CurrentPremera BluecrossPolicy N/A

Preventive Care

Defines coverage of preventive services required by the ACA for in-network members, including screenings, immunizations, counseling, and specified women's health services; applies to providers administering preventive care under the plan.

Policy Summary

PayerPremera Bluecross

PolicyPreventive Care

Policy CodePolicy N/A

Change TypeAnnual review — no material changes

Effective DateOct 1, 2025

Next Review DateOct 1, 2025

Key ActionObtain prior authorization through Carelon Medical for CT colonography (74263) before scheduling the service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

MultipleUSPSTF‑referenced services

45Colorectal screening start age

50-80Lung CT eligibility

~100+Listed codes

Non‑MAScope exclusion

Coverage Criteria for Preventive Services

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General Preventive Coverage

Covered when services meet one of the following evidence-based guideline categories:

Guideline sources: Services recommended with USPSTF grade A or B; ACIP immunization recommendations; HRSA-supported comprehensive guidelines including Bright Futures; and services meeting Washington state preventive care law.

Services must be provided per the specific guideline to be covered as preventive.

Screening vs Surveillance / Follow-up

Determines preventive benefit status for index and subsequent procedures

Initial screening: Screening exams are for asymptomatic individuals and covered when matching guideline age/risk criteria.

If a screening test is positive, the immediate follow-up to evaluate the positive screen may remain preventive (e.g., colonoscopy after a positive stool-based test); however, subsequent procedures performed as surveillance (e.g., ongoing colonoscopy after high‑risk polyp removal) are not preventive and are covered under the medical benefit subject to member cost share.

Colorectal Cancer Screening

Covered modalities and billing requirements

Average-risk screening: Screening for individuals aged 45–75 using fecal occult blood testing, fecal immunochemical test (FIT), FIT‑DNA (Cologuard), flexible sigmoidoscopy, or colonoscopy; CT colonography and barium enema are covered as colorectal imaging options.Begin age 45

When stool‑based tests, sigmoidoscopy, or CT colonography are positive, follow‑up colonoscopy is covered as preventive when billed with modifier 33. Colonoscopy performed for diagnostic, therapeutic, or surveillance indications is not preventive and is subject to member cost share.

Lung Cancer Screening

Covered when ALL criteria met

Eligibility: Annual low‑dose computed tomography (LDCT) screening is covered for individuals aged 50–80 years with a 20 pack‑year smoking history who currently smoke or quit within the past 15 years.20 pack‑year; quit <15 years; age 50–80

Screening should be discontinued when an individual has not smoked for 15 years or has a health problem that substantially limits life expectancy or the ability to undergo curative lung surgery.

Cervical cancer screening

Covered when consistent with USPSTF recommendations

Cervical cancer screening: Screening is covered according to USPSTF: women aged 21–29 years — cervical cytology (Pap) every 3 years; women aged 30–65 years — options include cytology every 3 years, high‑risk HPV testing alone every 5 years, or hrHPV testing plus cytology (cotesting) every 5 years.age‑based

Use the cervical cancer screening and HPV testing CPT/HCPCS codes listed in the coding section when billing preventive services.

Osteoporosis screening

Covered when consistent with guideline age/risk recommendations

Osteoporosis screening: Screening for osteoporosis with bone density testing is covered for women aged 65 years and older and for younger women at increased risk of fracture.age/risk‑based

Use listed bone density procedure codes when billing preventive osteoporosis screening.

Newborn and pediatric screening

Covered for newborns/children per Bright Futures and USPSTF

Newborn and pediatric screenings recommended by Bright Futures and USPSTF (examples: newborn metabolic screens such as PKU, bilirubin as recommended, newborn hearing, developmental/autism screening at recommended ages, lead screening, vision) are covered per the recommended periodicity.age‑based

Refer to the newborn and pediatric code group when billing; some newborn screens (e.g., bilirubin) may be included in the delivery or hospital charge and not separately reimbursable.

STI screening and counseling

Covered when USPSTF recommends or HRSA requires

Sexually transmitted infection screening and counseling: Screening and counseling for STIs (including chlamydia, gonorrhea, syphilis) and related preventive counseling are covered for populations identified by USPSTF recommendations and for pregnant individuals as specified by HRSA guidance.risk/pregnancy‑based

Some STI services require being billed with a pregnancy diagnosis or specific diagnosis linkage for correct preventive benefit adjudication; see coding and billing notes.

General coverage stance and applicability

Policy statements and coverage decisions reflect incorporation of national guideline changes (e.g., USPSTF) and are subject to member benefit plan limits.

Policy applicability: Coverage decisions apply when services meet guideline‑based criteria and when the member benefit plan permits coverage; providers should verify member benefits and plan‑specific limits prior to service delivery.

Preventive services must be provided by an in‑network provider to be covered without member cost share; this policy does not apply to Medicare Advantage. Coding updates and historical changes are documented in the policy history.

A colonoscopy performed for diagnostic, therapeutic, or surveillance indications is excluded from the preventive benefit. Such colonoscopies are covered under the medical benefit and are subject to applicable member cost‑sharing (deductible, coinsurance, or copayment). Providers should bill these services as medical (not preventive) when the procedure is performed for symptoms, treatment, or ongoing surveillance.

Services and procedures that are considered inclusive to the wellness (preventive) exam or office visit are not reimbursed separately. When a screening or procedure is part of the comprehensive preventive evaluation and management visit (for example the elements described by AAP Bright Futures or the listed wellness E&M CPTs), separate billing for those included services may be denied.

This medical policy does not apply to Medicare Advantage. Coverage determinations remain subject to the limits and conditions of the member's specific benefit plan; providers and members should consult the member benefit booklet or contact customer service for plan‑specific applicability and any benefit limitations.

Coding and Code Tables

Covered CPT Codes (examples)CPTCovered

76706

Adult aortic aneurysm screening ultrasound

Cholesterol and lipid screeningCPTCovered

80061	Lipid panel
82465	Cholesterol test
83700	Triglycerides

Colorectal cancer screeningmixedCovered

0464U	FIT-DNA (Cologuard)
81528	FIT-DNA
82270	Fecal occult blood
45330	Sigmoidoscopy
45378	Colonoscopy
88305	Colonoscopy pathology
74263	CT colonography

Lung cancer screeningCPTCovered

71271	Low-dose CT for lung cancer screening
G0296	LDCT lung cancer screening

HIV screeningCPT/HCPCSCovered

87537	HIV test
87538	HIV test
S3645	HIV testing

Tobacco use counselingCPTCovered

99406	Tobacco counseling
99407	Tobacco counseling intensive

Pregnancy-related anemia screeningCPTCovered

85013	Hematocrit
85014	Hematocrit

Adult preventive counseling and infectious disease screeningCPTCovered

G0445	Sexually transmitted disease counseling
99401	Preventive counseling (example code listed for STD counseling)
99402	Preventive counseling
99403	Preventive counseling
99404	Preventive counseling
99411	Group counseling
99412	Group counseling
86592	Syphilis test
86593	Syphilis test
86780	Syphilis test (Treponema)

1–10 of 15

1/2

Women's healthcare preventive services and contraceptivesmixedCovered

85013	Hematocrit
85014	Hemoglobin
85018	Hematocrit automated
85025	Blood count
85027	Complete blood count
81000	Urinalysis
81003	Urinalysis complete
81007	Urinalysis automated
87081	Urine culture
87084	Bacteriuria culture

1–10 of 26

1/3

Pregnancy-related and genetic testingmixedCovered

86762	Rubella serology
86592	Syphilis test
81162	BRCA1/2 sequencing
81163	BRCA analysis
81165	BRCA testing
81166	BRCA testing
81167	BRCA testing

Cervical cancer screening and HPV testingmixedCovered

88141	Cytopathology Pap smear
88142	Cytopathology Pap smear
88143	Cytopathology Pap smear
88147	Cytopathology Pap smear
88148	Cytopathology Pap smear
88150	Cytopathology Pap smear
88152	Cytopathology Pap smear
88153	Cytopathology Pap smear
88155	Cytopathology Pap smear
88164	Cytopathology Pap smear

1–10 of 26

1/3

Newborn and pediatric screeningmixedCovered

76977	Bone density (ultrasound)
77080	Bone density
77081	Bone density
77085	Bone density
G0130	Bone density
96110	Developmental screening
96127	Brief emotional/behavioral assessment
60451	Autism screening (listed)
92551	Hearing screening
92552	Hearing screening

1–10 of 19

1/2

Wellness preventive examinations (E&M) for all agesCPTCovered

59425	Antepartum care
59426	Antepartum care
59430	Postpartum care
99381	Initial comprehensive preventive visit (new patient, infant)
99382	Initial comprehensive preventive visit
99383	Initial comprehensive preventive visit
99384	Initial comprehensive preventive visit
99385	Initial comprehensive preventive visit
99386	Initial comprehensive preventive visit
99387	Initial comprehensive preventive visit

1–10 of 22

1/3

Historical coding additionsCPT

81165

CPT code added

Various CPT/HCPCS historically added or updatedmixed

90832	Depression screening related CPT added
90834	Depression screening related CPT added
90837	Depression screening related CPT added
90847	Depression screening related CPT added
90853	Depression screening related CPT added
77061	Breast cancer screening CPT added
77062	Breast cancer screening CPT added
G0279	Breast cancer screening HCPCS added
87810	Coding correction for test code
71271	New CPT added

1–10 of 29

1/3

ICD-10-CM and HCPCS codes added/updatedmixed

Z29.81	ICD-10-CM code added to HIV Screen/PrEP section
E66.01	Obesity ICD-10-CM added
E66.9	Obesity ICD-10-CM added
G0473	HCPCS added to obesity screening
Z30.8	ICD-10-CM added to birth control app portion
Z13.220	Dx code added to lipid panel recommendation
Z00.110	Updated Dx code under Depression and anxiety screening
Z00.111	Updated Dx code under Depression and anxiety screening

AAA screening age and smoking status

Target populationMen aged 65 to 75 years

Smoking history requirementHave ever smoked (ever-smokers)

Service exampleOne-time abdominal aortic aneurysm screening ultrasound (CPT 76706)

Colorectal screening start age

Recommended start age (average risk)Begin colorectal cancer screening at age 45

Covered modalitiesFIT, FOBT, FIT‑DNA (e.g., 0464U/81528), sigmoidoscopy, colonoscopy, CT colonography

Follow-up colonoscopy billing noteFollow-up colonoscopy after a positive non-colonoscopy screen is covered as preventive when billed with modifier 33

Lung cancer screening eligibility

Age rangeAdults aged 50 to 80 years

Smoking exposure20 pack‑year smoking history

Tobacco statusCurrent smokers or those who quit within the past 15 years

Cervical cancer screening ages

Ages 21–29Cervical cytology (Pap) every 3 years

Ages 30–65 — option 1Cervical cytology (Pap) every 3 years

Ages 30–65 — option 2High‑risk HPV testing alone every 5 years or cotesting (hrHPV + cytology) every 5 years

Osteoporosis screening age

Primary recommendationWomen aged 65 years and older

Younger womenYounger women at high fracture risk may be screened earlier per guideline criteria

Typical testingBone density testing (e.g., CPT 77080, 77081, 77085, G0130)

Prostate cancer shared decision-making age range

Recommended age range for shared decision-makingMen aged 55 to 69 years

Discussion topicDiscuss potential benefits and harms of PSA‑based screening

Billing noteReimbursement for counseling may be included in E&M visit and not separately reimbursable in some cases

Colorectal cancer screening age (historical update)

Previous start ageHistorically began at age 50 or 55 (varied by earlier guidance)

Updated start ageUSPSTF age threshold changed to begin screening at age 45

Effective update dateDocument reflects change effective 01/01/22

Lung cancer screening age/pack-year (historical update)

Previous criteriaAge 55 and 30 pack‑year history (earlier guidance)

Updated criteriaAge lowered to 50 and pack‑year lowered to 20 per USPSTF update

ContextChange incorporated into policy during 2021–2022 coding/criteria updates

Provider Actions, Prior Authorization, and Billing Notes

Billing Rule

Bundled services not separately reimbursable

Screenings and procedures that are considered inclusive to the wellness exam or office visit are not reimbursed separately from the office visit. Providers should not bill separately for services bundled into the preventive E&M visit.

Wellness/ preventive E&M visit CPT codes (e.g., 99381-99397, 99461, 99460) include screenings and procedures that are integral to the visit and are not separately reimbursable.
If a service is separately payable by policy language (e.g., certain vaccines or lab tests), bill per guidance; otherwise, do not submit separate reimbursement claims for items included in the wellness exam.

Billing Rule

Required diagnosis linkage and billing notes

Certain services must be billed with specific diagnosis codes or linkages to ensure correct benefit classification (preventive vs. diagnostic) and appropriate payment. Verify diagnosis coding and attach required modifiers where applicable.

Screening colonoscopy billed as preventive must include an appropriate screening diagnosis (e.g., Z12.10, Z12.11, Z12.12) and when applicable, bill the follow-up colonoscopy with modifier 33 to indicate a preventive service.
Some tests for pregnancy-related care or women’s healthcare require being billed with pregnancy diagnosis codes (e.g., Rubella screening billed with pregnancy Dx as applicable) to trigger the correct coverage.
When a stool-based test, sigmoidoscopy, or CT colonography is positive and a follow-up colonoscopy is performed, ensure proper diagnosis linkage and modifier use to reflect preventive follow-up status per policy rules.

Prior Authorization

PrEP prior authorization

Pre-exposure prophylaxis (PrEP) services, including counseling visits, required laboratory testing, and PrEP medication acquisition, require authorization and medical necessity review as specified by the referenced HIV policy.

PrEP-related office visits, counseling, pregnancy testing, STI screening, and HIV testing as part of PrEP initiation should follow the referenced HIV policy for prior authorization and coverage criteria.
Certain PrEP medications or long-acting injectable cabotegravir may require prior authorization through Carelon Medical Benefits Management as outlined in the HIV policy.

Documentation Required

Confirm member benefits

Providers should consult the member benefit booklet or contact customer service to confirm coverage, applicable limits, and any plan-specific prior authorization requirements before billing.

Coverage is subject to the limits and conditions of the member's benefit plan; verification of eligibility and benefit details is required to avoid denials.
If a service appears excluded under the member's plan, obtain prior authorization or plan confirmation before performing the service when possible.

Revision History and Document Dates

2019-09-19annual_review

Annual review approved; coding update added CPT 81165 and other coding edits noted in Nov 2019 and Jan 2020 entries.

2020-04-01interim_review

Interim review approved clarifying screening colonoscopy ages and adding FIT-DNA information and coding updates in 2020.

2021-06-01coding_update

Updated lung cancer screening age range and pack‑year criteria per USPSTF (age lowered from 55 to 50; pack‑years from 30 to 20) and added CPT 71271.

2022-01-01coding_update

Coding update changed colorectal cancer screening age criterion from 50 to 45 effective 01/01/22.

2022-07-01interim_review

Interim review updated PrEP coverage to include Apretude (HCPCS J0739) and referenced related medical policy 5.01.588.

2023-09-01annual_review

Annual review approved with coding and guideline updates through 2023, including additions to HIV screening and depression screening guidance; no changes to policy statements noted in 09/01/24 entry leading into 2023–2024 updates.

2024-11-01coding_update

Added CPT 0502U to HPV testing and CPT 0464U to colorectal screening (Cologuard Plus); other coding additions made effective 11/01/24 and early 2025 coding updates followed.

2025-06-01coding_update

Multiple coding updates in 2025 including replacement of CPT 96040 with 96041 and addition of CPT 77085 to osteoporosis screening; minor link and duplicate‑code fixes were made through June–July 2025.

2025-10-01annual_reviewLatest

Annual review approved September 22, 2025; minor edits made with guideline statements otherwise unchanged and several ICD‑10‑CM codes added to the HPV testing section.

OpenPayer

Preventive Care

Coverage Criteria for Preventive Services

Coding and Code Tables

Provider Actions, Prior Authorization, and Billing Notes

Background and Guideline Basis

Definitions and Screening Options

Revision History and Document Dates