 (venipuncture) payable as preventive when required for listed preventive services; laboratory panels and specific test CPTs (e.g., 83036 for A1C) should be billed with the preventive visit/diagnosis pairing required by the service.
PrEP initiation/monitoring and labs: PrEP procedure codes and lab codes (see detailed list in policy) are payable as preventive regardless of diagnosis code for covered members per USPSTF 'A' recommendation.
Modifier 33 usage: Use modifier 33 only when the service is an ACA-mandated preventive service and no other code designates the service as preventive; documentation must support preventive rationale.
Out-of-network and plan checks: Confirm member plan type (POS/PPO) for out‑of‑network preventive limits — many plans do not cover preventive services out‑of‑network except as specified (e.g., mammography exceptions).
Procedure codes
Glucose and HbA1c CPTs listed (e.g., 82947–82950, 83036)
USPSTF: screen general adult population including pregnant/postpartum; ensure systems for diagnosis and follow-up — Depression screening in adults
USPSTF recommendationScreen general adult population for depression, including pregnant/postpartum persons, with systems for diagnosis, treatment, and follow‑up.
Procedure codesG0444 and other brief assessment CPTs listed (e.g., 96127, 96160, 96161)
Coverage noteIf G0444 is submitted it is payable as preventive regardless of medical diagnosis code
TimingAt first prenatal visit; repeat at 24–28 weeks for unsensitized Rh(D)-negative women
Procedure codesCPTs 86900, 86850, 86901 listed
BMI ≥ 30 (offer/refer to intensive, multicomponent behavioral interventions) — Obesity screening threshold for referral
Adult obesity thresholdBMI ≥ 30
Provider actionOffer or refer to intensive, multicomponent behavioral interventions
Relevant codesG0447, G0473 and behavioral intervention codes referenced
Cervical cancer screening — WPSI recommends screening average-risk women 21–65: ages 21–29 cytology every 3 years; ages 30–65 cytology + HPV cotesting every 5 years ...
Age range and intervalsAverage‑risk women 21–65 years: ages 21–29 cytology every 3 years; ages 30–65 cytology + HPV cotesting every 5 years or cytology every 3 years
Do not overscreenDo not screen average‑risk women more than once every 3 years
High BMI in children/adolescents — USPSTF recommends clinicians provide or refer children/adolescents 3E=6 years with BMI 3E=95th percentile to comprehensive, intensive behavio...
Child/adolescent high BMI threshold>=95th percentile for age and sex
ActionProvide or refer to comprehensive, intensive behavioral interventions
Gestational diabetes screening — USPSTF and HRSA/WPSI recommend screening asymptomatic pregnant persons for gestational diabetes at or after 24 weeks' gestation (preferab...)
Timing for GDM screeningScreen asymptomatic pregnant persons at 24 weeks' gestation or after (preferably 24–28 weeks)
Earlier screeningWPSI recommends earlier screening before 24 weeks for those with diabetes risk factors
Procedure codesGlucose CPTs (82947–82952) and HbA1c (83036) listed
Lung cancer LDCT screening eligibility — USPSTF recommends annual LDCT in adults (document contains both older 55–80 with 30 pack-year and updated 50–80 with 20 pack-year criteri...)
RecommendationAnnual LDCT for lung cancer per USPSTF
Eligibility language includedDocument contains both older (55–80 with 30 pack‑year) and updated (50–80 with 20 pack‑year) criteria
Procedure codesLDCT CPTs 71271 and G0296 listed; payable as preventive regardless of diagnosis
PrEP — Preexposure prophylaxis using effective antiretroviral therapy for persons at increased risk of HIV acquisition; includes specified basel...
ServicePrEP — preexposure prophylaxis initiation and monitoring
Coverage stanceCovered consistent with USPSTF 'A' recommendation; baseline and monitoring labs listed
CodesMultiple CPTs and lab codes listed for initiation/monitoring (e.g., 86632, G0499 and infectious disease labs)
INR Testing — International Normalized Ratio (INR) testing for liver disease or bleeding disorders (CPT 85610, 85611)
INR testing descriptionInternational Normalized Ratio (INR) testing for liver disease or bleeding disorders (CPTs 85610, 85611)
ContextListed under IRS Expanded Preventive Services (EPS) Notice 2019-45 inclusion
UseIncluded with diagnosis code lists for applicable liver/bleeding disorder conditions
A1C Testing — Hemoglobin A1C testing for diabetes (CPT 83036)
A1C testing descriptionHemoglobin A1C testing for diabetes (CPT 83036)
ContextListed for diabetes screening and post‑pregnancy diabetes screening; IRS EPS Notice 2019‑45 referenced
Associated diagnosis codesZ01.01, Z13.5 and extensive diabetes-related ICD-10 codes listed