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HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Documentation Required
- All ICD-10, CPT and HCPCS codes billed for a preventive service should follow standard coding guidelines and be reported with diagnosis and procedure codes that identify the services as preventive and not for treatment of injury or illness.
- Preventive services must be submitted with a designated wellness diagnosis code or maternity diagnosis code in the primary position where indicated (select the appropriate Designated Wellness Code from the pertinent Code Group).
- Precertification documentation may be required when reasonable medical management techniques are applied; providers must follow plan-specific precertification processes when required.
- For items that require a prescription (e.g., hospital-grade breast pump E0604; certain blood pressure monitors A4660/A4663/A4670), the order/prescription must be present and the item must be ordered through an in-network provider as specified.
Key Coverage Criteria
- Preventive care services designated by the Affordable Care Act (ACA) and ACA-designated resources (USPSTF grade A or B recommendations; ACIP recommendations adopted by CDC Director; HRSA-supported comprehensive guidelines such as Bright Futures, Uniform Panel of Secretary's Advisory Committee on Heritable Disorders in Newborns and Children, HRSA Women's Preventive Services Guidelines).
- Wellness examinations (preventive medicine comprehensive E/M services) for well-baby, well-child, well-adult and well-woman visits (CPT codes 99381-99387, 99391-99397, 99461; HCPCS G0402, G0438, G0439, S0610, S0612, S0613).
- Age-specific well visit frequencies: ages 0 to 5 per AAP Bright Futures; ages 5 and above annual wellness exam; additional visits for women's contraception management.
- Administration/interpretation of health risk assessment instruments (e.g., suicide risk assessment; sudden cardiac arrest/death risk assessment) (96160, 96161).
- Autism screening (as part of preventive services).
- Anxiety screening for adults, children and adolescents, including pregnant and postpartum persons (96127, 96161).
1 Active Policy
CIGNA-A004, Preventive Care Services
Related Codes
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