Coverage Policy Manual
Policy #: 2013023
Category: PPACA Preventive
Initiated: July 2013
Last Review: August 2018
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: HEPATITIS C VIRUS 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 Hepatitis C Virus Infection in Adults is covered one time for members of “non-grandfathered” plans without cost-sharing (i.e., deductible, co-insurance, or co-pay) born between 1945 and 1965.
 
Screening for Hepatitis C Virus Infection in persons at high risk for infections is covered 3 times per year for members of “non-grandfathered” plans without cost-sharing (i.e., deductible, co-insurance, or co-pay). Persons at high risk for infection include the following:
    • Persons with past or current drug use
    • Persons in receipt of a blood transfusion before 1992  
    • Persons on long-term hemodialysis   
    • Persons born to an HCV-infected mother   
    • Persons incarcerated
    • Persons taking illicit drugs intranasally
    • Persons who have received an unregulated tattoo  
    • Persons who have received other percutaneous exposures (i.e., health care workers or surgery before the implementation of universal precautions).   
 
The appropriate ICD-9 codes to report these services are: V01.79, V15.85, V69.8, V69.9, V70.0, V73.89 or V73.99.
 
The appropriate ICD-10 codes to report these services are: Z00.00-Z00.01, Z11.59, Z20.5, Z57.8, Z72.89, Z72.9, Z73.9
 
Codes that may be used to report the screening for Hepatitis C Virus are HCPCS G0472 and CPT 86803 and 87521.  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 USPSTF recommendations (Moyer, 2013) include the following information:
 
    • “Hepatitis C virus is the most common chronic bloodborne pathogen in the United States and a leading cause of complications from chronic liver disease”.
    • “The USPSTF found adequate evidence that anti–HCV antibody testing followed by confirmatory polymerase chain reaction testing accurately detects chronic HCV infection”.
    • “According to data from 1999 to 2008, about three fourths of patients in the United States living with HCV infection were born between 1945 and 1965, with a peak prevalence of 4.3% in persons aged 40 to 49 years from 1999 to 2002” (Chou, 2012; Smith, 2011).
    • “The most important risk factor for HCV infection is past or current injection drug use, with most studies reporting a prevalence of 50% or more”.
    • The recommendation applies to asymptomatic adults at high risk for HCV virus infection without known liver disease or functional abnormalities.
    • Risk factors for HCV infection include the following:
        • Past or current injection drug use;
        • Receipt of a blood transfusion before 1992;
        • Long-term hemodialysis;
        • Being born to an HCV-infected mother;
        • Incarceration;
        • Intranasal drug use;
        • Getting an unregulated tattoo; or
        • Other percutaneous exposures such as healthcare workers or from having surgery before the implementation of universal precautions.
      • Adequate evidence was found that “anti-HCV antibody testing followed by confirmatory PCR testing accurately detects chronic HCV infection”.
      • “Persons with continued risk for HCV infection (injection drug users) should be screened periodically. The USPSTF found no evidence about how often screening should occur in persons who continue to be at risk for new HCV infection”.
      • There have been no randomized trials comparing clinical outcomes between persons screened versus not screened for HCV infection. However, the USPSTF concludes, “there is a linkage between SVR [sustained virologic response] and clinical outcomes and that the overall net benefit of screening is moderate”.
 

CPT/HCPCS:
86803Hepatitis C antibody;
87521Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, amplified probe technique, includes reverse transcription when performed
G0472Hepatitis C antibody screening for individual at high risk and other covered indication(s)

References: Chou R, Cottrell EB, Wasson N et al.(2012) Screening for Hepatitis C Virus Infection in Adults. Comparative Effectiveness Review no. 69.AHRQ publication no. 12-EHC090-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2012. Accessed at www.ncbi.nlm.nih.gov/books /NBK115423 on 24 May 2013.

Moyer VA.(2013) Screening for hepatitis c virus infection in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 25 June 2013. epub ahead of print. Available at www.annals.org.

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

Smith BD, Patel N, Beckett GA et al.(2011) Hepatitis C virus antibody prevalence, correlates and predictors among persons born from 1945 through 1965, United States, 1999-2008 [Abstract]. Hepatology. 2011;54(Suppl 1):554A-5A.


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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