RELATED MEDICAL POLICIES: N/A. Select a hyperlink below to be directed to that section.

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1 BENEFIT COVERAGE GUIDELINE Preventive Care Effective Date: Feb. 1, 2018 Last Revised: March 28, 2018 Replaces: N/A RELATED MEDICAL POLICIES: N/A Select a hyperlink below to be directed to that section. POLICY CRITERIA CODING RELATED INFORMATION EVIDENCE REVIEW REFERENCES HISTORY Clicking this icon returns you to the hyperlinks menu above. Introduction The health plan covers preventive services that are required by the Affordable Care Act (ACA) without cost share by the member. The services need to be provided by an in-network provider to be covered with no member cost. There are some plans that may not cover these preventive services. Plans that are grandfathered, or have an exemption allowed by the law, are not required to cover the ACA preventive services. (Please contact the health plan to find out if you have one of these plans and to find details on your specific preventive coverage.) The ACA covered preventive care services are identified and updated by the following organizations: United States Preventive Services Task Force (USPSTF) grade A or B recommendations Advisory Committee on Immunization Practices (ACIP) recommendations adopted by the Director of the Center for Disease Control and Prevention (CDC) Health Resources and Services Administration (HRSA) supported comprehensive guidelines which are published by any of the following sources: The Bright Futures Recommendations for Pediatric Preventive Health Care schedule of services Uniform Panel of the Secretary s Advisory Committee on Heritable Disorders in Newborns and Children

2 Specific women s health care services and guidelines adopted by HRSA The health plan only covers in-network preventive services with no member cost if they are provided within the specific guidelines issued by the above organizations, as noted in this benefit coverage guideline Preventive services are recommended by the organizations based on what is best for the general population. For each individual person, the doctor might recommend other tests. This means that for the patient, the tests a doctor orders may not all be covered under the preventive care benefit. Blood tests that are run as panels and include multiple tests are not considered preventive, although one or two of the individual test may be covered. Preventive care services, as provided by the guidelines, include wellness exams and immunizations for children and adults. Specific screening tests are also covered for people who have no symptoms or known diseases, and are in a specified age group or at risk population, when provided in accordance with the applicable guidelines. Care associated with a screening colonoscopy or sterilization services for women are also covered without cost share. This may include a pre-op visit office visit, medically necessary anesthesia services, facility fees, and pathology services. The list of preventive services may be updated at regular intervals by the sponsoring agencies, and new services will be added or changed usually within 12 months of the guidance issued by the designated organizations. Reasonable medical management techniques may be used by health plans, and this might include prior authorization, concurrent review, or claims review. Screening Versus Diagnostic, Monitoring, or Surveillance Testing: Screening exams are done in people with no symptoms or known disease. Diagnostic tests are done to evaluate abnormal lab results, physical findings or symptoms. Surveillance or monitoring tests are done in individuals who have a known condition or history that increases their risk of disease, and is no longer considered a screening exam. Usually surveillance tests are done more frequently than screening tests for the general population. If a screening test is positive, or shows an abnormality, that test is still considered preventive, however the same test in the future will not be considered preventive. Here are some examples: 1. A screening colonoscopy shows presence of a polyp, which is removed. In the future colonoscopies will be done more frequently as surveillance, that is looking for more polyps. Page 2 of 15

3 These subsequent colonoscopies are not preventive and are paid for under your medical benefit. 2. A stool test is done and is positive. The next test needed is a diagnostic colonoscopy, which is not preventive. That test is covered under your medical benefit. Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered. Guidelines Coverage Information Preventive services are defined as follows: Evidence-based items or services with a rating of A or B in the current recommendations of the U.S. Preventive Task Force (USPSTF). Preventive care and screenings for women as provided for in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA). Immunizations as recommended by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control (CDC) and Prevention. Evidence-informed infant, child and adolescent preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA, Bright Futures). Services that meet the guidelines for preventive care under Washington state law. Preventive service performed within an inpatient setting: If a preventive service is performed within an inpatient setting, the preventive service will be covered in full. However, the preventive service is considered incidental. The facility fees are not covered under preventive benefits since the service is incidental to and is not the primary reason for the admission. Page 3 of 15

4 Coverage Information Members need to refer to their plan s benefit booklet for a comprehensive discussion of coverage and payment information. Some services may require prior authorization; refer to our online code check tool for information. Coding Service Procedure Code(s) Comments Adult aortic aneurysm The USPSTF recommends one-time screening for screening ultrasound abdominal aortic aneurysm by ultrasonography in men ages 65 to 75 years who have ever smoked. Alcohol misuse screening and counseling care 99408, 99409, G0442, G0443 The USPSTF recommends that clinicians screen adults age 18 years or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse. Aspirin to prevent cardiovascular disease Blood pressure screening Aspirin requires a written prescription and is processed under the member s prescription drug plan. Blood pressure screening is not reimbursed separately from the office visit. The USPSTF recommends the use of aspirin: For men ages 45 to 79 years when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage. For women ages 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage The USPSTF recommends: Screening for high blood pressure in adults aged 18 years or older. Obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment. Page 4 of 15

5 Service Procedure Code(s) Comments Cholesterol screening 80061, 82465, 83695, 83700, 83718, 83719, 83721, when billed with the following diagnosis: Z00.00 & Z00.01 The USPSTF: Strongly recommends screening men age 35 years and older for lipid disorders. Recommends screening men ages 20 to 35 years for lipid disorders if they are at increased risk for coronary heart disease. Strongly recommends screening women age 45 years and older for lipid disorders if they are at increased risk for coronary heart disease. Recommends screening women ages 20 to 45 years for lipid disorders if they are at increased risk for coronary heart disease. Colorectal cancer screening Fecal occult blood and FIT 81528, 82270, 82274, G0328 Sigmoidoscopy 45330, 45331, 45333, 45334, 45346, 45338, G0104 Colonoscopy 00812, 45378, 45380, 45381, 45384, 45385, 45388, 88305, 99152, 99153, G0105, G0121, G0500 when billed with the following criteria: Screening for patients at average risk beginning at age 50: Z12.10, Z12.11, Z12.12,, Z80.0, Z83.71, Z83.79 Screening for patients under age 50, at increased risk for colon cancer due to a strong family history of colon cancer: Z80.0, Z83.71, Z83.79, Z84.81 Screening colonoscopy for patients with personal history of inflammatory bowel disease (Crohn disease or ulcerative colitis) will be recognized as preventive with a screening diagnosis in the primary position, and a disease specific diagnosis in secondary position: The USPSTF: Recommends screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary. The plan also covers several colon imaging tests which may be preferred by some members Page 5 of 15

6 Service Procedure Code(s) Comments Z12.10, Z12.11, Z12.12 Colonoscopy Pathology when billed with the following diagnosis: D12.6, D37.4, D49.0, K63.5, Z12.10-Z12.12, Z84.81 Colonoscopy Preoperative Assessment S0285 Barium enema 74263G0106, G0120, G requires prior authorization through AIM Depression screening (adults, children, and adolescents) Diabetes screening, type 2 and gestational Diet counseling Healthy diet and physical activity counseling to prevent cardiovascular disease: adults with cardiovascular risk factors 96127, G0444 when billed with diagnosis Z , 82948, 82950, 82951, 82952, 83036, when billed with any maternity diagnosis and the following diagnosis: Z00.00, Z00.01, Z , 97803, 97804, 99078, 99401, 99402, 99403, 99404, 99411, 99412, G0108, G0109, G0270, G0271, S9140, S9145, S9452, S9465, S9470, G0446 The USPSTF recommends screening: Adolescents (ages years) for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and followup. Adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and followup. The USPSTF recommends: Screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity. Diet counseling The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in: Adults aged 40 to 70 years who are overweight or obese. Clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity. Page 6 of 15

7 Service Procedure Code(s) Comments Healthy diet and physical activity counseling to prevent cardiovascular disease: adults with cardiovascular risk factors The USPSTF recommends offering or referring adults who are overweight or obese and have additional cardiovascular disease (CVD) risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention. Fall prevention older adults Fall prevention vitamin D 97010, 97012, 97014, 97110, 97112, 97113, 97161, 97162, 97163, 97165, 97166, 97167, When billed with diagnosis Z91.81, Z91.89 Vitamin D requires a written prescription and is processed under the member s prescription drug plan. Hepatitis B screening 80055,87350,86704, 86705, 86706, 86707, 87340, 87341, G0499 The USPSTF recommends exercise or physical therapy to prevent falls in community-dwelling adults age 65 years and older who are at increased risk for falls. The USPSTF recommends vitamin D supplementation to prevent falls in community-dwelling adults age 65 years and older who are at increased risk for falls. The USPSTF: Recommends screening for hepatitis B virus infection in persons at high risk for infection. Strongly recommends screening for hepatitis B virus infection in pregnant women at their first prenatal visit. Hepatitis C screening 86803, 86804, G0472 The USPSTF recommends: Screening for hepatitis C virus (HCV) infection in persons at high risk for infection. Offering one-time screening for HCV infection to adults born between 1945 and HIV screening 86689, 86701, 86702, 86703, 87806,G0432, G0433, G0435, G0475, S3645 When billed with any pregnancy diagnosis codes or the following screening diagnosis: Z00.00, Z00.01, Z22.6, Z22.8, Z22.9, Z11.3, Z11.4, Z11.59, Z11.9, Z26.0 The USPSTF recommends that: Clinicians screen for HIV infection in adolescents and adults ages 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. Clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown. Immunizations All immunizations are fully covered under the preventive services benefit. Page 7 of 15

8 Service Procedure Code(s) Comments Lung cancer screening (CT scan) for those at higher risk G0296 & G0297 G0297 requires prior authorization through AIM. The USPSTF recommends: Annual screening for lung cancer with low-dose computed tomography in adults ages 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. Obesity screening and counseling Prostate cancer screening Sexually transmitted disease counseling Syphilis screening 97802, 97803, 97804, 99401, 99402, 99403, 99404, G0447, S9452, S9470 when billed with the following diagnosis: Z68.3-Z68.39, Z68.4-Z68.45, Z68.53, Z , 84153, 84154, G0102, G0103 G0445, 99401, 99402, 99403, 99404, 99411, ,86593, when billed with the following diagnosis: Z00.00, Z00.01, Z11.2, Z11.3, Z11.9, Z20.2 The USPSTF recommends: Screening all adults for obesity. Clinicians should offer or refer patients with a body mass index of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions. o Clinicians screen children age 6 years and older for obesity and offer them or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status. The USPSTF recommends that clinicians inform men ages 55 to 69 years about the potential benefits and harms of prostate-specific antigen (PSA) based screening for prostate cancer. Per the RCW , prostate cancer screening can be covered as preventive once a year The USPSTF recommends intensive behavioral counseling for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections. The USPSTF recommends clinicians screen: Persons at increased risk for syphilis infection. All pregnant women for syphilis infection. Tobacco use counseling and interventions 99406, The USPSTF recommends that clinicians: Ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and U.S. Food and Drug Administration (FDA) approved pharmacotherapy for cessation to adults who use tobacco. Provide interventions, including education or brief counseling, to prevent initiation of tobacco use in school-aged children and adolescents. Ask all pregnant women about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who Page 8 of 15

9 Service Procedure Code(s) Comments use tobacco. Tuberculosis (TB) testing 86480, 86481, Bright Futures recommends tuberculosis if the risk assessment is positive and test is administered. Otherwise, the risk assessment is subsumed by the preventive medicine services code and not separately reported. The USPSTF recommends screening for latent tuberculosis infection (LTBI) in populations at increased risk Women s Healthcare If not listed below, additional women s healthcare categories may be included in the table above Service Procedure Code(s) Comments Anemia screening hematocrit or hemoglobin Bacteriuria screening: pregnant women and urinary tract Breastfeeding counseling interventions to support breast feeding 85013, 85014, 85018, 85025, when billed with any pregnancy diagnosis or any patients ages 18 and under , 81003, 81007, 87081, 87084, 87086, when billed with any pregnancy diagnosis 99401, 99402, 99403, 99404, S9442, S9443 when billed with DX Z39.1 The USPSTF recommends routine screening for iron deficiency anemia in asymptomatic pregnant women. Also covered in any patient ages 18 or under. The USPSTF recommends screening for asymptomatic bacteriuria with urine culture in pregnant women at 12 to 16 weeks' gestation or at the first prenatal visit, if later. The USPSTF recommends interventions during pregnancy and after birth to promote and support breastfeeding. Breast pump and supplies Contraceptive visits Contraceptive implantable devices (insertion and removal) Contraceptive injectables Birth control pharmacy E0603, E0604, A4281, A4282, A4283, A4284, A4285, A4286- Hospital grade pumps are not available for purchase and are covered as rentals for 12 months Reimbursement is included in E&M visit when billed with diagnosis codes Z Z30.2, Z30.40-Z30.42, Z Z30.9, Z30.44-Z30.46, Z31.61, Z31.7, Z , 11981, 11982, 11983, 57170, 58300, A4261, A4264, A4266, G0516, G0517, G0518, J7296, J7297, J7298, J7300, J7301, J7303, J7306, J7307 when billed with diagnosis codes Z Z30.2, Z30.40-Z30.42, Z Z30.9, Z30.44-Z30.46, Z31.61, Z31.7, Z , J1050 Generic birth control pills are covered under the pharmacy plan. Page 9 of 15

10 Women s Healthcare If not listed below, additional women s healthcare categories may be included in the table above Service Procedure Code(s) Comments Birth control IUD 58300, 58301, S4981, S4989 Birth control sterilization 58340, 58565, 58600, 58605, 58611, 58615, 58670, 58671, 74740, A4264 Birth control anesthesia 00851, 00940, 00942, 00950, for sterilization Folic acid supplementation Covered with written prescription by physician. Gestational diabetes screening: pregnant women Gonorrhea screening Pre-eclampsia prevention: aspirin Rh incompatibility screening 82947, 82948, 82950, 82951, 82952, 83036, When billed with any pregnancy diagnosis or the following diagnosis: Z57.8, Z00.00, Z00.01, Z , 87591, 87592, When billed with any pregnancy diagnosis or the following diagnosis: Z00.00, Z00.01, Z11.3. Z11.9, Z20.2 Covered with a written prescription by physician 86901, when billed with any pregnancy diagnosis The USPSTF recommends that all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid. The USPSTF recommends screening for gestational diabetes mellitus in asymptomatic pregnant women after 24 weeks of gestation. The USPSTF recommends screening for gonorrhea in sexually active women age 24 years or younger and in older women who are at increased risk for infection The USPSTF recommends the use of low-dose aspirin (81 mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia. The USPSTF: Strongly recommends Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care. Rubella screening by history of vaccination or by serology when billed with any pregnancy diagnosis Syphilis screening 86592, 86780, The USPSTF: Recommends repeated Rh (D) antibody testing for all unsensitized Rh (D)-negative women at 24 to 28 weeks' gestation, unless the biological father is known to be Rh (D)-negative. Strongly recommends that clinicians screen persons at increased risk for syphilis infection. Recommends that clinicians screen all pregnant women for syphilis infection. Breast cancer chemoprevention counseling 96040, 99401, 99402, 99403, S0265 When billed with diagnosis Z80.3, Z80.3, Z80.41, Z85.3, Z85.43, Z15.01, Z15.02 The USPSTF Recommends: Clinicians engage in shared, informed decision-making with women who are at increased risk for breast cancer about medications to reduce their risk. Page 10 of 15 For women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians

11 Women s Healthcare If not listed below, additional women s healthcare categories may be included in the table above Service Procedure Code(s) Comments should offer to prescribe risk-reducing medications, such as tamoxifen or Raloxifene. BRCA screening risk assessment and genetic counseling testing Breast cancer screening mammography Cervical cancer screening (PAP smear) 81211, 81212, 81213, 81214, 81215, 81216, When billed with diagnosis Z80.3, Z80.41, Z85.3, Z85.43, Z15.01, Z This test requires Prior Authorization under medical policy , 77065, 77066, and when billed with diagnosis codes Z00.00, Z00.01, Z12.31-Z12.39, Z80.3, Z , 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88155, 88164, 88165, 88166, 88167, 88174, 88175, G0101, G0123, G0124, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091 The USPSTF recommends: Primary care providers screen women who have family members with breast, ovarian, tubal, or peritoneal cancer with one of several screening tools designed to identify a family history that may be associated with an increased risk for potentially harmful mutations in breast cancer susceptibility genes (BRCA1 or BRCA2). Women with positive screening results should receive genetic counseling and, if indicated after counseling, BRCA testing. The USPSTF recommends screening mammography for women, with or without clinical breast examination, every 1 to 2 years for women age 40 years and older. The USPSTF recommends screening for cervical cancer: In women ages 21 to 65 years with cytology (Pap smear) every 3 years. For women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years. HPV testing (human papillomavirus DNA test) 0500T, 87623, 87624, 87625, G0476 When billed with the following diagnosis: Z00.00, Z00.01 Chlamydial infection 86631, 86632, 87110, 87270, 87320, 87485, 87486, 87490, 87491, When billed with any Pregnancy diagnosis or the following diagnosis: Z00.00, Z00.01, Z11.3, Z11.9, Z20.2 Domestic violence screening Reimbursement is included in E&M visit. Not separately reimbursable. HHS recommends high-risk human papillomavirus DNA testing in women with normal cytology (pap smear) results, every 3 years for women who are 30 or older. The USPSTF recommends screening for chlamydia: In sexually active women age 24 years or younger. In older women who are at increased risk for infection. The USPSTF recommends that clinicians screen women of childbearing age for intimate partner violence, such as domestic violence, and provide or refer women who screen positive to intervention services. This recommendation applies to women who do not have signs or symptoms of abuse. Osteoporosis screening bone density 76977, 77080, 77081, G0130 The USPSTF recommends screening for osteoporosis in women age 65 years and older and in younger women whose fracture risk is equal to or greater than that of a 65- year-old white woman who has no additional risk factors. Sexually transmitted disease counseling G0445 Page 11 of 15 The USPSTF recommends counseling for those individuals

12 Women s Healthcare If not listed below, additional women s healthcare categories may be included in the table above Service Procedure Code(s) Comments at higher risk for sexually transmitted diseases. Newborn and Children s Healthcare If not listed in below, additional newborn/children s healthcare categories may be included in the tables above Service Procedure Code(s) Comments Dental caries prevention fluoride application (primary care) 99188, D1206, D1208 for ages 0-6 years The USPSTF recommends: Application of fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption in primary care practices. Primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is fluoride deficient. Fluoride chemoprevention supplements Developmental screening (including autism) Covered with a written prescription by physician , 96127, G0451 The Bright futures recommends: A formal, standardized developmental screen is recommended during the 9 month visit. Dyslipidemia screening (lipids) Gonorrhea prophylactic medications (newborn) Hearing loss screening newborn and children Height, weight, and body max index (BMI) Hemogloinopathies (sickle cell screening) 80061, 82465, 83718, 83719, 83721, Not separately reimbursable, medication included in delivery charge , When billed with the following diagnosis: Z00.121, Z Reimbursement is included in office visit. Not separately reimbursable , 83021, 83030, 83033, 83051, S3850 A formal, standardized developmental screen is recommended during the 18 month visit, including a formal autism screen. A formal, standardized autism screen is recommended during the 24 month visit. A formal, standardized developmental screen is recommended Bright futures recommends screening for dyslipidemia once between the ages 9 to 11 and once between the ages 17 to 21 years. The USPSTF recommends prophylactic ocular topical medication for all newborns for the prevention of gonococcal ophthalmia neonatorum. The USPSTF recommends screening for hearing loss in all newborn infants. The USPSTF recommends screening for sickle cell disease in newborns. Hypothyroidism 84436, 84437, 84439, The USPSTF recommends screening for congenital hypothyroidism in newborns. Page 12 of 15

13 Newborn and Children s Healthcare If not listed in below, additional newborn/children s healthcare categories may be included in the tables above Service Procedure Code(s) Comments Iron supplements Covered with a written prescription by physician. Lead screening Bright Futures recommends screening for any children under age 18. Phenylkentonuria (PKU) 84030, S3620 Considered preventive for newborn children. Skin cancer behavioral counseling Vision acuity screening (for all children) 99401, 99402, 99403, The USPSTF recommends counseling children, adolescents, and young adults ages 10 to 24 years who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer , 99173, 99174, The USPSTF recommends screening for any children under age 18. Comprehensive preventive evaluation and management (E&M) services (preventive visits for baby, child, and adult, including women) If not listed in below, additional newborn/children s healthcare categories may be included in the tables above Service Procedure Code(s) Comments Wellness preventive examinations 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99411, 99460, 99461, 99462, 99463, G0101, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, G0402, G0513, G0514, S0610, S0612, S0613, S0622 The frequency of visits for infants, children and adolescents complies with the American Academy of Pediatrics (AAP) Bright Futures periodicity Schedule. Comprehensive preventive medicine evaluation and management of an individual includes: An age-and gender-appropriate history Physical examination Counseling/anticipatory guidance Risk Factor reduction interventions The ordering of appropriate immunization(s) and laboratory/screening procedures Note: CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). HCPCS codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS). Related Information Page 13 of 15

14 N/A Evidence Review N/A References 1. American Academy of Pediatrics / Bright Futures / Recommendations for Pediatric Preventive Healthcare. (For ages 0 21). Available at: Accessed February Advisory Committee on Heritable Disorders in Newborns and Children. Recommended Uniform Screening Panel. Available at: Accessed January Health and Human Services. Preventive Services Covered under the Affordable Care Act. Available at: Accessed January Health and Human Services. Center for Consumer Information and Insurance Oversight. Affordable Care Act Implementation. FAQs-Set 12. Available at: FAQs/aca_implementation_faqs12.html Accessed January Health and Human Services. The Center for Consumer Information and Insurance Oversight. Fact Sheets and Frequently Asked Questions. Available at: Accessed January United States Preventive Services Task Force Recommendation (USPSTF) for Prostate Cancer screening. Available at: Accessed January United States Preventive Services Task Force Recommendations (USPSTF). Available at: Accessed January United States Preventive Services Task Force. Recommendations for Primary Care Practice. Published Recommendations. Accessed December 6, Available at: Accessed January Centers for Disease Control (CDC) and Prevention / Immunization Schedules. Available at: Accessed January Health Resources & Services Administration (HRSA) for Women s Preventive Services: Required Health Plan Coverage Guidelines. Available at: Accessed January Institute of Medicine. Clinical Preventive Services for Women-Closing the Gaps.. Available at: Accessed January Advisory Committee on Immunization Practices ) ACIP) Recommendations. Available at: Accessed January Page 14 of 15

15 13. Washington Administrative Code (WAC). Available at: Accessed January History Date Comments 02/01/18 New benefit coverage guideline, approved January 16, Add to the Administrative section. 02/09/18 Coding correction, removed terminated CPT codes 77052, 77055, 77056, and Added CPT codes 77065, 77066, and /20/18 Coding update, removed CPT code 80051, added J7296 under the contraceptive implantable devices section. Clarified any pregnancy diagnosis in the Rh incompatibility screening section. 03/09/18 Coding update, removed HCPCS code J /16/18 Coding update, added CPT codes and /28/18 Minor clarification made to the Introduction section. Added clarification regarding inpatient preventive services to the Guidelines section. Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA) Premera All Rights Reserved. Scope: Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage. Page 15 of 15

16 Discrimination is Against the Law Premera Blue Cross complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Premera does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Premera: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact the Civil Rights Coordinator. If you believe that Premera has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator - Complaints and Appeals PO Box 91102, Seattle, WA Toll free , Fax , TTY AppealsDepartmentInquiries@Premera.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW, Room 509F, HHH Building Washington, D.C , , (TDD) Complaint forms are available at Getting Help in Other Languages This Notice has Important Information. This notice may have important information about your application or coverage through Premera Blue Cross. There may be key dates in this notice. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. Call (TTY: ). አማሪኛ (Amharic): ይህ ማስታወቂያ አስፈላጊ መረጃ ይዟል ይህ ማስታወቂያ ስለ ማመልከቻዎ ወይም የ Premera Blue Cross ሽፋን አስፈላጊ መረጃ ሊኖረው ይችላል በዚህ ማስታወቂያ ውስጥ ቁልፍ ቀኖች ሊኖሩ ይችላሉ የጤናን ሽፋንዎን ለመጠበቅና በአከፋፈል እርዳታ ለማግኘት በተውሰኑ የጊዜ ገደቦች እርምጃ መውሰድ ይገባዎት ይሆናል ይህን መረጃ እንዲያገኙ እና ያለምንም ክፍያ በቋንቋዎ እርዳታ እንዲያገኙ መብት አለዎት በስልክ ቁጥር (TTY: ) ይደውሉ (Arabic): العربية يحوي ھذا اإلشعار معلومات ھامة. قد يحوي ھذا اإلشعار معلومات مھمة بخصوص طلبك أو التغطية التي تريد الحصول عليھا من خالل.Premera Blue Cross قد تكون ھناك تواريخ مھمة في ھذا اإلشعار. وقد تحتاج التخاذ إجراء في تواريخ معينة للحفاظ على تغطيتك الصحية أو للمساعدة في دفع التكاليف. يحق لك الحصول على ھذه المعلومات والمساعدة بلغتك دون تكبد أية تكلفة. اتصل ب( (TTY: 中文 (Chinese): 本通知有重要的訊息 本通知可能有關於您透過 Premera Blue Cross 提交的申請或保險的重要訊息 本通知內可能有重要日期 您可能需要在截止日期之前採取行動, 以保留您的健康保險或者費用補貼 您有權利免費以您的母語得到本訊息和幫助 請撥電話 (TTY: ) Oromoo (Cushite): Beeksisni kun odeeffannoo barbaachisaa qaba. Beeksisti kun sagantaa yookan karaa Premera Blue Cross tiin tajaajila keessan ilaalchisee odeeffannoo barbaachisaa qabaachuu danda a. Guyyaawwan murteessaa ta an beeksisa kana keessatti ilaalaa. Tarii kaffaltiidhaan deeggaramuuf yookan tajaajila fayyaa keessaniif guyyaa dhumaa irratti wanti raawwattan jiraachuu danda a. Kaffaltii irraa bilisa haala ta een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabaattu. Lakkoofsa bilbilaa (TTY: ) tii bilbilaa. Français (French): Cet avis a d'importantes informations. Cet avis peut avoir d'importantes informations sur votre demande ou la couverture par l'intermédiaire de Premera Blue Cross. Le présent avis peut contenir des dates clés. Vous devrez peut-être prendre des mesures par certains délais pour maintenir votre couverture de santé ou d'aide avec les coûts. Vous avez le droit d'obtenir cette information et de l aide dans votre langue à aucun coût. Appelez le (TTY: ). Kreyòl ayisyen (Creole): Avi sila a gen Enfòmasyon Enpòtan ladann. Avi sila a kapab genyen enfòmasyon enpòtan konsènan aplikasyon w lan oswa konsènan kouvèti asirans lan atravè Premera Blue Cross. Kapab genyen dat ki enpòtan nan avi sila a. Ou ka gen pou pran kèk aksyon avan sèten dat limit pou ka kenbe kouvèti asirans sante w la oswa pou yo ka ede w avèk depans yo. Se dwa w pou resevwa enfòmasyon sa a ak asistans nan lang ou pale a, san ou pa gen pou peye pou sa. Rele nan (TTY: ). Deutsche (German): Diese Benachrichtigung enthält wichtige Informationen. Diese Benachrichtigung enthält unter Umständen wichtige Informationen bezüglich Ihres Antrags auf Krankenversicherungsschutz durch Premera Blue Cross. Suchen Sie nach eventuellen wichtigen Terminen in dieser Benachrichtigung. Sie könnten bis zu bestimmten Stichtagen handeln müssen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten zu behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Rufen Sie an unter (TTY: ). Hmoob (Hmong): Tsab ntawv tshaj xo no muaj cov ntshiab lus tseem ceeb. Tej zaum tsab ntawv tshaj xo no muaj cov ntsiab lus tseem ceeb txog koj daim ntawv thov kev pab los yog koj qhov kev pab cuam los ntawm Premera Blue Cross. Tej zaum muaj cov hnub tseem ceeb uas sau rau hauv daim ntawv no. Tej zaum koj kuj yuav tau ua qee yam uas peb kom koj ua tsis pub dhau cov caij nyoog uas teev tseg rau hauv daim ntawv no mas koj thiaj yuav tau txais kev pab cuam kho mob los yog kev pab them tej nqi kho mob ntawd. Koj muaj cai kom lawv muab cov ntshiab lus no uas tau muab sau ua koj hom lus pub dawb rau koj. Hu rau (TTY: ). Iloko (Ilocano): Daytoy a Pakdaar ket naglaon iti Napateg nga Impormasion. Daytoy a pakdaar mabalin nga adda ket naglaon iti napateg nga impormasion maipanggep iti apliksayonyo wenno coverage babaen iti Premera Blue Cross. Daytoy ket mabalin dagiti importante a petsa iti daytoy a pakdaar. Mabalin nga adda rumbeng nga aramidenyo nga addang sakbay dagiti partikular a naituding nga aldaw tapno mapagtalinaedyo ti coverage ti salun-atyo wenno tulong kadagiti gastos. Adda karbenganyo a mangala iti daytoy nga impormasion ken tulong iti bukodyo a pagsasao nga awan ti bayadanyo. Tumawag iti numero nga (TTY: ). Italiano (Italian): Questo avviso contiene informazioni importanti. Questo avviso può contenere informazioni importanti sulla tua domanda o copertura attraverso Premera Blue Cross. Potrebbero esserci date chiave in questo avviso. Potrebbe essere necessario un tuo intervento entro una scadenza determinata per consentirti di mantenere la tua copertura o sovvenzione. Hai il diritto di ottenere queste informazioni e assistenza nella tua lingua gratuitamente. Chiama (TTY: ) ( )

17 日本語 (Japanese): この通知には重要な情報が含まれています この通知には Premera Blue Cross の申請または補償範囲に関する重要な情報が含まれている場合があります この通知に記載されている可能性がある重要な日付をご確認ください 健康保険や有料サポートを維持するには 特定の期日までに行動を取らなければならない場合があります ご希望の言語による情報とサポートが無料で提供されます (TTY: ) までお電話ください 한국어 (Korean): 본통지서에는중요한정보가들어있습니다. 즉이통지서는귀하의신청에관하여그리고 Premera Blue Cross 를통한커버리지에관한정보를포함하고있을수있습니다. 본통지서에는핵심이되는날짜들이있을수있습니다. 귀하는귀하의건강커버리지를계속유지하거나비용을절감하기위해서일정한마감일까지조치를취해야할필요가있을수있습니다. 귀하는이러한정보와도움을귀하의언어로비용부담없이얻을수있는권리가있습니다 (TTY: ) 로전화하십시오. ລາວ (Lao): ແຈ ງການນ ມ ຂ ມ ນສ າຄ ນ. ແຈ ງການນ ອາດຈະມ ຂ ມ ນສ າຄ ນກ ຽວກ ບຄ າຮ ອງສະ ໝ ກ ຫ ຄວາມຄ ມຄອງປະກ ນໄພຂອງທ ານຜ ານ Premera Blue Cross. ອາດຈະມ ວ ນທ ສ າຄ ນໃນແຈ ງການນ. ທ ານອາດຈະຈ າເປ ນຕ ອງດ າເນ ນການຕາມກ ານ ດ ເວລາສະເພາະເພ ອຮ ກສາຄວາມຄ ມຄອງປະກ ນສ ຂະພາບ ຫ ຄວາມຊ ວຍເຫ ອເລ ອງ ຄ າໃຊ ຈ າຍຂອງທ ານໄວ. ທ ານມ ສ ດໄດ ຮ ບຂ ມ ນນ ແລະ ຄວາມຊ ວຍເຫ ອເປ ນພາສາ ຂອງທ ານໂດຍບ ເສຍຄ າ. ໃຫ ໂທຫາ (TTY: ). ភ ស ខមរ (Khmer): សចកត ជ នដ ណ ង ន ម នព ត ម នយ ងស ខ ន សចកត ជ នដ ណ ង ន រប ហល ជ ម នព ត ម នយ ងស ខ ន អ ព ទរមង បបបទ ឬក ររ ប រងរបស អនកត មរយ Premera Blue Cross រប ហលជ ម ន ក លបរ ចឆទស ខ ន ន កន ង សចកត ជ ន ដ ណ ង ន អនករប ហលជ រត វក រប ញច ញសមតថភ ព ដល ក ណត ថងជ ក ចប ស ន ន ដ មប ន ងរកស ទ កក រធ ន រ ប រងស ខភ ពរបស អនក ឬរប ក ជ ន យ ចញ ថល អនកម នស ទធ ទទ លព ត ម ន ន ន ងជ ន យ ន កន ងភ ស របស អនក ដ យម នអស ល យ ឡ យ ស មទ រស ពទ (TTY: ) ਪ ਜ ਬ (Punjabi): ਇਸ ਨ ਟਸ ਵਚ ਖ ਸ ਜ ਣਕ ਰ ਹ. ਇਸ ਨ ਟਸ ਵਚ Premera Blue Cross ਵਲ ਤ ਹ ਡ ਕਵਰ ਜ ਅਤ ਅਰਜ ਬ ਰ ਮਹ ਤਵਪ ਰਨ ਜ ਣਕ ਰ ਹ ਸਕਦ ਹ. ਇਸ ਨ ਜਸ ਜਵਚ ਖ ਸ ਤ ਰ ਖ ਹ ਸਕਦ ਆ ਹਨ. ਜ ਕਰ ਤ ਸ ਜਸਹਤ ਕਵਰ ਜ ਰ ਖਣ ਹ ਵ ਜ ਓਸ ਦ ਲ ਗਤ ਜ ਵ ਚ ਮਦਦ ਦ ਇਛ ਕ ਹ ਤ ਤ ਹ ਨ ਅ ਤਮ ਤ ਰ ਖ਼ ਤ ਪ ਹਲ ਕ ਝ ਖ ਸ ਕਦਮ ਚ ਕਣ ਦ ਲ ੜ ਹ ਸਕਦ ਹ,ਤ ਹ ਨ ਮ ਫ਼ਤ ਵ ਚ ਤ ਆਪਣ ਭ ਸ਼ ਵ ਚ ਜ ਣਕ ਰ ਅਤ ਮਦਦ ਪ ਰ ਪਤ ਕਰਨ ਦ ਅ ਧਕ ਰ ਹ,ਕ ਲ (TTY: ). (Farsi): فارسی اين اعالميه حاوی اطالعات مھم ميباشد.اين اعالميه ممکن است حاوی اطالعات مھم درباره فرم تقاضا و يا پوشش بيمه ای شما از طريق Premera Blue Cross باشد. به تاريخ ھای مھم در اين اعالميه توجه نماييد.شما ممکن است برای حقظ پوشش بيمه تان يا کمک در پرداخت ھزينه ھای درمانی تان به تاريخ ھای مشخصی برای انجام کارھای خاصی احتياج داشته باشيد.شما حق اين را داريد که اين اطالعات و کمک را به زبان خود به طور رايگان دريافت نماييد. برای کسب اطالعات با شماره (کاربران TTY تماس باشماره ) تماس برقرار نماييد. Polskie (Polish): To ogłoszenie może zawierać ważne informacje. To ogłoszenie może zawierać ważne informacje odnośnie Państwa wniosku lub zakresu świadczeń poprzez Premera Blue Cross. Prosimy zwrócic uwagę na kluczowe daty, które mogą być zawarte w tym ogłoszeniu aby nie przekroczyć terminów w przypadku utrzymania polisy ubezpieczeniowej lub pomocy związanej z kosztami. Macie Państwo prawo do bezpłatnej informacji we własnym języku. Zadzwońcie pod (TTY: ). Português (Portuguese): Este aviso contém informações importantes. Este aviso poderá conter informações importantes a respeito de sua aplicação ou cobertura por meio do Premera Blue Cross. Poderão existir datas importantes neste aviso. Talvez seja necessário que você tome providências dentro de determinados prazos para manter sua cobertura de saúde ou ajuda de custos. Você tem o direito de obter esta informação e ajuda em seu idioma e sem custos. Ligue para (TTY: ). Română (Romanian): Prezenta notificare conține informații importante. Această notificare poate conține informații importante privind cererea sau acoperirea asigurării dumneavoastre de sănătate prin Premera Blue Cross. Pot exista date cheie în această notificare. Este posibil să fie nevoie să acționați până la anumite termene limită pentru a vă menține acoperirea asigurării de sănătate sau asistența privitoare la costuri. Aveți dreptul de a obține gratuit aceste informații și ajutor în limba dumneavoastră. Sunați la (TTY: ). Pусский (Russian): Настоящее уведомление содержит важную информацию. Это уведомление может содержать важную информацию о вашем заявлении или страховом покрытии через Premera Blue Cross. В настоящем уведомлении могут быть указаны ключевые даты. Вам, возможно, потребуется принять меры к определенным предельным срокам для сохранения страхового покрытия или помощи с расходами. Вы имеете право на бесплатное получение этой информации и помощь на вашем языке. Звоните по телефону (TTY: ). Fa asamoa (Samoan): Atonu ua iai i lenei fa asilasilaga ni fa amatalaga e sili ona taua e tatau ona e malamalama i ai. O lenei fa asilasilaga o se fesoasoani e fa amatala atili i ai i le tulaga o le polokalame, Premera Blue Cross, ua e tau fia maua atu i ai. Fa amolemole, ia e iloilo fa alelei i aso fa apitoa olo o iai i lenei fa asilasilaga taua. Masalo o le a iai ni feau e tatau ona e faia ao le i aulia le aso ua ta ua i lenei fa asilasilaga ina ia e iai pea ma maua fesoasoani mai ai i le polokalame a le Malo olo o e iai i ai. Olo o iai iate oe le aia tatau e maua atu i lenei fa asilasilaga ma lenei fa matalaga i legagana e te malamalama i ai aunoa ma se togiga tupe. Vili atu i le telefoni (TTY: ). Español (Spanish): Este Aviso contiene información importante. Es posible que este aviso contenga información importante acerca de su solicitud o cobertura a través de Premera Blue Cross. Es posible que haya fechas clave en este aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su cobertura médica o ayuda con los costos. Usted tiene derecho a recibir esta información y ayuda en su idioma sin costo alguno. Llame al (TTY: ). Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue Cross. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na walang gastos. May karapatan ka na makakuha ng ganitong impormasyon at tulong sa iyong wika ng walang gastos. Tumawag sa (TTY: ). ไทย (Thai): ประกาศน ม ข อม ลส าค ญ ประกาศน อาจม ข อม ลท ส าค ญเก ยวก บการการสม ครหร อขอบเขตประก น ส ขภาพของค ณผ าน Premera Blue Cross และอาจม ก าหนดการในประกาศน ค ณอาจจะต อง ด าเน นการภายในก าหนดระยะเวลาท แน นอนเพ อจะร กษาการประก นส ขภาพของค ณหร อการช วยเหล อท ม ค าใช จ าย ค ณม ส ทธ ท จะได ร บข อม ลและความช วยเหล อน ในภาษาของค ณโดยไม ม ค าใช จ าย โทร (TTY: ) Український (Ukrainian): Це повідомлення містить важливу інформацію. Це повідомлення може містити важливу інформацію про Ваше звернення щодо страхувального покриття через Premera Blue Cross. Зверніть увагу на ключові дати, які можуть бути вказані у цьому повідомленні. Існує імовірність того, що Вам треба буде здійснити певні кроки у конкретні кінцеві строки для того, щоб зберегти Ваше медичне страхування або отримати фінансову допомогу. У Вас є право на отримання цієї інформації та допомоги безкоштовно на Вашій рідній мові. Дзвоніть за номером телефону (TTY: ). Tiếng Việt (Vietnamese): Thông báo này cung cấp thông tin quan trọng. Thông báo này có thông tin quan trọng về đơn xin tham gia hoặc hợp đồng bảo hiểm của quý vị qua chương trình Premera Blue Cross. Xin xem ngày quan trọng trong thông báo này. Quý vị có thể phải thực hiện theo thông báo đúng trong thời hạn để duy trì bảo hiểm sức khỏe hoặc được trợ giúp thêm về chi phí. Quý vị có quyền được biết thông tin này và được trợ giúp bằng ngôn ngữ của mình miễn phí. Xin gọi số (TTY: ).