Currentsierra health and lifePolicy MP.016.58

Preventive Care Services – Commercial and Individual Exchange Medical Policy(PDF) PDF Opens in new windowopens in a new tab

Defines UnitedHealthcare's preventive care services benefit for commercial and individual exchange plans, including USPSTF/ACIP/HRSA-recommended services, member cost-sharing rules, covered breastfeeding equipment, colonoscopy preventive vs medical benefit distinctions, coverage limitations/exclusions, FAQ clarifications, and extensive applicable CPT/HCPCS/ICD-10 code listings and billing instructions in part 1 of the policy.

Policy Summary

Payersierra health and life

PolicyPreventive Care Services – Commercial and Individual Exchange Medical Policy(PDF) PDF Opens in new windowopens in a new tab

Policy CodePolicy MP.016.58

Change TypeCodes and preventive service updates (04/01/2026)

Effective DateApr 1, 2026

Next Review Date

Key ActionDocument whether the service is preventive versus diagnostic and include appropriate screening diagnosis codes per the policy's provider actions.

SourceLink

POLICY UPDATE CHANGES

04/01/2026 Summary of Changes: Applicable Codes; Preventive Care Services; Cervical Cancer Screening; Added ICD-10 d...

Added ICD-10 diagnosis codes Z01.42, Z12.72, and Z12.79 (04/01/2026).

Osteoporosis screening service description revised to remove June 2018 USPSTF 'B' rating and add Jan. 2025 USPSTF 'B' rating specifying screening for women 65+ and postmenopausal women <65 at increased risk.

Applied summary of changes to applicable codes, preventive care services, and cervical cancer screening (04/01/2026).

USPSTF A/BReferenced Recommendation Ratings

45-75Colonoscopy preventive age range

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.

E0603, A4287Breastfeeding equipment codes (examples)

5BRCA Lab Procedure Codes listed

PA_may_applyPrior authorization risk for some services

2026-04-01Last revision date

Coverage Summary

Policy implements PPACA preventive services coverage for UnitedHealthcare Commercial and Individual Exchange plans and aligns coverage with USPSTF, ACIP, and HRSA recommendations. Non-grandfathered network preventive services are covered with no member cost-sharing; out-of-network or grandfathered plan rules may allow cost sharing — refer to the member-specific benefit plan. The policy clarifies the preventive vs diagnostic distinction and billing expectations and points users to the Applicable Codes section for detailed CPT/HCPCS/ICD-10 lists and coding instructions.

Key thresholds (policy thresholds row)

Colonoscopy Age Range45-75 years (coverage ends on 76th birthday)

Diabetes screening ageAdults aged 35-70 years (coverage ends on 71st birthday); requires screening diagnosis plus overweight/obesity code; preventive benefit not applied if diabetes diagnosis present

Cholesterol screening ageAdults aged 40-75 years (coverage ends on 76th birthday); listed lipid panel procedure codes and ASCVD risk codes

Fecal DNA frequencyFecal DNA (0464U, 81528) limited to once every 3 years; age limits 45-75

G0446/G0445 frequency limitsG0446 (behavioral counseling for healthy diet/physical activity) limited to once per year; G0445 (STI behavioral counseling) limited to twice per year

LDCT pack-year and age limitsLDCT (71271) limited to annual screening for ages 50-80 (ends on 81st birthday) with ≥20 pack-year history and current smoker or quit within past 15 years; limited to one per year

E0603 one-per-birth limitPersonal-use electric breast pump (E0603) limited to one pump per birth (one pump if multiple infants); E0603/A4281-A4287 require listed diagnosis codes when billed

Medical-Necessity & Preventive Criteria

General Indications for Preventive Coverage

General indications — ALL: Preventive services are covered without member cost-sharing for non-grandfathered plans when provided by a network provider and when the service meets USPSTF, ACIP, or HRSA recommendations as specified in this policy. Preventive services are considered when performed on asymptomatic individuals within recommended age and interval guidelines.

Service is provided to a member of the population specified by the applicable recommendation (e.g., USPSTF A/B grade, ACIP routine immunization schedule, HRSA women's preventive services, Bright Futures pediatric recommendations).

Service is provided by a network provider (non-network services may be subject to member cost-sharing unless the member's plan document states otherwise).

Service is billed using the correct preventive service CPT/HCPCS/ICD-10 coding as specified in the relevant rows of this policy.

Service is not excluded under Coverage Limitations and Exclusions (see policy exclusions: vocational/school/travel/employment requirements, investigational services, non-covered breastfeeding items, etc.).

Applicable Codes (grouped)

Covered Breastfeeding Equipment (HCPCS)HCPCSCovered

E0603	Personal-use electric breast pump
A4287	Breastmilk storage bags
S3645	Breast pump supplies (example)
A4264	Breast pump single-use part (example)

Colorectal Cancer Screening (mixed)mixedCovered

G0121	Colorectal cancer screening; colonoscopy
G0105	Colorectal cancer screening; high risk, colonoscopy
G0106	Screening flexible sigmoidoscopy
G0464	Outpatient hospital/ambulatory surgery facility facility fee for screening colonoscopy
G0476	Screening colonoscopy, non-facility
G0472	Colorectal cancer screening furnished by a physician
G0432	Prostate cancer screening PSA

Applicable Preventive Screening Procedure Codes (examples included in part 1)CPTCovered

45378	Diagnostic colonoscopy, flexible; with biopsy
45380	Colonoscopy with removal of tumor, polyp
45381	Colonoscopy with directed submucosal injection
44388	Colonoscopy, flexible; with ablation
44389	Colonoscopy, flexible; with transendoscopic stent
44392	Colonoscopy, flexible; with removal of tumor
44394	Colonoscopy with polypectomy
45384	Colonoscopy, flexible; with mucosal resection
45385	Colonoscopy, flexible; with submucosal injection
45388	Colonoscopy with dilation

1–10 of 11

1/2

Diagnosis Codes (screening / pregnancy examples)ICD-10

Z00.121	Encounter for routine child health supervision with abnormal findings
Z00.129	Encounter for routine child health supervision without abnormal findings
Z11.3	Encounter for screening for infections with a predominantly sexual mode of transmission
Z11.4	Encounter for screening for viral diseases
Z11.2	Encounter for screening for syphilis
Z13.820	Encounter for screening for COVID-19
Z20.2	Contact with and (suspected) exposure to COVID-19
Z20.6	Contact with and (suspected) exposure to HIV
Z00.121	Wellness exam - see wellness examinations row
O91.011	Infection of nipple associated with childbirth

1–10 of 13

1/2

Evaluation and Management (Office Visits) CPTs / Preventive Visit CodesCPTCovered

99381	Initial comprehensive preventive visit; infant
99382	Initial comprehensive preventive visit; early childhood
99383	Initial comprehensive preventive visit; late childhood
99384	Initial comprehensive preventive visit; adolescent
99391	Periodic comprehensive preventive visit; infant
99392	Periodic comprehensive preventive visit; early childhood
99393	Periodic comprehensive preventive visit; late childhood
99394	Periodic comprehensive preventive visit; adolescent
99078	Physician educational/behavioral intervention
G0008	Administration of influenza vaccine (inpatient)

BRCA Laboratory Screening Procedure Codes (consolidated)CPTCovered

81211	BRCA1, BRCA2, full sequence analysis (example consolidated)
0502U	BRCA related genomic testing (example)
G0475	Genetic screening for BRCA - payer-specific code

Diabetes Screening and Blood Draw (CPT/HCPCS)mixedCovered

83020	Hemoglobin; glycosylated (A1C)
83021	Hemoglobin; glycated
83030	Hemoglobin A1c
82947	Glucose; quantitative, blood glucose
36415	Collection of venous blood by venipuncture (example)
99000	Handling code (example)
Z72.51	Tobacco use counseling
R73.01	Impaired fasting glucose

Mammography (CPT/HCPCS)mixedCovered

77080	Diagnostic mammography, including CAD when performed
77081	Breast MRI (example)
77082	Breast tomosynthesis (example)
G0202	Screening mammography film/screen

Cervical Cancer / HPV Testing (CPT/HCPCS)mixedCovered

87624	Human papillomavirus (HPV) DNA, high-risk types, amplified probe technique
87625	HPV genotypes 16 and 18
87626	HPV genotyping, other
87490	Infectious agent detection by nucleic acid (HPV)
87491	Infectious agent detection by nucleic acid; high-risk HPV
87492	Infectious agent detection by nucleic acid; low-risk HPV
87494	HPV testing
87801	Influenza antigen detection (example)
G0472	Cervical cancer screening

Colorectal Screening - Colonoscopy/Sigmoidoscopy and relatedCPTCovered

45378	Colonoscopy, flexible; diagnostic with biopsy
45380	Colonoscopy with removal of tumor, polyp
45381	Colonoscopy with submucosal injection
44388	Colonoscopy with ablation
44389	Colonoscopy with stent
44392	Colonoscopy with excision
44394	Polypectomy
45384	Endoscopic mucosal resection (EMR)
44388	(consolidated duplicates removed)

Fecal Testing (FIT/FOBT) and Stool DNAHCPCSCovered

G0464	Fecal occult blood test screening (example)
82270	Fecal occult blood; qualitative
82274	Fecal occult blood by immunoassay
87328	Fecal occult blood test (example)
87810	Infectious agent antigen detection
87389	Stool DNA test (example)
87390	Stool DNA test, expanded
87391	Stool DNA test, other
87806	Clostridium difficile antigen

Breastfeeding Equipment & Supplies (HCPCS/ICD-10)mixedCovered

E0603	Personal-use electric breast pump (covered; limited to one per birth)
S0610	Breast pump rental (example)
S0612	Breast pump supply kit
S0613	Breast pump replacement parts
O91.011	Infection of nipple associated with childbirth (ICD-10)
B37.89	Other candidiasis of skin and mucous membrane (ICD-10)

Vaccines — Preventive Vaccine Codes (CPT/HCPCS)mixedCovered

90620	Diphtheria, tetanus toxoids and acellular pertussis vaccine
90714	Pneumococcal vaccine, polyvalent
90633	Hepatitis A vaccine, pediatric or adolescent
90686	Influenza virus vaccine, quadrivalent
90739	Influenza nasal spray
90696	Rotavirus vaccine
Q2034	HPV vaccine
G0008	Administration of influenza vaccine in the home
90460	Immunization administration (multiple)

Extensive ICD-10 code list (Instructions for Use section)ICD-10

Z82.62	Family history of BRCA1 and BRCA2
E66.01	Morbid (severe) obesity due to excess calories
R73.01	Impaired fasting glucose
Z86.32	Personal history of cervical cancer
Z20.6	Contact with and (suspected) exposure to HIV
I70.0	Atherosclerosis of aorta
I70.1	Atherosclerosis of renal artery
E10.11	Type 1 diabetes with ketoacidosis
E11.00	Type 2 diabetes mellitus without complications
O26.00	Pregnancy screening code (example)

1–10 of 11

1/2

Provider Actions & Billing Rules

Prior Authorization

Prior authorization may be required

Prior authorization may be required for certain preventive services. Examples that frequently require prior authorization include BRCA laboratory screening (CPT 81162–81166), CT colonography (74263), low-dose CT lung cancer screening (71271), and certain PrEP injectable agents (J0739).

Prior authorization may be required for BRCA lab screening (procedure codes 81162–81166).
Prior authorization may be required for CT colonography (74263).
Prior authorization may be required for LDCT lung cancer screening (71271) depending on plan.
Prior authorization may apply for certain PrEP agents (e.g., J0739).

Documentation Required

Required documentation and diagnosis coding

Document the clinical purpose and required diagnoses to support preventive benefit application. Key documentation actions: note whether service is preventive versus diagnostic; document a positive familial risk assessment and that genetic counseling occurred prior to BRCA testing (use Z15.01/Z15.02 or Z80.*/Z85.* as appropriate); include a pregnancy diagnosis code when billing diabetes-in-pregnancy screening; include required diagnosis codes for diabetes screening (one of Z00.00, Z00.01, or Z13.1 plus an overweight code such as E66.* or Z68.*); and when billing Code Group 2 contraceptive procedures (IUDs/implants/injections) include one of the Z30.* contraceptive management diagnosis codes.

Background & References

Scope summary: Implements PPACA preventive services requirements for UnitedHealthcare Commercial and Individual Exchange plans and aligns coverage to USPSTF (A/B), ACIP (routine immunizations), and HRSA (women’s preventive services/Bright Futures) guidance. Covered services include evidence‑based preventive screenings, immunizations, HRSA‑recommended women’s services, BRCA risk assessment and selective BRCA lab screening (with counseling and PA requirements), colorectal and other cancer screenings, behavioral counseling, and HRSA breastfeeding supports. Exclusions and limits include travel-specific vaccines, items not listed under Covered Breastfeeding Equipment, services judged investigational or not medically necessary, and situations where a listed disease diagnosis removes the preventive benefit. Preventive medications (pharmacy) are administered under the member’s pharmacy plan administrator. For full code lists, diagnosis requirements, age thresholds and billing instructions see the Applicable Codes / Coding section of this policy.

Reference	Source
ACIP
References: ACIP vaccine-specific recommendations; CDC immunization schedules (see References).
AAFP
American Academy of Family Physicians clinical preventive services recommendations (see References).
AAP Bright Futures
American Academy of Pediatrics Bright Futures guidelines (4th ed.) — HRSA-supported comprehensive guidance for infants/children/adolescents (see References).
USPSTF
United States Preventive Services Task Force recommendations (A/B ratings) — referenced throughout policy as basis for covered preventive services.
FDA vaccine lists
U.S. Food and Drug Administration vaccine listings referenced for vaccine FDA-labeling requirements in preventive benefit determinations (see References).
HRSA WPSI guidance
Health Resources and Services Administration / Women's Preventive Services Initiative recommendations (WPSI/HRSA) for women's preventive services and lactation support (see Expanded Women's Preventive Health).

FAQs (common billing questions)

Q: If a polyp is removed during a preventive screening colonoscopy, are future colonoscopies considered preventive?

A: No. If a polyp is removed during a preventive screening colonoscopy, future colonoscopies would normally be considered diagnostic because the time intervals between future colonoscopies would be shortened. (FAQ#1)

Q: Are related therapeutic services for a preventive colonoscopy covered under the preventive benefit?

A: Yes. Related integral services (pre-operative exam, facility, anesthesia, polyp removal if necessary, pathology, and physician fees) are covered under the preventive benefit, but the preventive benefit does not include a post‑operative examination. (FAQ#2)

Q: Do any preventive services require prior authorization?

A: Yes. Certain services commonly require prior authorization on most benefit plans, including BRCA lab screening, CT colonography (virtual colonoscopy), and lung cancer screening with low‑dose CT. (FAQ#3)

Q: If follow-up colonoscopy after a positive stool‑based screening or CT colonography is performed, is it preventive?

A: Yes. For members aged 45–75 years, a follow‑up colonoscopy after a positive stool‑based screening (e.g., FIT, FOBT, fecal DNA) or CT colonography is considered preventive when billed in accordance with the Colorectal Cancer Screening coding rules in this policy. (FAQ#4)

Q: For preventive services that have a diagnosis code requirement, does the listed diagnosis code need to be primary?

A: Generally no. Most preventive services do not require the preventive diagnosis code to be the primary diagnosis. However, certain services (e.g., chemoprevention counseling for breast cancer, genetic counseling/evaluation for BRCA testing, and HIV prevention services) do require the listed diagnosis code in the primary position. (FAQ#5)

Revision History

2026-04-01codes_addedLatest

Added ICD-10 diagnosis codes Z01.42, Z12.72, Z12.79 (effective 04/01/2026).

2026-04-01codes_removedLatest

Removed CPT/HCPCS codes 76977, 77081, and G0130 (effective 04/01/2026).

2026-04-01

Policy Summary

Payersierra health and life

PolicyPreventive Care Services – Commercial and Individual Exchange Medical Policy(PDF) PDF Opens in new windowopens in a new tab

Policy CodePolicy MP.016.58

Change TypeCodes and preventive service updates (04/01/2026)

Effective DateApr 1, 2026

Next Review Date

Key ActionDocument whether the service is preventive versus diagnostic and include appropriate screening diagnosis codes per the policy's provider actions.

SourceLink

On This Page

If a service is performed for diagnostic, surveillance, therapeutic, or non-preventive indications (including symptom-driven evaluation or shortened interval surveillance), it will be considered under the medical benefit and may be subject to member cost-sharing.

Colonoscopy - Preventive Care Services Benefit (no member cost-sharing)

Colonoscopy preventive coverage (no member cost-sharing) — ALL:

Patient age 45 through 75 years (coverage applies up to the 76th birthday).

Service performed by a network provider.

Colonoscopy billed in accordance with the Colorectal Cancer Screening coding rows in this policy (preventive screening codes).

Colonoscopy performed for routine screening in an asymptomatic individual (not for diagnostic, surveillance, therapeutic, or shortened-interval reasons).

Site-of-service review may apply; refer to Screening Colonoscopy Procedures - Site of Service and Outpatient Surgical Procedures - Site of Service policies.

Colonoscopy - Medical Benefit (with member cost-sharing)

Colonoscopy as a medical benefit (member cost-sharing may apply) — ANY of the following:

Patient age outside USPSTF screening recommendation (younger than 45 or 76 years and older).

Provider is non-network.

Colonoscopy performed at a shortened time interval outside USPSTF screening intervals (e.g., follow-up after polyp removal requiring earlier surveillance).

Colonoscopy performed for diagnostic indications (symptoms, abnormal prior test results requiring diagnostic evaluation).

Colonoscopy performed for surveillance purposes (history of polyps or cancer requiring surveillance).

Colonoscopy performed for therapeutic/treatment purposes (procedures beyond screening, e.g., complex polypectomy).

Advanced notification and/or site-of-service review may be required; refer to Gastrointestinal Colonoscopy Procedure Guidelines and Outpatient Surgical Procedures - Site of Service.

Covered Breastfeeding Equipment

Covered breastfeeding equipment — ALL:

One personal-use electric breast pump (HCPCS E0603) per birth. For multiple births from a single delivery, only one pump is covered.

Purchase of E0603 includes necessary supplies for the pump to operate.

Replacement supplies necessary for the personal-use electric breast pump to operate (examples: standard power adaptor, tubing adaptors, tubing, locking rings, pump-specific bottles, pump-specific caps, valves, filters, breast shield/splash protector).

Breastmilk storage bags (HCPCS A4287).

Coverage limited to items listed; quantities and frequency subject to plan administration and applicable coding rules.

Excluded Breastfeeding Equipment and Supplies

Excluded breastfeeding equipment and supplies — ANY of the following items are not covered under the preventive breastfeeding equipment benefit:

Manual breast pumps and related equipment and supplies.

Hospital-grade breast pumps and related equipment and supplies.

Batteries, battery-powered adapters, battery packs, and electrical power adapters for travel.

Bottles not specific to breast pump operation (including associated bottle nipples, caps, lids).

Travel bags and carrying accessories.

Breast pump cleaning supplies (soap, sprays, wipes, steam cleaning bags, etc.).

Baby weight scales.

Garments or devices that allow hands-free pump operation.

Breast milk storage accessories other than HCPCS A4287 (ice packs, labels, labeling lids, etc.).

Nursing bras, bra pads, breast shells, nipple shields, and similar products.

Creams, ointments, and other products to relieve breastfeeding-related symptoms (e.g., nipple creams).

Preventive vs Diagnostic Service Determination

Determination rules for Preventive versus Diagnostic services — use ALL/ANY logic below to classify a service:

Preventive service criteria (service considered preventive when ALL of the following apply):

ALL of the following

Service performed for routine screening (asymptomatic individual).
Member falls within age/population and interval recommendations of the applicable guideline (e.g., USPSTF, ACIP, HRSA, Bright Futures).
Service billed using preventive service codes and documentation supports screening intent.

Diagnostic service criteria (service considered diagnostic when ANY of the following apply):

ANY of the following

Abnormal findings on prior preventive or diagnostic studies that require further diagnostic evaluation.
Symptoms prompting evaluation (e.g., bleeding, pain, change in bowel habits).
Shortened interval repeat testing recommended due to prior abnormal results or findings (surveillance).
Member does not fall within the applicable population for the preventive recommendation.

Note: When a colonoscopy follows a positive stool-based screening test (FIT/FOBT/fecal DNA) or an abnormal visual screening (sigmoidoscopy/CT colonography), the colonoscopy is diagnostic — see FAQs and Colorectal sections for coding guidance.

BRCA Risk Assessment and Follow-up; BRCA Lab Screening Coverage Conditions; BRCA Lab Screening

BRCA risk assessment and follow-up — coverage conditions and follow-up counseling/testing when criteria are met:

BRCA Risk Assessment and Follow-up (ALL):

ALL of the following

Individual has family history or personal history that meets guideline-based thresholds for increased genetic risk assessment (per USPSTF/ACS/NCCN as applicable).
Risk assessment performed using guideline-recommended tools and documented in the medical record.
When risk assessment identifies increased risk, appropriate follow-up genetic counseling and testing referrals are provided as recommended by guideline (billing and coding must follow Genetic Testing for Hereditary Cancer policy).

BRCA Lab Screening Coverage Conditions (ALL):

ALL of the following

Laboratory genetic testing for BRCA is covered only when medical necessity criteria and guideline-based indications are met (documented personal/family history meeting testing criteria).
Testing must follow company genetic testing policies and any required prior authorization or routing to contracted labs as applicable.

BRCA Lab Screening (any relevant billing guidance):

ANY of the following

Tests billed as screening without meeting medical necessity criteria may be denied or shifted to medical benefit with member cost-sharing.
Refer to Genetic Testing for Hereditary Cancer policy for codes, prior authorization, and documentation requirements.

Diabetes / Pre-diabetes Screening

Diabetes and pre-diabetes screening — criteria and populations covered:

Diabetes / Pre-diabetes Screening (ALL):

ALL of the following

Adults with sustained blood pressure greater than 135/80 mm Hg or per USPSTF recommendation for screening adults aged 35-70 who are overweight or obese as applicable to plan coding and guideline updates.
Screening tests include fasting plasma glucose, HbA1c, or 2-hour oral glucose tolerance test as appropriate and billed with the correct preventive screening codes.
Refer to Screening for Diabetes in Pregnancy and Postpartum screening rows for gestational diabetes guidance (separate criteria below).

Pre-diabetes follow-up and counseling: When screening identifies pre-diabetes, counseling and referral to intensive behavioral interventions or diabetes prevention programs are recommended per USPSTF guidance; billing and coverage follow relevant preventive counseling and service codes.

Screening Mammography

Screening mammography — criteria and intervals:

Screening Mammography (ALL):

ALL of the following

Women in the age range recommended by USPSTF/ACS for routine screening (follow applicable guideline and member plan interpretation).
Screening performed on asymptomatic individuals and billed with the appropriate screening mammography CPT/HCPCS codes.
Diagnostic mammography or additional imaging performed for symptoms, abnormal screening results, or diagnostic evaluation is billed under the medical benefit and may be subject to cost-sharing.

Patient navigation and reminders: Counseling, patient navigation, and outreach related to screening mammography may be covered as preventive services where supported by HRSA/USPSTF guidance.

Pre-Op Consultation (Preventive when applicable)

Pre-operative consultations that qualify as preventive when they are part of routine preventive care:

Pre-Op Consultation — Preventive when ALL:

ALL of the following

Visit is a routine wellness/preventive visit (not pre-operative clearance for acute surgery) and part of periodic preventive care (e.g., annual well-visit with standard preventive services performed).
Services provided are consistent with preventive visit components and billed with preventive visit codes (preventive medicine CPT codes) rather than preoperative evaluation codes.

If the consultation is solely for preoperative medical clearance or to evaluate a symptomatic/acute condition prior to surgery, it is considered medical service and not covered under the preventive benefit.

Computed Tomographic Colonography (Virtual Colonoscopy)

Computed tomographic colonography (CT colonography / virtual colonoscopy) — preventive screening criteria:

Computed Tomographic Colonography (ALL):

ALL of the following

Member meets age and risk-based screening recommendations for colorectal cancer screening as applicable (follow USPSTF age guidelines).
CT colonography is performed for routine screening in an asymptomatic individual and billed with the appropriate screening CPT codes for CT colonography.
When CT colonography identifies abnormalities requiring follow-up colonoscopy, subsequent colonoscopy is considered diagnostic and billed under the medical benefit.

Site-of-service and coding: Follow applicable coding rows for Colorectal Cancer Screening and local site-of-service policies.

Cholesterol / Statin Prevention Screening

Cholesterol and statin prevention screening — population-based preventive recommendations:

Cholesterol / Statin Prevention Screening (ALL):

ALL of the following

Adults as recommended by USPSTF for lipid screening intervals and risk-based statin preventive therapy (e.g., adults aged 40-75 for risk assessment and statin preventive use when indicated).
Screening includes lipid panels (TC, LDL-C, HDL-C, triglycerides) and is billed per preventive screening coding guidance.
If lipid testing or statin initiation is for diagnosis or treatment of known disease (e.g., established atherosclerotic cardiovascular disease), those services are provided under the medical benefit and may be subject to cost-sharing.

AS/HTN/CV/Diabetes/Atherosclerosis Related Diagnostic Code Lists: Use the policy's diagnostic code lists when distinguishing preventive from diagnostic/therapeutic indications for cholesterol testing and statin management (apply when coding reflects treated/established disease).

General Preventive Benefit Instructions

General preventive benefit instructions and administrative rules:

General Preventive Benefit Instructions (ALL):

ALL of the following

Preventive services are covered without member cost-sharing only for non-grandfathered plans when provided by network providers and billed correctly with preventive codes.
Out-of-network preventive services are not required to be covered without cost-sharing by PPACA; check the member-specific plan document for out-of-network benefits.
Vaccines are covered only if they meet FDA labeling and have ACIP recommendations for routine use as published in the MMWR; see Preventive Care Services: Vaccine Codes.
Services required solely for employment, school, travel, licensure, research, or legal requirements are excluded from the preventive benefit.
Services that are investigational, experimental, unproven, or not medically necessary are excluded.

Billing/data elements: Document preventive intent in the medical record and use appropriate preventive CPT/HCPCS codes and ICD-10 codes to reflect screening (not diagnostic) services to avoid denials or reprocessing as medical benefit.

Smoking/Tobacco Cessation (Nonpregnant Adults & Adolescents)

Tobacco cessation counseling and support for nonpregnant adults and adolescents:

Smoking/Tobacco Cessation (Nonpregnant Adults & Adolescents) (ALL):

ALL of the following

Coverage for counseling interventions and preventive pharmacotherapy per USPSTF recommendations when provided to nonpregnant adults and adolescents who use tobacco.
Refer to the member's pharmacy plan administrator for coverage of prescription and over-the-counter tobacco cessation medications; preventive coverage for counseling is a medical benefit when billed with appropriate preventive counseling codes.

Documentation: Document tobacco use and counseling in the medical record; billing should reflect preventive counseling to qualify for preventive benefit coverage.

Visual Impairment Screening in Children

Visual impairment screening in children as part of Bright Futures / pediatric preventive care:

Visual Impairment Screening in Children (ALL):

ALL of the following

Screening performed according to Bright Futures schedule for age-appropriate vision screening in infants and children.
Screening may include objective vision testing, photoscreening, or visual acuity testing per recommended ages and billed with appropriate pediatric screening codes.

Abnormal findings: Referral to ophthalmology/optometry for diagnostic evaluation is billed under the medical benefit.

Behavioral Counseling to Prevent Skin Cancer

Behavioral counseling to prevent skin cancer — preventive counseling coverage per USPSTF:

Behavioral Counseling to Prevent Skin Cancer (ALL):

ALL of the following

Counseling provided to young adults, adolescents, children, and parents about minimizing exposure to UV radiation and avoiding tanning beds as per USPSTF/ACIP/dermatology guidance when billed as preventive counseling.
Document counseling content and time as required for preventive counseling codes.

Services for evaluation or treatment of suspicious lesions are diagnostic and billed under the medical benefit.

LDCT Lung Cancer Screening

Low-dose CT (LDCT) lung cancer screening — eligibility and coverage conditions:

LDCT Lung Cancer Screening (ALL):

ALL of the following

Asymptomatic individuals meeting USPSTF criteria for LDCT (age and smoking history thresholds) are eligible for annual LDCT screening when provided by network providers and billed with appropriate screening LDCT codes.
Shared decision-making visit documentation is required as part of LDCT screening per guidelines; document counseling and decision-making in the record.

Diagnostic CT imaging for symptomatic individuals or diagnostic workup is billed under the medical benefit.

Fluoride Varnish Application (Children birth through 5 years)

Fluoride varnish application for children birth through 5 years — preventive oral health service:

Fluoride Varnish Application (ALL):

ALL of the following

Application of fluoride varnish for children from birth through 5 years per Bright Futures schedule is covered as a preventive service when billed with the appropriate preventive codes.
Application may be performed in primary care settings per Bright Futures recommendations and billed accordingly.

Diagnostic dental evaluations or treatment of caries are billed under dental/medical benefit as applicable.

Latent Tuberculosis Infection (LTBI) Screening - Adults; TB Testing (Bright Futures / Pediatrics)

Latent tuberculosis infection (LTBI) screening in adults — preventive screening criteria:

Latent Tuberculosis Infection (LTBI) Screening - Adults (ALL):

ALL of the following

Screening for LTBI (e.g., IGRA or TST) is covered for asymptomatic adults at increased risk for TB exposure per CDC/USPSTF recommendations and when billed with appropriate screening codes.
Follow-up evaluation and treatment for LTBI identified on screening may be billed under medical benefit per treatment guidelines.

TB Testing (Bright Futures / Pediatrics): Pediatric TB screening/testing per Bright Futures schedule is covered for pediatric populations at increased risk and billed with appropriate pediatric screening codes.

Anemia Screening in Children (Bright Futures); Hepatitis B Screening (Bright Futures)

Anemia screening in children per Bright Futures — coverage and follow-up:

Anemia Screening in Children (ALL):

ALL of the following

Screening for iron deficiency anemia in infants and children per Bright Futures schedule is covered as preventive when asymptomatic and billed with appropriate screening codes.
Follow-up diagnostic evaluation and treatment for identified anemia are billed under the medical benefit.

Hepatitis B Screening (Bright Futures): Hepatitis B screening for infants/children per Bright Futures schedule and maternal screening per prenatal guidance is covered when billed appropriately.

PrEP (HIV Preexposure Prophylaxis); HIV Screening (Bright Futures)

HIV prevention and screening — PrEP and routine screening coverage per guidelines:

PrEP (HIV Preexposure Prophylaxis) (ALL):

ALL of the following

PrEP-related preventive services (HIV testing prior to initiation, periodic HIV testing, counseling, and related preventive visits) are covered when offered to individuals at substantial risk per USPSTF and CDC guidance.
Coverage of PrEP medications may be administered through the member's pharmacy plan; medical benefit covers clinical preventive services and counseling.

HIV Screening (Bright Futures and Adults) (ALL):

ALL of the following

Routine HIV screening for adolescents and adults and pregnant persons per USPSTF and Bright Futures recommendations is covered as preventive when billed with appropriate screening codes.
Screening in the context of symptomatic STI evaluation is diagnostic and billed under the medical benefit.

HIV Screening and Counseling for STIs: Counseling and screening associated with STI prevention may be covered as preventive where recommended; diagnostic STI testing based on symptoms or exposure is medical benefit.

Hearing Tests; Formal Developmental/Autism Screening; Lead Screening; Dyslipidemia Screening; Emotional Screening; Sudden Cardiac Arrest/Death Risk Assessment (Bright Futures)

Hearing, developmental, and related Bright Futures pediatric screening services:

Hearing Tests (Bright Futures) (ALL):

ALL of the following

Newborn hearing screening and periodic pediatric hearing screening per Bright Futures are covered as preventive when billed with appropriate screening codes.

Formal Developmental / Autism Screening (Bright Futures) (ALL):

ALL of the following

Age-appropriate formal developmental and autism screening per Bright Futures schedule is covered as preventive when asymptomatic and billed with recommended screening codes.

Lead Screening (Bright Futures) (ALL):

ALL of the following

Lead screening per Bright Futures for at-risk children is covered as preventive; confirm local public health guidelines for timing and billing.

Dyslipidemia Screening (Bright Futures) (ALL):

ALL of the following

Pediatric dyslipidemia screening per Bright Futures is covered as preventive for recommended ages and risk groups and billed with appropriate codes.

Emotional Screening / Depression and Suicide Risk Screening (Bright Futures) (ALL):

ALL of the following

Screening for depression, emotional/behavioral concerns, and suicide risk per Bright Futures is covered as preventive in recommended age groups and billed with appropriate screening codes.

Sudden Cardiac Arrest/Death Risk Assessment and ECG Screening (Bright Futures) (ALL):

ALL of the following

Screening for risk factors for sudden cardiac arrest/death and ECG screening when recommended by Bright Futures/clinical guidance is covered per plan preventive rules and billed appropriately.

Well-Woman Preventive Visits; Expanded Women's Preventive Health

Well-woman preventive visits and expanded women's preventive health services required by HRSA:

Well-Woman Preventive Visits (ALL):

ALL of the following

Routine well-woman preventive visits (periodic preventive visits) are covered without member cost-sharing when provided by network providers and billed with preventive visit CPT codes.
Components include recommended preventive screenings, counseling, and services as defined by USPSTF and HRSA women's preventive services (e.g., contraceptive counseling, breastfeeding support, HPV testing per guidelines).

Well-Woman Preventive Visits / Expanded Women's Preventive Health (ALL):

ALL of the following

HRSA-required expanded women's preventive services (e.g., contraceptive methods and counseling, breastfeeding support and supplies listed in policy) are covered per applicable requirements when billed and documented appropriately.

Prenatal / Prenatal Office Visits; Screening for Diabetes in Pregnancy; Postpartum Diabetes Screening after GDM

Prenatal and pregnancy-related screening — routine prenatal visits and diabetes screening in pregnancy:

Prenatal / Prenatal Office Visits (ALL):

ALL of the following

Routine prenatal visits and recommended preventive screenings during pregnancy are covered when billed with appropriate prenatal care and preventive codes per plan rules.

Screening for Diabetes in Pregnancy (ALL):

ALL of the following

Screening for gestational diabetes per USPSTF/ACOG recommendations (typically 24-28 weeks or earlier for high-risk individuals) is covered as preventive when billed with appropriate codes.

Screening for Diabetes After Pregnancy (Postpartum) for history of GDM (ALL):

ALL of the following

Postpartum screening for diabetes for women with a history of gestational diabetes mellitus (GDM) is covered per guideline-recommended timing (e.g., 4-12 weeks postpartum and periodic surveillance thereafter) and billed appropriately.

HIV Screening and Counseling for STIs

HIV screening and counseling in the context of STI prevention and contraception services:

HIV Screening and Counseling for STIs (ALL):

ALL of the following

Routine HIV and STI screening and counseling recommended by USPSTF and Bright Futures are covered as preventive when performed for screening purposes and billed with appropriate preventive codes.
Diagnostic STI testing for symptomatic individuals or exposure events is billed under the medical benefit.

Contraceptive Methods (Including Sterilizations); Contraception / Sterilization Related Visits

Contraceptive methods and sterilization — coverage of methods and related supplies per HRSA and USPSTF:

Contraceptive Methods (Including Sterilizations) (ALL):

ALL of the following

FDA-approved contraceptive methods, sterilization procedures, and contraceptive counseling recommended by HRSA/USPSTF are covered as preventive services when billed and documented appropriately.
Contraceptive medications and devices may be administered through the member's pharmacy benefit; procedural coverage (e.g., sterilization) follows medical benefit coding and may require separate consideration for facility/provider payment.

Contraception / Sterilization Related Visits (Code Groups 4-7) (ALL):

ALL of the following

Contraception-related counseling visits, initiation visits, and device insertion/removal visits are covered as preventive when they meet HRSA preventive definitions and are billed with appropriate codes (refer to the policy's code groupings for correct CPT/HCPCS groups).

Documentation and coding: Use the policy's Contraceptive Code Groups to ensure services are billed to the preventive benefit when applicable; services provided for non-preventive indications may be medical benefit.

Breastfeeding Services and Supplies (HRSA)

Breastfeeding services and supplies aligned with HRSA requirements and policy details:

Breastfeeding Services and Supplies (ALL):

ALL of the following

Coverage includes one personal-use electric breast pump (E0603) per birth and necessary pump supplies; breastmilk storage bags (A4287) are covered as listed in the policy.
Breastfeeding counseling and lactation support provided as preventive services are covered when billed with appropriate preventive visit or counseling codes and documented in the medical record.

Average Risk Diagnosis Codes (Breast)

Average risk diagnostic codes and screening guidance for breast cancer (screening vs diagnostic mammography):

Average Risk Diagnosis Codes (Breast) (ALL):

ALL of the following

Screening mammography is intended for asymptomatic average-risk women and should be billed with screening mammography CPT codes and appropriate average-risk ICD-10 screening diagnosis codes as specified in the policy code tables.
If symptoms, abnormal findings, or prior diagnostic results exist, imaging is diagnostic and should be billed with diagnostic codes which may result in member cost-sharing.

Patient navigation and patient education services related to breast and cervical cancer screening may be covered as preventive services per policy guidance.

Cervical Cancer Screening & HPV Testing

Cervical cancer screening and HPV testing — screening intervals and appropriate populations:

Cervical Cancer Screening & HPV Testing (ALL):

ALL of the following

Cervical cancer screening (Pap smear, HPV testing, or co-testing) is covered per USPSTF/ACS/ACOG recommended intervals for age groups; screening must be performed on asymptomatic individuals and billed with preventive screening codes.
HPV testing for primary screening, co-testing, or triage as recommended by guidelines is covered when billed appropriately.
Diagnostic pelvic exams, testing for symptomatic patients, or management of abnormal results are billed under the medical benefit.

Patient navigation services for cervical cancer screening may be offered and billed per preventive service codes where supported.

Screening for Anxiety; Emotional Screening / Depression and Suicide Risk Screening

Screening for anxiety and emotional/depression screening — preventive mental health screening coverage:

Screening for Anxiety (ALL):

ALL of the following

Screening for anxiety, depression, and related emotional disorders per USPSTF/Bright Futures recommended ages is covered as preventive when asymptomatic and billed with appropriate screening codes.
Positive screens requiring diagnostic evaluation or treatment are billed under the medical benefit.

Patient resources and brief counseling tied to screening may be covered as preventive services when consistent with guideline recommendations.

Patient Navigation Services for Breast and Cervical Cancer Screening

Patient navigation services specific to breast and cervical cancer screening:

Patient Navigation Services for Breast and Cervical Cancer Screening (ALL):

ALL of the following

Navigation, outreach, and follow-up services to assist eligible members in obtaining recommended breast and cervical cancer screening are supported and may be covered as preventive-related services when documented and billed appropriately.
Navigation for diagnostic follow-up after abnormal screening results is part of care coordination; billing should reflect whether services are preventive outreach or diagnostic follow-up per coding guidance.

Document preventive vs diagnostic purpose on the claim.
For BRCA testing document positive familial risk assessment and that genetic counseling occurred (Z15.01/Z15.02/Z80.*/Z85.*).
For prenatal diabetes screening include a pregnancy diagnosis code.
For diabetes screening include one required diagnosis (Z00.00/Z00.01/Z13.1) plus an overweight diagnosis (e.g., E66.*, Z68.*).
When billing Code Group 2 contraceptive procedures include a Z30.* contraceptive management diagnosis code.

Billing Rule

Billing rules, frequency limits and reporting-only codes

Follow billing rules and frequency/quantity limits and pairing requirements: blood draw codes (36415/36416) must accompany applicable laboratory procedure codes; colorectal asterisked colonoscopy codes are preventive only when billed with listed preventive diagnoses or paired with specified preventive codes; E0603 (personal electric breast pump) is limited to one purchase per birth; G0446 is limited to once per year and G0445 is limited to twice per year; reporting-only lung screening codes G9275/G9276 are not separately reimbursable; pelvic exam add-on 99459 may be payable when billed with a related preventive E/M; and consult the Consultation Services reimbursement policy for reimbursement of 99242–99245.

Blood draw codes 36415/36416 must be billed with the applicable lab procedure codes.
Asterisked colonoscopy codes are preventive only when billed with the listed diagnosis codes or in addition to specified preventive codes (follow the asterisked-code instructions).
E0603 (personal electric breast pump) limited to one purchase per birth.
G0446 limited to once per year; G0445 limited to twice per year.
G9275/G9276 are reporting-only codes and not separately reimbursable.
Pelvic exam add-on 99459 may be payable when billed with a related preventive E/M visit (subject to other policies).
For consultation code reimbursement guidance for 99242–99245, refer to the Consultation Services reimbursement policy.

Denial Risk

Denial risks / common exclusions

Services may be denied as excluded from the preventive benefit in specific situations. Examples of denial risk: travel-related vaccines and vaccines lacking FDA labeling or explicit ACIP routine-use recommendations are excluded from preventive coverage; and the preventive benefit does not apply when a disease diagnosis is present (for example, a diabetes diagnosis in any claim position precludes the diabetes screening preventive benefit).

Travel vaccines (e.g., typhoid, yellow fever, cholera, Japanese encephalitis) are excluded from the preventive benefit.
Vaccines without FDA labeling and explicit ACIP routine-use recommendations published in MMWR are not covered as preventive.
If a disease diagnosis code is present (e.g., diabetes), the preventive benefit does not apply and the service should be billed diagnostically.

Note

Pharmacy benefit referral and member-specific verification; Modifier 33 usage

Refer to the member's pharmacy benefit administrator for coverage details of preventive medications and verify member-specific benefit documents before rendering services. Modifier 33 may be reported to identify preventive services but UnitedHealthcare does not rely on Modifier 33 alone when determining preventive benefit eligibility.

Refer preventive medication questions (e.g., smoking cessation pharmacotherapy, PrEP agents) to the plan's pharmacy benefit administrator.
Verify member-specific benefit plan documents; member-specific documents govern coverage decisions.
Modifier 33 may be reported but is not used by UnitedHealthcare to determine preventive benefit eligibility.

Q: Are travel vaccines covered under preventive benefits?

A: No. Vaccines specific to travel (for example, typhoid, yellow fever, cholera, plague, Japanese encephalitis) are excluded from the preventive care services benefit. (FAQ#13)

Policy effective 04/01/2026 (Summary of Changes: Applicable Codes; Preventive Care Services; Cervical Cancer Screening; other revisions).

2026-04-01service_updateLatest

Osteoporosis screening service description revised to reference Jan. 2025 USPSTF 'B' recommendation and specify screening criteria for women 65+ and postmenopausal women <65 at increased risk (04/01/2026).

archived_versionLatest

Archived previous policy version MP.016.57.