NOTE: Please append modifier 33 when indicated. If modifier 33 is not appended, regular plan benefits will be applied.

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1 Policy name: Health Guidelines - Men This policy applies only to non-grandfathered plans as defined in the Affordable Care Act section The following chart contains procedure, diagnosis and modifier code combinations that identify services covered under HMSA's Health Guidelines Men medical policy. Please refer to the medical policy for additional criteria. * For professional claims, the applicable code must be identified as the primary line diagnosis to ensure appropriate application of benefits. * You will not receive the maximum payment allowed for these services under the new guidelines if the code combinations below are not submitted on your claim. NOTE: Please append modifier when indicated. If modifier is not appended, regular plan benefits will be applied. Abdominal Aortic Aneurysm Ultrasound B-scan and/or real time with image documentation; for adominal aortic aneurysm (AAA) screening Z13.6 Colorectal Cancer Z12.11 Z12.12 Z80.0 Z83.71 Z84.81 S0285 Colonoscopy consultation performed prior to a screening colonoscopy procedure G0104 G0105 G0121 Colorectal cancer screening; flexible sigmoidoscopy Colorectal cancer screening; colonoscopy on individual at high risk Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk 450 Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 451 with biopsy, single or multiple 452 with removal of foreign body 453 with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery 454 with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) 455 with directed submucosal injection(s), any substance 457 with decompression of volvulus, any method 458 with removal of tumor(s), polyp(s), or other lesion(s) by snare technique with dilation by balloon, 1 or more strictures with ablation of tumor(s), polyp(s), or other lesion(s) (includes preand post-dilation and guide wire passage, when performed) with endoscopic mucosal resection with band ligation(s) (eg, hemorrhoids) Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) with removal of foreign body with biopsy, single or multiple Updated on 1/24/2018 Health - Men - Coding Guidelines Page 1

2 Colorectal Cancer (con't) with directed submucosal injection(s), any substance with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery with removal of tumor(s), polyp(s), or other lesion(s) by snare technique with dilation by balloon, 1 or more strictures with ablation of tumor(s), polyp(s), or other lesion(s) (includes preand post-dilation and guide wire passage, when performed) with endoscopic stent placement (includes pre- and post-dilation and guide wire passage, when performed) with endoscopic ultrasound examination with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) with decompression (for pathologic distention) (eg, volvulus, megacolon), including placement of decompression tube, when performed with band ligation(s) (eg, hemorrhoids) G0328 Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous determinations Z12.11 Z12.12 Z80.0 Z83.71 Z Computed tomographic (CT) colonography, screening, including image postprocessing Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided 3 cards or single triple card for consecutive collection) Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy Level III - Surgical pathology, gross and microscopic examination Level IV - Surgical pathology, gross and microscopic examination Special stain including interpretation and report; Group I for microorganisms (eg, acid fast, methenamine silver) Special stain including interpretation and report; Group II, all other (eg, iron, trichrome), except stain for microorganisms, stains for enzyme constituents, or immunocytochemistry and immunohistochemistry Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure) Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure bowel preparation medication Updated on 1/24/2018 Health - Men - Coding Guidelines Page 2

3 Type 2 Diabetes Mellitus High Blood Pressure Collection of venous blood by venipuncture Z Glucose; quantitative, blood (except reagent strip) Hemoglobin; glycosylated (A1C) Z01.30 Z01.31 Z Counseling. medicine counseling and/or risk factor reduction HIV Collection of venous blood by venipuncture Antibody; HTLV or HIV antibody, confirmatory test (eg, Western Blot) Antibody; HIV Antibody; HIV Antibody; HIV-1 and HIV-2, single result (eff 1/1/2013) Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies, single result Z11.4 Z (eff 1/1/2013) (eff 1/1/2013) G0432 G04 G0435 G0475 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV-1 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; HIV-2 Infectious agent antibody detection by enzyme immunoassay (EIA) technique, HIV-1 and/or HIV-2, screening Infectious agent antibody detection by enzyme-linked immunosorbent assay (ELISA) technique, HIV-1 and/or HIV-2, screening Infectious agent antigen detection by rapid antibody test of oral mucosa transudate, HIV-1 or HIV-2, screening HIV antigen/antibody, combination assay, screening Syphilis Collection of venous blood by venipuncture Screening for hepatitis C virus (HCV) Screening for hepatitis B virus (HBV) Syphilis test, non-treponemal antibody; qualitative (e.g., VDRL, RPR, ART) Antibody; Treponema pallidum Collection of venous blood by venipuncture G0472 Hepatitis C antibody screening for individual at high risk and other covered indication(s) Collection of venous blood by venipuncture Z Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen (HBsAg) Z11.3 Z72.51 Z72.52 Z72.53 Z11.59 Z20.5 Z Updated on 1/24/2018 Health - Men - Coding Guidelines Page 3

4 Screening for hepatitis B virus (HBV) con't Aspirin for the prevention of Cardiovascular disease (CVD) Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; hepatitis B surface antigen (HBsAg) neutralization Hepatitis B core antibody (HBcAb); total Hepatitis B core antibody (HBcAb); IgM antibody Hepatitis B surface antibody (HBsAb) Z11.59 Alcohol Misuse Z71.41 F10.10-F F10.20-F F F F F10.26-F10.27 F F Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services. Differences in codes are timebased. Depression Z Counseling. medicine counseling and/or risk factor reduction Brief emotional/behavioral assessment (eg, depression inventory, attentiondeficit/hyperactivity disorder [ADHD] scale, with scoring and documentation, per standardized instrument Tobacco Use and Tobacco Caused Disease Counseling. medicine counseling and/or risk factor reduction Z71.6 Z F F F F F F F F Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes Updated on 1/24/2018 Health - Men - Coding Guidelines Page 4

5 Obesity Z04.6 Z13.1 E66.01-E66.1 E66.8-E66.9 Obesity con't Counseling. medicine counseling and/or risk factor reduction intervention(s) provided to an individual or individuals in a group setting (separate procedure). Differences Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes group (2 or more individual(s)) each 30 minutes S9470 Healthy Diet Nutritional counseling, dietitian visit Counseling. medicine counseling and/or risk factor reduction Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes Z04.6 Z13.1 E66.01-E66.1 E66.8-E66.9 Z71.3 with one of the following additional diagnoses: E10.10-E10.9 E11.00-E11.9 E13.00-E13.9 I10 E71.30 E75.21-E75.22 E E75.3 E75.5-E75.6 E77.0-E77.9 E78.00-E78.70 E78.79-E78.9 E88.1-E88.2 E group (2 or more individual(s)) each 30 minutes S9452 Nutrition classes, nonphysician provider, per session S9470 Nutritional counseling, dietitian visit Sexually Transmitted Infections (STI) Z70.0-Z70.1 Z71.7 Z71.89 Z72.51-Z72.53 Z77.21 Z77.9 Z Counseling. medicine counseling and/or risk factor reduction intervention(s) provided to an individual or individuals in a group setting (separate procedure). Differences Updated on 1/24/2018 Health - Men - Coding Guidelines Page 5

6 Prevention of falls Z Counseling. medicine counseling and/or risk factor reduction Vitamin D supplementation for the prevention of falls Skin cancer Z12.83 Z Counseling. medicine counseling and/or risk factor reduction Lung Cancer G0297 Low-dose computed tomography for lung cancer screening. Z12.2 Statin Use for the Prevention of Cardiovascular Disease Collection of venous blood by venipuncture Z Lipid panel Cholesterol, serum or whole blood, total Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) Tuberculosis Collection of venous blood by venipuncture Z Tuberculosis test, cell mediated immunity antigen response measurement; gamma interferon Tuberculosis test, cell mediated immunity antigen response measurement; enumeration of gamma interferon-producing T-cells in cell suspension Skin test; tuberculosis, intradermal Updated on 1/24/2018 Health - Men - Coding Guidelines Page 6

NOTE: Please append modifier 33 when indicated. If modifier 33 is not appended, regular plan benefits will be applied.

NOTE: Please append modifier 33 when indicated. If modifier 33 is not appended, regular plan benefits will be applied. Policy name: Preventive Health Guidelines - Men The following chart contains procedure and diagnosis code combinations that identify services covered under HMSA's Preventive Health s policy. * For professional