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Date Printed: June 23, 2017: 11:44 AM

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01-99385-03

Original Effective Date: 12/15/13

Reviewed: 05/25/17

Revised: 06/15/17

Subject: Preventive Services

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position
Statement
Billing/Coding Reimbursement Program
Exceptions
Definitions Related
Guidelines
           
Other References Updates    
           

DESCRIPTION:

Preventive services include a broad range of services. Florida Blue has adopted the following:

POSITION STATEMENT:

NOTE: Coverage for preventive services (including screening, prevention, counseling and immunizations/vaccines) is subject to the member’s benefit terms, limitations and maximums. Refer to member’s contract language regarding preventive services.

Preventive services may be covered under the member’s contract benefits. Preventive services include, but are not limited to (screening, prevention, counseling and immunizations/vaccines).

Preventive services are covered according to the member’s contract benefits.

Screening services are covered according to the member’s contract benefits.

Immunization/vaccines are covered according to the member’s contract benefits.

The following preventive services have a rating of A or B from the U.S. Preventive Services Task Force (USPSTF).

Service

Description

Abdominal aortic aneurysm screening: men

The USPSTF recommends one-time screening for abdominal aortic aneurysm by ultrasonography in men ages 65 to 75 years who have ever smoked.

Grade: B

Alcohol misuse: screening and counseling

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.

Grade: B

Aspirin preventive medication: adults aged 50 to 59 years with a ≥ 10% 10-year cardiovascular risk

The USPSTF recommends initiating low-dose aspirin use for the primary prevention of cardiovascular disease and colorectal cancer in adults aged 50 to 59 years who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years.

Grade: B

Bacteriuria screening: pregnant women

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.

Grade: A

Blood pressure screening: adults

The USPSTF recommends screening for high blood pressure in adults age 18 years and older. The USPSTF recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment.

Grade: A

BRCA risk assessment and genetic counseling/testing

The USPSTF recommends that 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.

Grade: B

Breast cancer preventive medications

The USPSTF recommends that clinicians engage in shared, informed decision-making with women who are at increased risk for breast cancer about medications to reduce their risk. For women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene.

Grade: B

Breast cancer screening

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.

Grade: B

Breastfeeding interventions

The USPSTF recommends providing interventions during pregnancy and after birth to promote and support breastfeeding.

Grade: B

Cervical cancer screening

The USPSTF recommends screening for cervical cancer in women ages 21 to 65 years with cytology (Pap smear) every 3 years or, 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.

Grade: A

Chlamydia screening: women

The USPSTF recommends screening for chlamydia in sexually active women age 24 years or younger and in older women who are at increased risk for infection.

Note: (includes pregnant women)

Grade: B

Cholesterol abnormalities screening: men 35 and older

The USPSTF strongly recommends screening men age 35 years and older for lipid disorders.

Grade: A

Cholesterol abnormalities screening: men younger than 35

The USPSTF recommends screening men ages 20 to 35 years for lipid disorders if they are at increased risk for coronary heart disease.

Grade: B

Cholesterol abnormalities screening: women 45 and older

The USPSTF strongly recommends screening women age 45 years and older for lipid disorders if they are at increased risk for coronary heart disease.

Grade: A

Cholesterol abnormalities screening: women younger than 45

The USPSTF recommends screening women ages 20 to 45 years for lipid disorders if they are at increased risk for coronary heart disease.

Grade: B

Colorectal cancer screening

The USPSTF recommends screening for colorectal cancer starting at age 50 years and continuing until age 75 years.

Grade: A 

Dental caries prevention: infants and children up to age 5 years

The USPSTF recommends the 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.

The USPSTF recommends primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is fluoride deficient.

Grade: B

Depression screening: adolescents

The USPSTF recommends screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years. Screening should be implemented when systems are in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.

Grade: B

Depression screening: adults

The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.

Grade: B

Diabetes screening

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.

Grade: B

Falls prevention in older adults: exercise or physical therapy

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.

Grade: B

Falls prevention in older adults: vitamin D

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.

Grade: B

Folic acid supplementation

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.

Grade: A

Gestational diabetes mellitus screening

The USPSTF recommends screening for gestational diabetes mellitus in asymptomatic pregnant women after 24 weeks of gestation.

Grade: B

Gonorrhea prophylactic medication: newborns

The USPSTF recommends prophylactic ocular topical medication for all newborns for the prevention of gonococcal ophthalmia neonatorum.

Grade: A

Gonorrhea screening: women

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.

Grade: B

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.

Grade: B

Hearing loss screening: newborns

The USPSTF recommends screening for hearing loss in all newborn infants.

Grade: B

Hemoglobinopathies screening: newborns

The USPSTF recommends screening for sickle cell disease in newborns.

Grade: A

Hepatitis B screening: pregnant women

The USPSTF strongly recommends screening for hepatitis B virus infection in pregnant women at their first prenatal visit.

Grade: A

Hepatitis B screening: nonpregnant adolescents and adults

The USPSTF recommends screening for hepatitis B virus infection in persons at high risk for infection.
Grade: B

Hepatitis C virus infection screening: adults

The USPSTF recommends screening for hepatitis C virus (HCV) infection in persons at high risk for infection. The USPSTF also recommends offering one-time screening for HCV infection to adults born between 1945 and 1965.

Grade: B

HIV screening: nonpregnant adolescents and adults

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.

Grade: A

HIV screening: pregnant women

The USPSTF recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown.

Grade: A

Hypothyrodism screening: newborns

The USPSTF recommends screening for congenital hypothyroidism in newborns.

Grade: A

Intimate partner violence screening: women of childbearing age

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.

Grade: B

Lung cancer screening

The USPSTF recommends annual screening for lung cancer with low-dose computed tomography in adults aged 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.

Grade: B

Obesity screening and counseling: adults

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.

Grade: B

Obesity screening and counseling: children

The USPSTF recommends that 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.

Grade: B

Osteoporosis screening: women

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.

Grade: B

Phenylketonuria screening: newborns

The USPSTF recommends screening for phenylketonuria in newborns.

Grade: B

Preeclampsia prevention: aspirin

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.

Grade: B

Preeclampsia: screening

The USPSTF recommends screening for preeclampsia in pregnant women with blood pressure measurements throughout pregnancy.

Grade: B

Rh incompatibility screening: first pregnancy visit

The USPSTF strongly recommends Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care.

Grade: A

Rh incompatibility screening: 24–28 weeks' gestation

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.

Grade: B

Sexually transmitted infections counseling

The USPSTF recommends intensive behavioral counseling for all sexually active adolescents and for adults who are at increased risk for sexually transmitted infections.

Grade: B

Skin cancer behavioral counseling

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.

Grade: B

Tobacco use counseling and interventions: non-pregnant adults

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.

Grade: A

Tobacco use counseling: pregnant women

The USPSTF recommends that clinicians ask all pregnant women about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who use tobacco.

Grade: A

Tobacco use interventions: children and adolescents

The USPSTF recommends that clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use in school-aged children and adolescents.

Grade: B

Syphilis screening: non-pregnant persons

The USPSTF recommends screening for syphilis infection in persons who are at increased risk for infection.

Grade: A

Syphilis screening: pregnant women

The USPSTF recommends that clinicians screen all pregnant women for syphilis infection.

Grade: A

Visual acuity screening in children

The USPSTF recommends vision screening for all children at least once between the ages of 3 and 5 years, to detect the presence of amblyopia or its risk factors.

Grade: B

Appendix A – USPSTF Grade Definitions

Grade

Definition

A

The USPSTF recommends the service. There is high certainty that the net benefit is substantial.

B

The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

Immunizations

NOTE: Coverage for immunizations/vaccines is subject to the member’s benefit terms, limitations and maximums. Refer to member’s contract language regarding immunizations/vaccines.

Therapeutic Immunizations (Covered as Medical Care)

Therapeutic vaccines are given when there is exposure or possible exposure to a bacteria or virus. Examples include (but not limited to) a tetanus booster after stepping on a rusty nail or a meningitis vaccine for possible exposure to meningitis, or Rabies vaccine after a bite from an animal with possible Rabies, pneumococcal polysaccharide vaccine for individuals who are at increased risk for pneumococcal disease or its complications, or meningococcal vaccine for college students living in dormitories or residence halls to prevent bacterial meningitis.

Childhood and Adolescent Immunizations

Hepatitis B

Rotavirus

Diphtheria, tetanus, & acellular pertussis

Tetanus, diphtheria & acellular pertussis

Haemophilus influenzae type b

Inactivated poliovirus

Measles, mumps, rubella

Varicella

Meningococcal

Pneumococcal

Influenza

Hepatitis A

*Human papillomavirus (HPV)

Adult Immunizations

Hepatitis A

Hepatitis B

Hemophilus influenzae b

*Human papillomavirus (HPV)

Influenza

Pneumococcal

Measles, mumps, rubella and varicella

Tetanus diphtheria toxoids and acellular pertussis vaccine (Td/TdaP)

Varicella

Meningococcal

Zoster (shingles)

*Note: HPV: ages 9-26

Other Vaccines

Coverage for immunizations/vaccines for travel and pre-exposure is subject to the member’s benefit terms, limitations and maximums. Refer to member’s contract language regarding immunizations/vaccines.

Cholera

Hepatitis A

Japanese encephalitis

Rabies

Tickborne encephalitis

Typhoid

Yellow fever

Women’s Preventive Services Guidelines

NOTE: Coverage for preventive services (including screening, prevention, counseling and immunizations/vaccines) is subject to the member’s benefit terms, limitations and maximums. Refer to member’s contract language regarding preventive services.

Women's Preventive Services Guidelines are supported by the Health Resources and Services Administration (Health and Human Service (HHS))

Service

HHS Guideline

Well woman visits

Well woman preventive care visit annually for adult women to obtain the recommended preventive services that are age and developmentally appropriate, including preconception care and services necessary for prenatal care.

Screening for gestational diabetes

Screening for gestational diabetes.  

Human papillomavirus testing

High-risk human papillomavirus DNA testing in women with normal cytology results.

Counseling for sexually transmitted infections

Counseling on sexually transmitted infections for all sexually active women.

Counseling and screening for human immune-deficiency virus

Counseling and screening for human immune-deficiency virus infection for all sexually active women.

Contraceptive methods and counseling

All Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity.

Breastfeeding support, supplies, and counseling

Comprehensive lactation support and counseling, by a trained provider during pregnancy and/or in conjunction with each birth the postpartum period, and costs for renting breastfeeding equipment.

Screening and counseling for interpersonal and domestic violence

Screening and counseling for interpersonal and domestic violence.

BILLING/CODING INFORMATION:

Refer to POSITION STATEMENT.

REIMBURSEMENT INFORMATION:

Reimbursement of newly recommended vaccines will be made as of the effective date, when the recommendation is made by any of the following:

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No Local Coverage Determination (LCD) were found at the time of the last guideline review date.

The following National Coverage Determination (NCD) was reviewed on the last guideline review date: Medicare National Coverage Determinations Manual Chapter 1, Part 4 (Section 210-Prevention) located at cms.gov.

The following Centers for Medicare & Medicaid Services (CMS) Decision Memo was reviewed on the last guideline review date: CMS Decision Memo for Screening for Hepatitis C Virus (HCV) in Adults (CAG-00436N), June 2, 2014 located at cms.gov.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Ambulatory Blood Pressure Monitoring (ABPM), 01-93875-16
Bone Mineral Density Studies, 04-70000-21

Computed Tomographic (CT) Colonography (virtual Colonoscopy), 01-91000-06

Computed Tomography (CT) Thorax (Chest), 04-70450-21

Durable Medical Equipment (DME), 09-E0000-01

Genetic Testing, 05-82000-28

Genetic Testing for Hereditary Breast or Ovarian Cancer, 05-82000-30

Human Papillomavirus (HPV) Testing, 05-86000-30

Medical Nutrition Therapy, 01-99000-05

OTHER:

Other names used to report preventive services:

Adult Wellness
Adult Wellness Preventive Care
Preventive Health Services|
Routine Adult Care
Routine Screening Services
Well Child Care
Well Child Services

Florida State Mandated Coverage for Newborn & Infant Hearing Screening HB 399 (Effective 07/01/00)

The intent of the mandate is to provide early hearing impairment screening, identification, and follow-up care for newborns and infants. The goal is to screen all newborns and infants for hearing impairment prior to discharge from the hospital, in order to alleviate the adverse effects of hearing loss on speech and language development, academic performance, and cognitive development. If the screening is not completed before discharge, the screening must be completed within 30 days after discharge. All health insurance policies and health maintenance organizations shall compensate providers for the covered benefit at the contracted rate. “Newborn” means an age range from birth through 29 days. “Infant” means an age range from 30 days through 12 months. “Screening” means a test or battery of tests administered to determine the need for an in-depth hearing diagnostic evaluation. All screenings are to be conducted by a licensed audiologist, physician, or appropriately supervised specifically trained individual.

Florida State Mandated Coverage for Mammograms (641.31095)

(1) Every health maintenance contract issued or renewed on or after January 1, 1996, shall provide coverage for at least the following: (a)A baseline mammogram for any woman who is 35 years of age or older, but younger than 40 years of age.(b)A mammogram every 2 years for any woman who is 40 years of age or older, but younger than 50 years of age, or more frequently based on the patient’s physician’s recommendations.(c)A mammogram every year for any woman who is 50 years of age or older.(d)One or more mammograms a year, based upon a physician’s recommendation for any woman who is at risk for breast cancer because of a personal or family history of breast cancer, because of having a history of biopsy-proven benign breast disease, because of having a mother, sister, or daughter who has had breast cancer, or because a woman has not given birth before the age of 30.

REFERENCES:

  1. Centers for Disease Control and Prevention Immunization Schedules, 2017.
  2. USPSTF A and B Recommendations. U.S. Preventive Services Task Force, April 2017.
  3. Women’s Preventive Services Health Resources and Services Administration (HRSA): Women’s Preventive Services Guideline, Accessed 04/26/17.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 05/25/17.

GUIDELINE UPDATE INFORMATION:

12/15/13

New Medical Coverage Guideline.

02/15/14

Revision; revised recommendation for: BRCA screening, breast cancer preventive medications, and added recommendation for gestational diabetes mellitus screening and lung cancer screening. Updated references.

05/15/14

Added Florida statute statement for mammograms. Updated references.

06/15/14

Revision; added USPSTF recommendation for screening for hepatitis B virus infection in persons at high risk for infection (Grade: B Recommendation) and updated Medicare Advantage program exception (added statement for prevention and screening for Hepatitis C Virus (HCV) in adults). Update references.

08/15/14

Updated reference; immunization schedules (2014).

10/15/14

Revision; added USPSTF recommendation for low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia (Grade: B Recommendation). Update references.

11/15/14

Revised immunization tables for clarity.

04/15/15

Revision; revised statement for chlamydia screening (women), dental caries, gonorrhea screening (women), and sexually transmitted infection counseling. Added statement regarding application of fluoride varnish to infants and children teeth. Revised headers for dental caries prevention and healthy diet counseling. Added heading and statement for healthy diet and physical counseling to prevent cardiovascular disease (adults with cardiovascular risk factors). Added statement for preeclampsia prevention (aspirin). Added related guidelines. Updated references.

05/15/15

Revised chlamydia screening for women.

07/15/15

Updated immunizations section.

02/15/16

Updated references.

03/15/16

Added USPSTF recommendation for biennial screening mammography for women aged 50 to 74 years. Added USPSTF recommendation for screening for depression in the general adult population, including pregnant and postpartum women. Deleted USPSTF recommendation for screening mammography for women, with or without clinical breast examination, every 1 to 2 years for women age 40 years and older. Deleted USPSTF recommendation for screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. Updated references.

06/15/16

Added USPSTF recommendation for aspirin use to prevent cardiovascular disease and colorectal cancer: prevention medicine. Added related guidelines to the Preventive Services MCG: Durable Medical Equipment (DME), Genetic Testing, and Medical Nutrition Therapy. Updated references and guideline information section.

08/15/16

Revised USPSTF recommendation for colorectal cancer screening and syphilis screening: nonpregnant persons. Updated references.

09/15/16

Revised recommendation for diabetes screening, tobacco use counseling and interventions: nonpregnant adults and tobacco use counseling: pregnant women. Revised service name and desciption for aspirin use to prevent cardiovascular disease and colorectal cancer: prevention medicine. Revised description for: blood pressure screening in adults,breast cancer screening, dental caries prevention: infants and children up to age 5 years, depression screening: adolescents and blood pressure screening in adults. Delete iron supplementation in children. Deleted medications for risk reduction of primary breast cancer in women. Changed Grade from “A” to “B” for phenylketonuria screening: newborns.

02/15/17

Revised service description for breastfeeding; deleted counseling and added interventions. Revised the description for breastfeeding; added “providing”. Updated references.

06/15/17

Revised “blood screening: adults”. Deleted high blood pressure in adults: screening. Added USPSTF recommendation for preeclampsia: screening. Revised women’s preventive service; screening for gestational diabetes and breastfeeding support, supplies, and counseling. Updated references.

Date Printed: June 23, 2017: 11:44 AM