Coverage Policy Manual
Policy #: 2011046
Category: PPACA Preventive
Initiated: September 2010
Last Review: August 2018
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: SICKLE CELL DISEASE, NEWBORN SCREENING

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 for sickle cell disease is covered for all members of “non-grandfathered” plans without cost sharing (i.e., deductible, co-pay or co-insurance).  This testing is done for all newborns and is mandated by state law.  
 
Screening for sickle cell is done as part of routine newborn care in hospitals and birthing centers but it is possible that initial screening might occur in the office if the baby is delivered in some other setting.  Confirmatory testing of an initial positive test should be done before two months of age.  
 
The appropriate ICD-9 code to report these services is V78.2 or V78.8.
 
The appropriate ICD-9 code to report these services is Z13.0
 
Codes that may be used to report these services include 83020, 83021 or S3620.
 
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 screening for sickle cell disease in newborns. (A recommendation)  This recommendation applies to all newborns.
 
Sickle cell anemia (hemoglobin SS) affects 1 in 375 African American newborns born in the United States and smaller proportions of children in other ethnic groups. Without prompt diagnosis and the initiation of prophylactic antibiotics and pneumococcal conjugate vaccination by 2 months of age, children with sickle cell anemia are vulnerable to life-threatening pneumococcal infections.
 
Screening for sickle cell disease in newborns is mandated in all 50 states and the District of Columbia. Most states use either thin-layer isoelectric focusing (IEF) or high performance liquid chromatography (HPLC) as the initial screening test. Both methods have extremely high sensitivity and specificity for sickle cell anemia. Specimens must be drawn prior to any blood transfusion due to the potential for a false negative result as a result of the transfusion. Extremely premature infants may have false positive results when adult hemoglobin is undetectable.
 
All newborns should undergo testing regardless of birth setting. In general, birth attendants should make arrangements for samples to be obtained, and the first physician to see the child at an office visit should verify screening results. Confirmatory testing should occur no later than 2 months of age.

CPT/HCPCS:
83020Hemoglobin fractionation and quantitation; electrophoresis (eg, A2, S, C, and/or F)
83021Hemoglobin fractionation and quantitation; chromatography (eg, A2, S, C, and/or F)
S3620Newborn metabolic screening panel, includes test kit, postage and the laboratory tests specified by the state for inclusion in this panel (e.g., galactose; hemoglobin, electrophoresis; hydroxyprogesterone, 17-d; phenylanine (PKU); and thyroxine, total)

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

Screening for Sickle Cell Disease in Newborns, Sep 2007: U.S. Preventive Services Task Force http://www. uspreventiveservicestaskforce.org/uspstf07/sicklecell/sicklers.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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