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HealthPartners

Coverage criteria policies

Preventive care services

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required for most Preventive Services.

Prior authorization is required for statin medications for the primary prevention of cardiovascular disease in adults and medications for risk reduction of breast cancer. See separate policies for further information.

Coverage

Routine Preventive services are routine healthcare services that include screenings, check-ups and counseling to prevent illness, disease, or other health problems before symptoms occur.

  • These services are covered at your preventive benefit level.
  • Services covered as preventive services are derived from the Patient Protection and Affordable Care Act requirements which include the US Preventive Services Task Force, A and B Recommendations, the Advisory Committee on Immunization Practices (ACIP), and the Health Resources and Services Administration (HRSA) Bright Futures Project and Institute of Medicine committee on women’s clinical preventive services.

Any service not listed in the guidelines by the above entities are covered at standard benefits, regardless of the reason for the service.

To view all of the HealthPartners preventive care guidelines based on age, gender, and frequency, please see the related content at right. Services not specifically addressed in this policy will be covered according to your plan documents.

Indications that are covered

The following lists detail services eligible for coverage under Preventive Services Benefits when received from in-network providers.

Routine wellness / preventive office visits may include:
  • Age and gender appropriate history.
  • Physical examination.
  • Risk factor reduction counseling and interventions.
  • Appropriate immunizations / labs
  • Administration / Interpretation of Health Risk Assessment Instrument.
  • Alcohol and substance abuse/misuse screening / counseling.
  • Depression screening.
  • Diet counseling for adults with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease.
  • Aspirin prophylaxis counseling for adults aged 50 to 59 years with cardiovascular risk factors.
  • Autism screening with instruments such as the M-CHAT (for children at 18 and 24 months).
  • Chemoprevention counseling with women at risk for breast cancer.
  • Blood pressure screening.
  • Discussion/referral for genetic counseling/evaluation for BRCA testing for women at higher risk for breast and ovarian cancer.
  • Breast-feeding counseling/support.
  • Domestic and interpersonal violence screening / counseling including referrals for intervention as needed.
  • Counseling/education to minimize exposure to ultraviolet radiation.
  • Basic hearing and vision screening.
  • Counseling/education regarding FDA-approved contraception methods for women including counseling regarding adherence and follow-up and management of side effects.
  • Obesity screening / counseling regarding weight loss, healthy diet, and exercise.
  • Counseling to prevent initiation of tobacco use.
  • Tobacco use screening/counseling - referral to programs to help stop tobacco use.
  • Psychosocial/Behavioral assessment.
  • Counseling related to sexual behavior / sexually transmitted infection (STI) prevention.
  • Critical congenital heart disease screening.
  • Oral health assessment/discussion of water fluoridation / referral to dental home for children.
Immunizations:

Doses, recommended ages, and recommended populations vary. See the related content at right for HealthPartners’ Preventive Health guidelines for specifics.

  • Tetanus, Diphtheria, Pertussis (TDaP)
  • Hepatitis A, Hepatitis B
  • Herpes zoster (shingles) for adults at age 60
  • Human papilloma virus (HPV)
  • Inactivated poliovirus
  • Influenza (flu)
  • Haemophilus Influenzae Type B (Hib)
  • Measles, mumps, rubella (MMR)
  • Meningococcal (meningitis)
  • Pneumococcal (pneumonia)
  • Varicella (chicken pox)
  • Rotavirus (for children)
Medications

These medications are covered with a prescription from your medical provider and per the HealthPartners formulary:

  • Aspirin to prevent cardiovascular disease for adults aged 50-59 with risk factors.
  • Oral fluoride supplementation where water source does not contain fluoride for children aged 6 months to preschool.
  • Iron supplementation for children aged 6-12 months at increased risk for iron-deficiency anemia.
  • Folic acid supplementation for women of childbearing age planning or capable of pregnancy.
  • Vitamin D supplementation to prevent falls in community dwelling adults age 65 and over who are at increased risk for falls.
  • Smoking cessation medications.
  • Medications for risk reduction of primary breast cancer in women (see “Medications for risk reduction of primary breast cancer in women” policy for specifics).
  • Gonorrhea preventive medication for the eyes of all newborns (usually given in the hospital at birth).
  • Fluoride varnish application by primary care providers to the primary teeth of all infants and children starting at the age of primary tooth eruption through age 5.
  • Preferred low-to-moderate dose statin medications for the prevention of CVD events and mortality are covered as a Preventive Benefit for adults ages 40 to 75 years for members with no history of CVD (i.e., symptomatic coronary artery disease or ischemic stroke), and one or more CVD risk factors (i.e., dyslipidemia, diabetes, hypertension, or smoking), and a calculated 10-year risk of a cardiovascular event of 10% or greater. (See “Statin Medications for Prevention of Cardiovascular Disease” policy for specifics).
Additional covered testing /counseling that may be ordered during a routine, preventive office visit but done separately:

See the related content at right for link to the HealthPartners’ Preventive Health guidelines for specifics.

  • One-time ultrasound (for men ages 65-75 who have ever smoked) for abdominal aortic aneurysm
  • One-time screening for Hepatitis C virus (HCV) infection for adults born between 1945 and 1965
  • 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.
  • Obtaining blood pressure measurements outside of the clinical setting for diagnostic confirmation before starting treatment.
  • Chlamydia infection (for younger women and other women at higher risk)
  • Cholesterol (for adults at higher risk).
  • Colonoscopy, sigmoidoscopy, fecal occult blood testing or stool based DNA testing (i.e. Cologuard) for adults beginning at age 50 for colon cancer This includes a pre–procedure consultation if required (code S0285) and the bowel preparation kits that are on the HealthPartners formulary for a preventive colonoscopy.
    Colon screening codes covered as Preventive: 82270, 82274, 44401, 45330, 45331, 45333, 45335, 45338, 45339, 45346, 45378, 45380, 45388, 45381, 45384, 45385, 44389, 44392, 44394, 74263, G0104-G0106, G0120-G0122, G0328 G6019, G6022, G6024, 81258, G0464 & 81528.
  • Gonorrhea (for all women at higher risk).
  • HIV (for all adults at higher risk).
  • Mammography every 1 to 2 years for women age 40 and older for breast cancer.
  • Newborn screening per state mandates (usually done in the hospital at birth).
  • Obesity screening/counseling regarding weight loss, healthy diet, and exercise - 12-26 group or individual sessions of high intensity counseling per year for overweight children or adults with a BMI 30 or above. Counseling codes covered at Preventive are G0447, G0473, and S9449.
  • Osteoporosis (for women over age 65, or younger depending on risk factors) by clinical examination, dual-energy x-ray absorptiometry (DEXA) of the hip and lumbar spine, and / or quantitative ultrasonography of the calcaneus.
  • Syphilis (for all adults at higher risk).
  • Type 2 diabetes for adults with high blood pressure.
  • Intensive behavioral dietary counseling for adults with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease Note: Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians.
  • Annual screening for lung cancer with low-dose computed tomography (LDCT) in persons age 55 through 80 years with a 30 pack year history of smoking who are currently smoking or have quit within the past 15 years.
  • Lipid disorders (dyslipidemia screening for children at higher risk).
  • Universal lipids screening in adults ages 40 to 75 years.
  • HIV for adolescents age 15 or older and any age for those at higher risk.
  • Lead (for children at risk of exposure).
  • Tuberculin testing for children at higher risk of tuberculosis.
  • Anemia.

Additional covered services for pregnant women

  • Anemia screenings.
  • Bacteriuria, urinary tract infection, HIV, syphilis, and chlamydial infection screenings.
  • Rh incompatibility screening, with follow-up testing for women at higher risk.
  • Hepatitis B screening and counseling (at the first prenatal visit).
  • Breast feeding counseling, including lactation consultants, and interventions to support and promote breast feeding during pregnancy and after delivery.
  • Tobacco use counseling.
  • Gestational diabetes mellitus screening in asymptomatic pregnant women after 24 weeks of gestation.

Additional covered services for women

  • FDA-approved forms of contraception, with a prescription from your medical provider, according to the HealthPartners formulary.
  • Standard and FDA-approved sterilization procedures. Codes covered at Preventive benefits for women when done in conjunction with Z30.2 Encounter for sterilization: 58565, 58600, 58605, 58611, 58615, 58670, 58671, A4264, 58661, 88302, 00851
  • BRCA testing for genetic predisposition for ovarian and breast cancer when coverage criteria are met. Please see “Genetic Testing for Cancer Predisposition” policy for details.

Services that are Not Covered

The following list, though not all inclusive, details services not eligible for coverage at any benefit level:

  1. Over the counter tests not ordered by your primary medical provider.
  2. Any supplements recommended at a preventive care visit, except those listed in the Medication section above.
  3. Preventive services or screenings including, but not limited to exams, lab tests, x-rays received from or ordered by:
  • Non-contracted, mobile, outpatient screening entities.
  • A non-medical care provider (e.g., naturopath).

The following list, though not all inclusive, details services not eligible for coverage under the Preventive Services benefit because they are considered diagnostic:

  • Genetic testing, other than BRCA when indicated, and state mandated testing of newborns.
  • Referrals to specialists for evaluation of findings during routine preventive screening.

Definitions

Routine Preventive services are routine healthcare services that include screenings, check-ups and counseling to prevent illness, disease or other health problems before symptoms occur. Treatment of illness is covered under standard benefits.

Diagnostic services are services are used to help a provider understand your symptoms, diagnose illness, and decide what treatment may be needed. They may be the same tests that are listed as preventive services, but they are being used as diagnostic services. These services are not preventive if received as part of a visit to diagnose, monitor an established condition, or treat an illness or injury. When that occurs, standard deductibles, co-pays or coinsurance apply.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

http://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/

https://www.healthcare.gov/preventive-care-children/

https://www.healthcare.gov/preventive-care-adults/

https://www.hrsa.gov/womensguidelines/

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Policy activity

  • 05/20/2011 - Date of origin
  • 11/01/2017 - Effective date
Review date
  • 11/2017
Revision date
  • 10/05/2017

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