Coverage Policy Manual
Policy #: 2011030
Category: PPACA Preventive
Initiated: May 2011
Last Review: May 2018
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: OBESITY IN CHILDREN; SCREENING AND COUNSELING

Description:
The Federal Patient Protection and Preventive Care Act was passed by Congress and signed into law by the President in March 2010.  The preventive services component of the law became effective 23 September 2010. A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to cover those preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task Force.  
 
Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.
 
Task Force recommendations are graded on a five-point scale (A-E), reflecting the strength of evidence in support of the intervention.  Grade A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination.  Grade B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination.  Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds.  Grade D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.  Grade E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.
 
Those preventive medicine services listed as Grade A & B recommendations are covered without cost sharing (i.e., deductible, co-insurance, or co-pay) by Health Plans for appropriate preventive care services provided by an in-network provider.  If the primary purpose for the office visit is for other than Grade A or B USPSTF preventive care services, deductible, co-insurance, or copay may be applied.
 
 

Policy/
Coverage:
Screening and counseling for obesity in children aged 6 years and older is covered for members of “non-grandfathered” plans on an annual basis, without cost-sharing (i.e., deductible, co-insurance, or co-pay).
 
Obesity screening by BMI calculation for all children at every well-child visit is covered for members of “non-grandfathered” plans without cost-sharing (i.e., deductible, co-insurance, or co-pay. (Bright Futures Recommendation) (EFFECTIVE 8/01/2012)
 
Note: Well-child visits are discussed in policy # 2012046 and recommended at the following  intervals: birth, first week after birth, at  age 1 month, 2 months, 4 months, 6 months, 9 months,  1 year, 15 months, 18 months, 2 years, 2 ½ years, annually until age 10 years and once between  11-14 years, 15-17 years and 18-21 years.
 
 
The appropriate ICD-9 codes to report these services are V20.2, V70.0 or V77.8, V82.89..
 
The appropriate ICD-10 codes to report these services are Z00.00, Z00.01, Z00.121, Z00.129, Z13.89.
 
Codes that may be used to report the screening and counseling for obesity in children are HCPCS codes G0447 and G0473 or CPT codes 99383-99384, 99393-99394, and 99401-99404. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.  The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 
 

Rationale:
The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen children aged 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 recommendation).
 
The USPSTF recommendations include the following information:
    • This recommendation applies to children and adolescents aged 6 to 18 years. The USPSTF is using the following terms to define categories of increased BMI: overweight is defined as an age- and gender-specific BMI between the 85th and 95th percentiles, and obesity is defined as an age- and gender-specific BMI at ≥95th percentile. The USPSTF did not find sufficient evidence for screening children younger than 6 years.
    • In 2005, the USPSTF found adequate evidence that BMI was an acceptable measure for identifying children and adolescents with excess weight. BMI is calculated from the measured weight and height of an individual.
    • The USPSTF found that effective comprehensive weight-management programs incorporated counseling and other interventions that targeted diet and physical activity. Interventions also included behavioral management techniques to assist in behavior change. Interventions that focused on younger children incorporated parental involvement as a component.
    • Moderate- to high-intensity programs involved >25 hours of contact with the child and/or the family over a 6-month period and showed results including improved weight status, defined as an absolute and/or relative decrease in the BMI 12 months after the beginning of the intervention. Most participants were obese, and it is not known whether these results can be applied to children who are overweight but not obese. In addition, evidence was limited on the long-term sustainability of BMI changes achieved through behavioral interventions and on the trajectory of weight gain in children and adolescents. Interventions generally took place in referral settings, and the results can only be generalized to children who follow through on treatment. Low-intensity interventions, defined as ≤25 contact hours over a 6-month period, did not result in significant improvement in weight status.
    • Interventions that combined pharmacologic agents (sibutramine or orlistat) with behavioral interventions resulted in modest short-term improvement in weight status in children aged 12 years and older. There were no long-term data on the maintenance of improvement after discontinuation of medications. The magnitude of the harms of these drugs in children could not be estimated with certainty. Adverse effects included elevated heart rate, elevated blood pressure, and adverse gastrointestinal effects. Sibutramine, a centrally acting appetite suppressant, has been approved by the US Food and Drug Administration (FDA) for use in adolescents aged 16 years and older. Orlistat, a lipase inhibitor, has been approved by the FDA for use in adolescents aged 12 years and older. Neither sibutramine nor orlistat has been approved for use in pediatric populations younger than 12 years.
    • No evidence was found regarding appropriate intervals for screening. Height and weight, from which BMI is calculated, are routinely measured during health maintenance visits.
 
 

CPT/HCPCS:
99383Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; late childhood (age 5 through 11 years)
99384Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years)
99393Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age 5 through 11 years)
99394Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years)
99401Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes
99402Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes
99403Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 minutes
99404Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 60 minutes
G0447Face-to-face behavioral counseling for obesity, 15 minutes
G0473Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes

References: PPACA & HECRA: Public Laws 111-148 & 111-152. The Patient Protection and Affordable Care Act.

Screening for Obesity in Children.(2011) U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspschobes.htm.


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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