Modifiedsierra health and lifePolicy MP.016.58

Preventive Care Services (Preventive Care Services Benefit) — UnitedHealthcare Commercial & Individual Exchange

Defines coverage, coding, exclusions, and member cost-sharing for preventive services (screenings, immunizations, breastfeeding equipment) under UnitedHealthcare commercial and individual exchange plans; applies to network providers and plan members as described.

Policy Summary

Payersierra health and life

PolicyPreventive Care Services (Preventive Care Services Benefit) — UnitedHealthcare Commercial & Individual Exchange

Policy CodePolicy MP.016.58

Change TypeCode and criteria updatesICD-10 additionsosteoporosis guidance revised

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization for BRCA lab screening (procedure codes 81162–81166) and ensure genetic counseling and required diagnosis codes are documented before testing.

SourceLink

POLICY UPDATE CHANGES

Added ICD-10 diagnosis codes Z01.42, Z12.72, and Z12.79.

Osteoporosis screening service description updated to reflect Jan. 2025 USPSTF 'B' rating and age/risk recommendations; removed CPT/HCPCS codes 76977, 77081, and G0130.

Updates to Applicable Codes and Preventive Care Services including Cervical Cancer Screening.

100%Preventive cost share waived

45-75Colorectal screening ages

1Breast pump per birth

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.

Prior AuthorizationBRCA PA required

A or BUSPSTF ratings

Coverage Criteria for Preventive Services

Covered Preventive Services

Preventive services covered under the preventive care services benefit

PPACA-mandated preventive services: Services with a USPSTF A or B rating, routine immunizations recommended by ACIP, and HRSA-supported preventive services for infants, children, adolescents, and women are covered without member cost-sharing when provided by network providers on non-grandfathered plans.network provider; non-grandfathered plan

See FAQs for diagnostic vs preventive distinctions and exceptions.

Colonoscopy - Preventive Care Benefit

Colonoscopy preventive benefit conditions

Preventive colonoscopy coverage: Colonoscopy screening benefit with waived member cost-sharing applies when patient age is 45-75, provider is in-network, and billed per colorectal cancer screening coding in this policy.age 45-75; in-network; correct billing

May require site of service review.

Colonoscopy - Medical Benefit (with cost-sharing)

Scenarios where colonoscopy is not covered as preventive under waived cost-sharing

Colonoscopy outside preventive benefit: Member cost-sharing may apply when age is outside USPSTF recommendation, provider is non-network, colonoscopy is at shortened intervals, performed for diagnostic/surveillance/therapeutic purposes, or not billed per preventive coding.any of the listed conditions

Such procedures may require advanced notification or site of service review.

Breastfeeding Equipment Coverage

Covered and excluded breastfeeding equipment

Covered breastfeeding equipment: Personal-use electric breast pump (E0603) — one per birth — necessary supplies for operation, replacement supplies, and breastmilk storage bags (A4287) are covered.one pump per birth

Includes supplies necessary for pump operation.

Not covered breastfeeding items: Manual pumps, hospital-grade pumps, accessories not listed (batteries, travel adapters), cleaning supplies, travel bags, baby scales, garments for hands-free operation, storage accessories other than A4287, nursing bras, creams/ointments, and other similar products are excluded from preventive benefit.listed items

Refer to Covered Breastfeeding Equipment for allowed items.

Abdominal Aortic Aneurysm Screening (USPSTF B)

Covered preventive screenings when USPSTF/Bright Futures recommendations apply

AAA screening criteria: One-time ultrasound screening for abdominal aortic aneurysm in men aged 65-75 who have ever smokedage 65-75; history of smoking

Procedure code 76706; requires appropriate diagnosis codes for smoking history if listed

Infectious disease screening (Chlamydia, Gonorrhea, Hep B/C, HIV, Syphilis)

Screening procedures recommended by USPSTF / Bright Futures with indicated populations

Chlamydia and Gonorrhea screening: Screen asymptomatic sexually active adolescents and adults per USPSTF guidance; includes pregnant persons; Bright Futures recommends screening when risk assessment positive for ages 11-21age and pregnancy status or screening diagnosis codes as specified

Requires listed procedure codes and appropriate screening or pregnancy diagnosis codes; blood draw codes apply when specific lab codes 86631/86632 used

Hepatitis B screening: Screen pregnant women at first prenatal visit; screen adolescents/adults at increased riskpregnancy diagnosis code required for pregnancy-related preventive benefit

Procedure codes 86704, 86706, 87340, 87341, 87467, G0499; blood draw codes 36415/36416 required when applicable

Hepatitis C screening:

BRCA Genetic Counseling and Testing

Genetic counseling and BRCA testing

Genetic counseling before BRCA testing: Assess women with personal/family history or ancestry associated with BRCA1/2; those who screen positive on an assessment tool should receive genetic counseling and, if indicated, testingpresence of relevant personal/family history or ancestry

Genetic counseling codes 96041, S0265 or specified E/M/preventive visit codes; BRCA lab codes require prior authorization for some plans and counseling may be required in primary position

Indications for BRCA genetic counseling and testing

Covered when ALL of the following are met

Clinical criteria: Women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or ancestry associated with BRCA1/2 mutations AND a positive result on a brief familial risk assessment tool should receive genetic counseling and, if indicated after counseling, genetic testing.

Counseling and appropriate diagnosis codes required; counseling may be required prior to lab testing for some plan types.

Coverage contingent on counseling and prior authorization

Covered when the following conditions are met

Counseling and Authorization: Member receives genetic counseling and, if indicated after counseling, genetic testing; prior authorization obtained for BRCA lab screening codes 81162-81166.

Derived from repeated statements that counseling is required and prior authorization applies.

Diabetes / Prediabetes Screening

Covered preventive interventions and age/diagnosis requirements

Diabetes/Prediabetes Screening and Interventions: Screening recommended by USPSTF for adults 35-70 with overweight or obesity; preventive interventions (medical nutrition therapy, counseling) available; diabetes screening procedures require specific diagnosis codes (Z00.00, Z00.01, Z13.1) and additional overweight/obesity codes.age 35-70

Preventive benefit does not apply if a diabetes diagnosis code is present in any position.

Mammography Screening

Breast and mammography preventive screening

Screening mammography: USPSTF recommends screening mammography every 1-2 years for women aged 40 and older; procedure codes 77063, 77067; preventive benefit applies to screening mammography only.age >=40

No diagnosis code required for preventive benefit.

Cervical Cancer Screening

Cervical cancer screening recommendations

Cervical cancer screening ages 21-65: USPSTF: ages 21-29 cytology every 3 years; ages 30-65 cytology every 3 years or hrHPV testing every 5 years or co-testing every 5 years; code groups and age limits apply.age 21-65

Code group 1 limited to 21-65; code group 2 requires listed diagnosis codes for preventive benefit.

Colorectal Cancer Screening

Colorectal cancer screening — colonoscopy, sigmoidoscopy, FOBT/FIT

Colorectal cancer screening ages 45-75: USPSTF recommends screening ages 45-49 (B) and ages 50-75 (A). Preventive colonoscopy codes (G0105, G0121) have no diagnosis requirement; other colonoscopy/sigmoidoscopy procedure codes marked with * are preventive only when billed with specified diagnosis codes (Z00.00, Z00.01, Z12.10, etc.) or when billed in addition to G0104/G0105/G0121/G0328/S0285. Pathology and anesthesia codes require the same preventive diagnosis codes and age limits 45-75.age 45-75

Codes with asterisk require specific diagnosis codes to be treated as preventive.

Cholesterol / ASCVD Risk Screening

Cholesterol screening and statin primary prevention

Cholesterol screening ages 40-75: USPSTF recommends cholesterol screening and ASCVD risk assessment for ages 40-75; specific procedure and diagnosis code requirements apply; refer to pharmacy plan for statin medication benefits.age 40-75

ASCVD risk assessment codes G0537/G0538 do not require the listed diagnosis codes.

Colorectal Screening (initial and surveillance)

Preventive colorectal screening coverage and related services

Colorectal screening preventive criteria: Preventive benefits apply for colonoscopy/FOBT/FIT/fecal DNA/CT colonography for members aged 45-75 (ends on 76th birthday). G0328 does not require diagnosis codes; codes with asterisk (82270, 82274, certain colonoscopy codes) are preventive when billed with one of the listed diagnosis codes or billed in addition to specified screening codes. Fecal DNA (0464U,81528) is limited to once every 3 years and does not require diagnosis codes for preventive benefits. Pathology and anesthesia for colonoscopy/sigmoidoscopy require listed diagnosis codes to be preventive.age 45-75

See code groups for exact codes and diagnosis pairs

Newborn metabolic and screening panel

Newborn screening and metabolic panels

Newborn screenings: Newborn hypothyroidism, phenylketonuria (PKU), sickle cell, and metabolic screening panels are preventive for all newborns aged 0-90 days. Required procedure codes for panels and blood draw codes must be present. No diagnosis code requirements apply for preventive benefit to apply for these newborn screenings.age 0-90 days

See list of panel codes and blood draw codes

Osteoporosis Screening

Osteoporosis screening

Osteoporosis screening criteria: DEXA (77080) preventive coverage for women 65 or older; postmenopausal women younger than 65 with one or more risk factors per USPSTF also eligible when one of listed diagnosis codes is present.women >=65 or postmenopausal <65 with risk factors

Diagnosis codes Z00.00, Z00.01, Z13.820, Z82.62 listed

Behavioral and Mental Health Screening

Behavioral health screening coverage

Alcohol/drug/depression/anxiety screening: USPSTF 'B' recommended screenings (unhealthy alcohol use, unhealthy drug use, depression in adults and adolescents, anxiety in adults) are covered preventive services with associated screening codes (99408,99409,G0442,G0443,96127,96161,G0136,G0444). Some codes (e.g., 96127) require specific encounter diagnosis codes (Z13.31, Z13.32 or Z13.39 for anxiety) when listed; others (G0136, G0444, 96161) do not require those diagnosis codes.per USPSTF age ranges (adult/adolescent as specified)

Bright Futures guidance referenced for pediatric intervals

High BMI in children — referral to intensive behavioral interventions

Covered when ALL of the following are met

Pediatric BMI referral: Children and adolescents 6 years or older with high BMI (>=95th percentile) should be provided or referred to comprehensive, intensive behavioral interventions per USPSTF; applicable procedure and diagnosis codes listedage >=6; BMI >=95th percentile

G0446 limited to once/year; diagnosis codes required for certain procedure codes

Adult obesity — intensive multicomponent behavioral interventions

Covered when ALL of the following are met

Adult BMI behavioral counseling: Adults with BMI >=30 referred to or provided intensive multicomponent behavioral interventions; applicable CPT/HCPCS codes apply; diagnosis codes should be present for certain claimsBMI >=30

G0446 limited to once/year

Anxiety screening (adults and children/adolescents)

Covered when ANY of the following are met

Anxiety screening: Screening for anxiety in adults (including pregnant/postpartum) and in children/adolescents 8-18 is recommended (USPSTF B); use procedure code 96127 and diagnosis Z13.39 as appropriateages per USPSTF guidance

Applies to adults <=64 per cited USPSTF note

Tobacco use cessation interventions

Covered when ALL of the following are met

Tobacco cessation: Clinicians should ask about tobacco use, advise cessation, and provide behavioral interventions for pregnant and nonpregnant adults; include FDA-approved pharmacotherapy for nonpregnant adults (pharmacy benefit administrator governs medications)none

Procedure codes 99406/99407 and preventive counseling codes listed

Pediatric vision screening

Covered when ALL of the following are met

Vision screening ages 3-5: Vision screening at least once in children age 3-5 years to detect amblyopia/risk factors; instrument-based screening recommended at 12 and 24 months and visual acuity screening at age 4-5age-specific per code: 99173 up to age 21; 99174/99177 age 1-5 and 6-21 with guidance

Instrument-based screening age buckets specified

LDCT Screening Coverage

Screening for Lung Cancer with Low-Dose CT — Covered when ALL of the following are met

LDCT eligibility: Age 50 to 80 years (ends on 81st birthday) AND at least 20 pack-years smoking history AND current smoker or quit within past 15 yearsas stated

Limited to one per year; prior authorization may apply depending on plan

Topical Fluoride Coverage

Fluoride varnish application — Covered when ALL of the following are met

Fluoride varnish: Children from tooth eruption through age 5 (ends on 6th birthday)age 0-5

No diagnosis code required for preventive benefit

LTBI Screening Coverage

Latent Tuberculosis Infection (LTBI) screening — Covered when ALL of the following are met

LTBI screening adults: Asymptomatic adults 18 years and up at increased risk; CPTs 86480/86481/86580 require one of the diagnosis codes listed; follow-up 99211 requires R76.11 or R76.12age >=18

Blood draw codes 36415/36416 billed with screening codes

Perinatal Depression Counseling Coverage

Perinatal depression prevention counseling — Covered when ALL of the following are met

Perinatal counseling: Pregnant and postpartum persons at increased risk should receive or be referred for counseling interventions; multiple E/M and counseling CPTs listed for billingper USPSTF Feb 2019

If counseling provided by mental health provider refer to mental health plan; coding guidance applies to network medical provider only

PrEP Prevention Coverage

HIV PrEP prevention services — Covered when ALL of the following are met

PrEP services: Clinicians should prescribe PrEP to persons at increased risk; coverage includes kidney function testing, pregnancy testing, serologic hepatitis B/C testing, STI testing, counseling, and administration codes for injectable antiretroviral where applicable; requires diagnosis codes listed in row and may require prior auth depending on planper USPSTF Aug 2023

Pharmacy supplying fee Q0521 and agents may be under pharmacy benefit

Pediatric Preventive Screening Coverage

Pediatric preventive screenings (vision, hearing, developmental, anemia, lead, dyslipidemia) — Covered when criteria met

Hearing tests: Bright Futures recommended ages and risk assessments as listed; some age groups require diagnosis codes; limit once per year for ages 91 days to 21 yearsage-specific per Bright Futures

Risk assessment included in wellness exam code

Developmental/autism screening: 96110 for ages prenatal to 2 years (ends on 3rd birthday) with recommended visits at 9, 18, 24 months; no frequency limitages prenatal-2

Requires diagnosis codes listed in the row

Lead screening: CPT 83655 with blood draw 36415/36416 for ages 6 months through 6 years (ends on 7th birthday); requires one of listed diagnosis codes

Preventive screening and well-woman coverage criteria

Coverage of preventive screenings and services when performed per Bright Futures or HRSA recommendations and associated coding rules:

Dyslipidemia Screening: Risk assessment per Bright Futures recommended ages; screening lab work performed if risk assessment positive or at specified ages (once between 9-11 years; once between 17-21 years); requires listed procedure and diagnosis codes; blood draw codes required for specimen collection.age-based

Risk assessment included in wellness exam codes

Emotional/Depression Screening: Bright Futures recommends annual behavioral/social/emotional screening from newborn to 21 years; adolescent depression/suicide risk screening recommended 12-21 years; maternal postpartum screening integrated into well-child visits at 1,2,4,6 months.age-based

Assessment included in wellness exam codes

HIV Screening:

Well-woman and prenatal preventive benefit

Preventive coverage application notes

Routine prenatal visits preventive portion: The routine, low-risk prenatal visits portion of global obstetrical codes is covered as preventive and does not have diagnosis code requirements for the preventive benefit to apply.

source: chunk 181

Screening for Diabetes in Pregnancy

Diabetes screening in pregnancy

Diabetes screening during pregnancy: Diabetes screening procedure codes require a pregnancy diagnosis code (regardless of gestational week); blood draw codes must be paired with a diabetes screening procedure code and a pregnancy diagnosis code. If a diabetes diagnosis code is present in any position, the preventive benefit will not be applied.

source: chunk 183

Screening for Diabetes After Pregnancy

Diabetes screening after pregnancy

Postpartum diabetes screening: Requires one of the required screening diagnosis codes (Z00.00, Z00.01, Z13.1) AND Z86.32 (personal history of gestational diabetes); no age limit.

source: chunk 185

Contraceptive and sterilization coverage criteria

Contraceptive methods and sterilization coverage groups

Code Group 1 coverage: Sterilizations (tubal ligation, oviduct occlusion, related supplies) — Code Group 1 does not have diagnosis code requirements for preventive benefits to apply.

source: chunk 190; 189

Code Group 2 coverage: IUDs, implants, injections require one of the Code Group 2 diagnosis codes (Z30 series) for preventive benefit application.

source: chunk 192; 193

Code Group 3 coverage: Anesthesia and sterilization procedural codes require one of the Code Group 3 diagnosis codes (Z30.2) for preventive benefit application.

source: chunk 194

Code Group 4 coverage: Tubal ligation follow-up and hysterosalpingography require one of Code Group 4 diagnosis codes as listed.

Covered with criteria

Covered when billed with required diagnosis or visit linkage as specified below

Contraception/Sterilization related visits: Related E/M visit codes (99202-99205, 99211-99215, 99417, G0463) billed for contraception or sterilization are associated with preventive benefits; pelvic exam add-on 99459 may apply when billed with the preventive E/M code.

Code Group 7 diagnosis required for some rows (see Code Group 7).

Breastfeeding equipment & supplies: E0603 and supplies A4281-A4287 are covered as preventive benefits when one of the specified diagnosis codes for breastfeeding is present; E0603 limited to one per birth; supplies and pump access should not depend on prior manual-pump failure.

S9443 does not require a diagnosis code for preventive benefit.

Breast cancer screening and diagnostic follow-up: Screening mammography procedure codes (77063, 77067) have no age limit for preventive coding; WPSI recommends initiation age 40-50 and biennial to annual frequency; diagnostic imaging and pathology codes to 'complete the screening process' require one of the Average Risk Diagnosis Codes listed in the document.

Additional imaging and pathology may be covered to complete screening up through at least age 74.

HRSA-recommended Preventive Services

Covered when following HRSA Women's Preventive Services Initiative recommendations and required codes are used

Cervical cancer screening: Average-risk women aged 21-65: ages 21-29 cytology every 3 years; co-testing and HPV testing intervals per HRSA guidance (HPV testing every 5 years when applicable). Use appropriate HPV procedure codes and diagnosis codes as listed.age 21-65

Women at average risk should not be screened more than once every 3 years (cytology)

Anxiety screening: Screen adolescent and adult women, including pregnant/postpartum; optimal intervals unknown — use clinical judgment. Use procedure code 96127 and diagnosis Z13.39.clinical judgement

Consider screening those not recently screened due to high prevalence

Patient navigation services for breast and cervical cancer screening: Recommend patient navigation (person-to-person, in-person/virtual/hybrid) individualized to patient needs, including assessment, planning, referrals (translation, transportation, social services), and education.

Osteoporosis Screening (revised)

Osteoporosis screening: USPSTF Jan. 2025 'B' recommendation: screen women 65+ and postmenopausal women <65 at increased risk for osteoporotic fracture as estimated by clinical risk assessment. CPT/HCPCS codes 76977, 77081, and G0130 removed.age and risk-based per USPSTF

Revised service description in 04/01/2026 update

Services are not covered under the preventive care benefit when they are provided solely to meet requirements for employment, school/education, sports/camp, travel (including travel vaccines), insurance, marriage, or adoption; when performed to satisfy judicial or administrative proceedings or orders; when conducted for research purposes; or when required to obtain or maintain any type of license. Additionally, services that are investigational, experimental, unproven, or not medically necessary are excluded from the preventive services benefit. Breastfeeding items not listed as covered (for example, manual pumps, hospital-grade pumps, cleaning supplies, travel accessories, garments for hands-free pump operation, baby scales, and other similarly listed items) are also excluded.

Listing of a procedure or diagnosis code in this policy is for reference only and does not by itself establish that the service represented by the code is covered. Benefit coverage and claim payment are determined by the member-specific benefit plan document and applicable law; other policies or guidelines may further restrict payability. Inclusion of a code does not guarantee reimbursement.

Some plan types (for example, Medical Necessity plans) require that a patient receive genetic counseling prior to BRCA laboratory testing. Absence of the required counseling or failure to use the appropriate genetic counseling/evaluation diagnosis codes in the primary position may result in non‑coverage or denial of BRCA lab screening claims.

Applicable Codes and Coding Guidance

ICD-10 Codes: Pregnancy & Obstetric (neutral)ICD-10

O09.6	Supervision of pregnancy with other poor reproductive or obstetric history, third trimester
O09.8	Supervision of pregnancy with other poor reproductive or obstetric history, unspecified trimester
O09.A	Supervision of pregnancy with other poor reproductive or obstetric history, antepartum condition
O10.0	Pre-existing hypertension complicating pregnancy, first trimester
O10.1	Pre-existing hypertension complicating pregnancy, second trimester
O10.2	Pre-existing hypertension complicating pregnancy, third trimester
O10.3	Pre-existing hypertension complicating pregnancy, unspecified trimester
O10.4	Pre-existing hypertension complicating pregnancy, puerperium
O10.9	Pre-existing hypertension complicating pregnancy, unspecified
O11.1	Pre-existing hypertension with pre-eclampsia, second trimester

1–10 of 111

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Covered Breastfeeding EquipmentHCPCSCovered

E0603	Personal-use electric breast pump (limited to one per birth)
A4287	Breastmilk storage bags

Breast Pump Supplies (covered)HCPCSCovered

A4281	Breast pump supply - tubing, valves, connectors (example)
A4282	Breast pump supply
A4283	Breast pump supply
A4284	Breast pump supply
A4285	Breast pump supply
A4286	Breast pump supply
A4288	Breast pump supply

BRCA Lab Screening Procedure CodesCPTCovered

81162	BRCA1/BRCA2 full sequence analysis
81163	BRCA1/BRCA2 duplication/deletion analysis
81164	BRCA variant analysis
81165	BRCA sequencing
81166	BRCA testing

Genetic Counseling & Evaluation — E/M and Counseling (neutral)CPT

96041	Medical genetics and genetic counseling services, each 30 minutes
S0265	Genetic counseling, under physician supervision
99212	Office/outpatient visit, established patient, low complexity
99213	Office/outpatient visit, established patient, moderate complexity
99214	Office/outpatient visit, established patient, high complexity
99215	Office/outpatient visit, established patient, highest complexity
G0463	Physician outpatient visit, primary care (for Medicare)

Key Age Limits, Frequency, and Special Coding Notes

inv-139: Colonoscopy age range — 45-75 years (ends on 76th birthday)

Colonoscopy age range45-75 years (ends on 76th birthday)

Preventive benefit conditionsMember cost-sharing waived when in-network provider and billed per colorectal cancer screening coding

Site-of-service noteColonoscopy may require site of service review; refer to Screening Colonoscopy Procedures - Site of Service policy

inv-140: Age for AAA screening — 65-75 years (men who have ever smoked)

AAA screening age range65-75 years (ends on 76th birthday)

PopulationOne-time ultrasound screening for abdominal aortic aneurysm in men who have ever smoked

Provider Action Items, Billing & Prior Authorization

Prior Authorization

Prior Authorization / Plan Authorization

Prior authorization may be required for certain preventive services. Check the member-specific plan for prior authorization requirements before performing BRCA lab screening, CT colonography (74263), or low-dose CT (LDCT) for lung cancer screening.

BRCA lab screening (CPT/HCPCS: 81162–81167, 81212, 81215–81217) — prior authorization requirements apply; medical-necessity plans require genetic counseling before BRCA testing and one of the genetic counseling/evaluation diagnosis codes in the primary position.
Computed tomographic colonography (74263) — may require prior authorization depending on plan; does not have preventive diagnosis code requirements to apply.
Low-dose CT (LDCT, e.g., 71271) — limited to one per year and requires age/pack-year/current smoking status criteria; prior authorization may apply depending on plan.

Policy Background and Scope

Preventive services covered under federal PPACA obligations include services with USPSTF grade A or B, routine immunizations recommended by ACIP, and HRSA‑supported preventive services for women, infants, children, and adolescents. Distinctions are made between routine preventive screening (asymptomatic, guideline‑interval care) and diagnostic/therapeutic services; some items excluded from the preventive benefit (see Coverage Limitations and Exclusions) may be covered under other portions of a member’s medical benefit.

Key Definitions and Terms

inv-217: Modifier 33 — Preventive service modifier indicating primary purpose is an evidence-based USPSTF A or B service; may be reported but not relied upon for benefit determinations.

Modifier 33 definitionPreventive service modifier indicating primary purpose is an evidence-based USPSTF A or B service; may be reported but is not used by UnitedHealthcare to determine preventive benefit applicability

Use noteModifier 33 may be reported but is not relied upon for benefit determinations

ApplicabilityDefinitions may not apply to all plans; refer to member-specific benefit plan document

inv-219: BRCA Lab Screening — Laboratory testing for BRCA1/2 gene mutations represented by procedure codes 81162-81166.

BRCA lab screening codesProcedure codes 81162–81166 (and related BRCA codes listed) represent BRCA lab screening

Prerequisite

Policy Revision History

2026-04-01codes_addedLatest

Added ICD-10 diagnosis codes Z01.42, Z12.72, and Z12.79 to the policy's Applicable Codes list.

Per the policy revision history (effective 04/01/2026), CPT/HCPCS codes 76977, 77081, and G0130 were removed from the applicable code lists. The Osteoporosis Screening description was updated to reflect the USPSTF Jan. 2025 B recommendation to screen women aged 65 and older and postmenopausal women younger than 65 at increased risk.

The policy includes a partial list of ICD‑10 pregnancy and obstetric diagnosis codes used throughout the preventive care tables. These ICD‑10 codes are provided to support proper diagnosis linkage for prenatal, pregnancy‑related screening, and well‑woman preventive services; when a conflict exists, the member‑specific benefit plan document governs application of the preventive benefit.

Policy Summary

Payersierra health and life

PolicyPreventive Care Services (Preventive Care Services Benefit) — UnitedHealthcare Commercial & Individual Exchange

Policy CodePolicy MP.016.58

Change TypeCode and criteria updatesICD-10 additionsosteoporosis guidance revised

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization for BRCA lab screening (procedure codes 81162–81166) and ensure genetic counseling and required diagnosis codes are documented before testing.

SourceLink

On This Page

Screen all adults aged 18-79 at least once

Procedure codes 86803, 86804, G0472; no diagnosis code requirement for preventive benefit

HIV screening: Screen adolescents and adults aged 15-65 and others at increased risk; all pregnant persons whose status is unknown should be screenedage 15-65 or risk/pregnancy

Requires listed HIV screening procedure codes and appropriate screening or pregnancy diagnosis codes; blood draw codes when applicable

Syphilis screening: Screen asymptomatic nonpregnant persons at increased risk and universally screen early in pregnancy; retest if not screened earlierpregnancy or increased risk

Procedure codes 0064U, 0065U, 0210U, 86592, 86593, 86780; blood draw codes 36415/36416

ages 6 months-6 years

Bright Futures recommends screening at 12 and 24 months

Dyslipidemia screening: Lab panel CPTs listed for ages 24 months to 21 years (ends on 22nd birthday); requires one of listed diagnosis codes; risk assessment timing per Bright Futuresages 24 months-21 years

No frequency limit stated except recommended intervals

Risk assessment at specific adolescent ages; screening lab work at least once between 15-21 years and when risk assessment is positive.

See adolescent/adult HIV screening row for codes

ECG for SCA/SCD: ECG screening indicated when concern for SCA/SCD; ECG should be first test and interpreted by appropriately trained physician; requires at least one screening diagnosis code and one additional diagnosis code from listed set; limited to ages 11-21 when specified.diagnosis-code-and-age-based

ECG codes 93000/93005/93010

Well-Woman Preventive Visits: HRSA requires at least one preventive care visit per year beginning in adolescence through lifespan; codes for well-woman and prenatal visits provided; some codes require pregnancy diagnosis codes for preventive benefit to apply; global obstetrical codes cover routine low-risk prenatal visits as preventive without diagnosis requirement for preventive benefit.annual

See preventive benefit instructions and Coverage Rationale for payment nuances

Code Group 5 coverage: IUD follow-up visits and pelvic examination add-on (99459) require one of the Code Group 5 diagnosis codes for preventive benefit application; 99459 may not be payable in all circumstances.

source: chunk 197

Code Group 6 coverage: Impacted IUD removal (58562) does not have diagnosis code requirements for preventive benefits to apply.

source: chunk 197

Code Group 7 coverage: Related E/M visits and pregnancy tests require one of the Code Group 7 diagnosis codes (including Z98.51, Z30.2, Z30.0x series) for preventive benefit application.

source: chunk 199

Cervical cancer screening: Refer to the Cervical Cancer Screening row in the Preventive Care Services; HPV testing guidance follows WPSI recommendations (HPV testing every 5 years or cytology every 3 years for average-risk women aged 21-65).

See Preventive Care Services for detailed age-based rules.

Anxiety screening for adolescent and adult women (including pregnant/postpartum) is supported; CPT 96127 requires the listed diagnosis Z13.39 for preventive benefit billing.

Per HRSA/WPSI guidance.

as relevant to screening and follow-up

HRSA Dec. 2024 recommendation

Breast screening completion documentation: Average risk diagnosis codes are required to complete screening process for mammography diagnostic, breast ultrasound, breast MRI, and pathology evaluation.diagnosis codes present on claim

See Applicable Codes rows

Procedure codeUltrasound screening study for AAA: 76706

inv-141: Age for Hepatitis C screening — Adults aged 18-79 years

Hepatitis C screening age rangeAdults aged 18-79 years

Procedure codes86803, 86804, G0472

Blood draw codes36415, 36416

inv-142: Age for HIV screening — Adolescents and adults aged 15-65 years (and others at increased risk)

HIV screening age rangeAdolescents and adults aged 15-65 years

Additional groupsYounger adolescents and older adults at increased risk; all pregnant persons with unknown status

Procedure and blood draw codesMultiple listed (e.g., 86689, 87389, G0432); blood draw 36415/36416 when applicable

inv-143: Age limits for colorectal and diabetes screening — Diabetes/prediabetes screening limited to ages 35-70; Cholesterol screening ASCVD: ages 40-75; Colorectal screening ages 45-75

Diabetes/prediabetes screening age limitsLimited to ages 35-70 (ends on 71st birthday)

Cholesterol/ASCVD screening age limitsAges 40-75

Colorectal screening age limitsAges 45-75 (ends on 76th birthday)

inv-144: Age limits for colorectal and related screenings — 45-75 years (ends on 76th birthday) for colonoscopy/FOBT/FIT/fecal DNA/CT colonography

Colorectal and related screening age range45-75 years (ends on 76th birthday)

Included modalitiesColonoscopy, FOBT/FIT, fecal DNA, CT colonography (virtual)

Diagnosis-code rulesSome colonoscopy/pathology/anesthesia codes require listed preventive diagnosis codes to be treated as preventive

inv-145: Fecal DNA frequency — Benefit limited to once every 3 years

Fecal DNA frequency limitBenefit limited to once every 3 years

Procedure codes0464U, 81528

Diagnosis code requirementCode 81528 does not have diagnosis code requirements for preventive benefits to apply

inv-146: Newborn screening window — Age 0-90 days

Newborn screening windowAge 0-90 days

Included panels/testsMetabolic screening panel, PKU, hypothyroidism, sickle cell (procedure codes listed)

Blood draw codes36415, 36416

inv-147: Pediatric high BMI — >= 95th percentile for age and sex (or >=120% of 95th percentile for some pediatric BMI codes)

Pediatric high BMI threshold>= 95th percentile for age and sex

Alternate pediatric criterion>= 120% of the 95th percentile for some pediatric BMI codes (Z68.54–Z68.56)

Referenced interventionsReferral to comprehensive, intensive behavioral interventions per USPSTF

inv-148: Adult obesity BMI — BMI >= 30.0

Adult obesity BMI thresholdBMI >= 30.0

Recommended interventionIntensive multicomponent behavioral interventions and related counseling codes (G0446, G0447, G0473)

Diagnosis codes examplesZ68.30–Z68.39 (BMI 30.0-39.9); Z68.41–Z68.45 (BMI >=40)

inv-149: LDCT eligibility — Age 50-80, >=20 pack-years, current smoker or quit within 15 years, limit one per year

LDCT eligibility age and smoking historyAge 50-80 (ends on 81st birthday) AND >=20 pack-years AND current smoker or quit within past 15 years

Frequency limitLimited to one per year

Prior authorization notePrior authorization may apply depending on plan; reporting codes G9275/G9276 are reporting only

inv-150: Pediatric age endpoints — Many pediatric preventive services end on 22nd birthday or specific younger ages

Pediatric preventive services age endpointMany pediatric preventive services end on the 22nd birthday (e.g., dyslipidemia labs ages 24 months–21 years)

Examples with earlier endpointsFluoride: age 0-5 ends on 6th birthday; lead screening: ages 6 months–6 years ends on 7th birthday

Well-child screening referenceBright Futures schedules and age-based intervals govern timing

inv-151: Pediatric age endpoints — Examples: Ages 24 months to 21 years (ends on 22nd birthday); ECG screening limited to ages 11-21

Example pediatric age rangesAges 24 months to 21 years (ends on 22nd birthday)

ECG screening age limitECG screening for SCA/SCD limited to ages 11-21 (ends on 22nd birthday) when specified

Bright Futures intervalsBright Futures screening intervals apply across 0-21 years for many services

inv-152: Gestational diabetes screening timing — After 24 weeks; preferably between 24 and 28 weeks

Gestational diabetes screening timingAfter 24 weeks of gestation; preferably between 24 and 28 weeks

Early screeningScreen earlier if risk factors for type 2 diabetes or GDM are present (ideally at first prenatal visit)

Source guidanceHRSA Requirement (Jan. 2023)

inv-153: Postpartum diabetes screening timing — Within first year postpartum (as early as 4–6 weeks); then at least every 3 years for minimum 10 years

Postpartum diabetes screening timingWithin the first year postpartum (as early as 4–6 weeks); then at least every 3 years for minimum 10 years

PopulationWomen with prior gestational diabetes mellitus (GDM)

Recommended codesDiabetes screening procedure codes (e.g., 82947–82952, 83036) and required diagnosis codes referenced in policy

inv-154: Mammography frequency — Screening should occur at least biennially and as frequently as annually; initiation no earlier than age 40 and no later than age 50 per ...

Mammography frequencyScreening should occur at least biennially and as frequently as annually

Initiation age guidanceInitiation no earlier than age 40 and no later than age 50 per WPSI guidance

Additional imagingWomen may require additional imaging/pathology to complete screening process as indicated

inv-155: Cervical cancer screening intervals — Cytology alone every 3 years; co-testing intervals referenced (HPV testing every 5 years) per HRSA guidance

Cervical cancer screening intervalsCytology alone every 3 years; co-testing/HPV testing intervals referenced with HPV testing every 5 years per HRSA guidance

Age rangeAverage-risk women aged 21-65 years (codes and age rules apply)

Billing noteUse appropriate HPV procedure codes and average-risk diagnosis codes where required

Billing Rule

Service Frequency Limits

Annual and biannual limits apply to specific preventive counseling codes. Apply frequency limits when billing preventive counseling codes to ensure correct application of preventive benefits.

G0446 (intensive behavioral counseling for cardiovascular disease) — limited to once per year.
G0445 (behavioral counseling for sexually transmitted infection prevention) — limited to twice per year.

Denial Risk

Coding, Diagnosis Linkage & Denial Triggers

Diagnosis code linkage and positioning matter for many preventive services. Some services require a specific screening or pregnancy diagnosis code (and in some cases that code must be the primary diagnosis) for the preventive benefit to apply; other services are excluded if certain diagnosis codes are present.

Certain preventive services require a listed screening or pregnancy diagnosis code to be present (examples: colonoscopy-related pathology/anesthesia require Z00.00/Z00.01/Z12.xx; diabetes screening in pregnancy requires a pregnancy diagnosis code regardless of gestational week).
Some services require the listed diagnosis code to be in the primary position (examples: Genetic Counseling and Evaluation for BRCA Testing; Prevention of HIV Infection – PrEP).
Preventive benefit will NOT apply if a diabetes diagnosis code is present in any position for diabetes screening services (see Diabetes Diagnosis Code List).
Codes with an asterisk (*) are preventive only when billed with one of the listed diagnosis codes or in addition to specific screening codes (see applicable code rows for details).
For LDCT lung screening: all eligibility criteria must be met (age 50–80, ≥20 pack-years, current smoker or quit within 15 years); limited to one per year — failure to meet criteria may result in denial.

Note

Code Listing Informational Notice

Code listings are informational only and do not guarantee coverage or payment. Inclusion of a code in this policy does not imply the service is covered, reimbursable, or payable under a member's specific benefit plan.

Benefit coverage is determined by the member-specific benefit plan document and applicable federal/state mandates.
Other policies and guidelines (e.g., site-of-service reviews, prior authorization, medical policy exclusions) may affect payability.

Documentation Required

Member-Specific Plan & Coverage Governance

Plan-specific coverage limits and member-specific plan govern. Always verify coverage and administrative rules (prior authorization, pharmacy sourcing, site-of-service review, frequency limits) against the member's benefit plan.

Certain plans may not be required to include PPACA-identified services — confirm member-specific benefit plan document.
For preventive medications and pharmacy-covered contraceptives, refer to the member's pharmacy benefit plan administrator for coverage and sourcing details.
Services identified by this policy may be covered under other portions of the medical benefit plan when excluded from the preventive benefit; check member plan for cost-sharing and benefit application.

Documentation Required

Documentation & Related Visit Requirements

Related visit documentation and breast/breastfeeding code requirements. When billing for contraception/sterilization, breastfeeding equipment, or breast-related screening completion, include required related visit or diagnosis codes to support preventive benefit.

Related office/outpatient E/M visits should be billed when contraception or sterilization services are provided (e.g., 99202–99205, 99211–99215, 99417, G0463).
E0603 (personal use electric breast pump) is limited to one purchase per birth and E0603 plus supplies A4281–A4287 require at least one of the breastfeeding diagnosis codes listed in this row (e.g., O92.70, O92.79, Z39.1, Z39.2). Breastfeeding equipment access should not be predicated on prior failure of a manual pump.
Average-risk breast diagnosis codes (e.g., Z40.01, Z90.10–Z90.13) are required to complete screening-related services (diagnostic mammography, breast ultrasound, breast MRI, pathology evaluation).
Related pregnancy tests (81025, 84702, 84703) and pelvic exam add-on (99459) — follow code-group diagnosis requirements when applicable.

Documentation Required

Genetic Counseling & BRCA Testing Workflow

Genetic counseling requirement before BRCA testing and counseling/testing pathway. Genetic counseling and evaluation codes should be used per the policy when assessing eligibility for BRCA lab screening; counseling is a prerequisite on medical-necessity plans.

Genetic Counseling and Evaluation procedure codes: 96041, S0265 and applicable E/M codes (e.g., 99212–99215, 99385–99387, 99395–99397, G0463) — requires one of the listed genetic counseling diagnosis codes (e.g., Z15.01, Z15.02, Z80.3, Z80.41) in the primary position on medical-necessity plans.
If indicated after counseling, BRCA lab screening may be performed (procedure codes include 81162–81166, 81167, 81212, 81215–81217) but prior authorization applies; ensure counseling documentation and required diagnosis codes are present.

Documentation Required

ECG Screening Diagnosis Requirements

ECG screening for SCA/SCD — required diagnosis coding rules. ECG screening requires at least one required screening diagnosis code and at least one additional diagnosis code from the listed set to qualify under the preventive benefit.

Procedure codes: 93000, 93005, 93010.
Required Screening Diagnosis Codes (at least one): Adult Z00.00 or Z00.01; Child Z00.121 or Z00.129.
Additional Diagnosis Codes (at least one required): include cardiomyopathy, conduction disorders, syncope, abnormal findings, congenital conditions, family history codes (examples: I42.0–I42.2, I45.81, I49.8–I49.9, R55, Q87.x, Z82.41, Z84.81, Z82.49).

Note

Final Verification & Cross-Policy Checks

Verify member-specific benefit and ancillary policy interactions before billing. Confirm applicable plan limits, prior authorizations, pharmacy sourcing, and other medical policies (site-of-service, outpatient surgical procedures, imaging policies) that may affect payment or member cost-sharing.

Colonoscopy may incur member cost-sharing or require advanced notification/site-of-service review when performed outside USPSTF age range, for diagnostic/surveillance/therapeutic indications, or when provider is non-network.
Refer to related medical policies (Outpatient Surgical Procedures - Site of Service; Screening Colonoscopy Procedures - Site of Service; MRI and CT Site of Service) for additional billing and site reviews.
Before using this policy, check the member-specific benefit plan document and any federal/state mandates; in a conflict, the member-specific plan governs.

Genetic counseling recommended and required for some plan types before BRCA testing; counseling diagnosis codes required in primary position for some rows

Prior authorizationPrior authorization requirements apply to BRCA lab screening procedures 81162–81166 for many plans

inv-220: Relevant diagnosis codes — ICD-10 codes cited for BRCA risk or family history: Z15.01, Z15.02, Z80.3, Z80.41, Z85.3, Z85.43.

BRCA-related diagnosis codesZ15.01, Z15.02, Z80.3, Z80.41, Z85.3, Z85.43

UseDiagnosis codes used to document personal/family history or genetic susceptibility associated with BRCA testing pathways

Counseling pathwayWomen with a positive result on a familial risk assessment tool should receive genetic counseling and, if indicated, testing

inv-223: USPSTF B — USPSTF B: Recommends the service; clinicians should offer or refer patients as specified (e.g., diabetes/prediabetes screening ages 35-70...)

USPSTF B meaningUSPSTF B: Recommends the service; clinicians should offer or refer patients as specified

Example applicationDiabetes/prediabetes screening ages 35-70 for adults with overweight or obesity is a USPSTF B recommendation

Coverage implicationServices with USPSTF B rating are covered as preventive under PPACA mandates when applicable

inv-224: Fecal DNA — Fecal DNA testing (codes 0464U, 81528) is a preventive colorectal screening option for ages 45-75, limited to once every 3 years; these c...

Fecal DNA codes & age/frequencyProcedure codes 0464U, 81528 for fecal DNA testing; indicated for ages 45-75 and limited to once every 3 years

Diagnosis requirementCode 81528 does not have diagnosis code requirements for preventive benefits to apply

Relation to other screening codesFecal DNA may be billed in addition to G0104/G0105/G0121/G0328/S0285 as indicated

inv-225: FOBT/FIT (G0328, 82270, 82274) — G0328 is preventive without diagnosis code requirements; codes 82270/82274 are preventive when billed with specified diagnosis codes or i...

FOBT/FIT codesG0328, 82270, 82274

Billing rulesG0328 is preventive without diagnosis code requirements; 82270/82274 are preventive when billed with listed diagnosis codes or in addition to specified screening codes

Age limitsAge limits for FOBT/FIT: 45-75 years (ends on 76th birthday)

inv-226: Encounter for Screening Examination for Other Mental Health and Behavioral Disorders — ICD-10 code Z13.39 used to indicate screening encounters for anxiety and related mental health screening.

Anxiety screening encounter codeEncounter for Screening Examination for Other Mental Health and Behavioral Disorders: Z13.39

Procedure code for anxiety screening96127 (brief emotional/behavioral assessment)

ApplicationUsed for anxiety screening in adults and children/adolescents per USPSTF and HRSA guidance

inv-227: Pack-year — A measure of smoking exposure calculated by multiplying packs per day by years smoked (definition noted in LDCT guidance).

Pack-year definitionA measure of smoking exposure calculated by multiplying packs per day by years smoked

Use in LDCT eligibilityPack-year threshold (>=20 pack-years) required for LDCT screening eligibility

SourceDefined in LDCT guidance within policy

inv-228: ECG Screening for SCA/SCD — Electrocardiogram performed for those at risk; limited to ages 11-21 in some instances and requires at least one screening and one additi...

ECG screening age limit and requirementsECG screening for SCA/SCD limited to ages 11-21 in specified instances; requires at least one screening diagnosis code and one additional diagnosis code from the listed set

Procedure codes93000, 93005, 93010

Interpretation noteECG should be interpreted by physician trained in recognizing electrical heart disease