Coverage Policy Manual
Policy #: 2015036
Category: PPACA Preventive
Initiated: January 2016
Last Review: January 2019
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: PREVENTION AND TREATMENT OF PREECLAMPSIA IN PREGNANT WOMEN

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:
EFFECTIVE JANUARY 2019
 
Screening for preeclampsia in pregnant women with blood pressure measurements is covered throughout pregnancy for members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay).
 
The use of low-dose aspirin (81 mg per day) when prescribed by a health care provider with prescribing authority is covered as a preventive medication after 12 weeks gestation in women who are high risk for preeclampsia for members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay).
 
The appropriate ICD-9 codes to report these services are V22.0-V22.2, V23.0- V23.9, V70.0.
 
The appropriate ICD-10 codes to report these services are Z00.00, Z00.01, Z33.1, Z34.00-Z34.93, O09-O09.40; O09.519, O09.529-O09.93.
 
This service is included as part of a preventative office visit, 99384, 99385, 99386. 99394, 99395, 99396, 99401, 99402, 99403 or 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.
 
EFFECTIVE PRIOR TO JANUARY 2019
 
The use of low-dose aspirin (81 mg per day) when prescribed by a health care provider with prescribing authority is covered as a preventive medication after 12 weeks gestation in women who are high risk for preeclampsia for members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay).
 
The appropriate ICD-9 codes to report these services are V22.0-V22.2, V23.0- V23.9, V70.0.
 
The appropriate ICD-10 codes to report these services are Z00.00, Z00.01, Z33.1, Z34.00-Z34.93, O09-O09.40; O09.519, O09.529-O09.93.
 
This service is included as part of a preventative office visit, 99384, 99385, 99386. 99394, 99395, 99396, 99401, 99402, 99403 or 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 USPSTF recommends the use of low-dose aspirin (81 mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia (Grade B Recommendation).
 
The USPSTF recommendation (LeFevre, 2014) includes the following information:
 
Preeclampsia is one of the most serious health problems affecting pregnant women. It is a complication in 2% to 8% of pregnancies worldwide and contributes to both maternal and infant morbidity and mortality. Preeclampsia also accounts for 15% of preterm births in the United States. The disorder is defined by the onset of hypertension (blood pressure greater than 140/90 mm Hg) and proteinuria (greater than or equal to 0.3 g of protein in the urine within a 24-hour period) during the second half of pregnancy (greater than 20 weeks). In the absence of proteinuria, preeclampsia is classified as hypertension with any of the following: thrombocytopenia, impaired liver function, renal insufficiency, pulmonary edema, or cerebral or visual disturbances.
 
Important risk factors for preeclampsia include history of preeclampsia (including early-onset preeclampsia), intrauterine growth restriction (IUGR), or preterm birth; placental abruption or fetal death; maternal comorbid conditions (including type 1 or 2 pre-gestational diabetes, chronic hypertension, renal disease, and autoimmune diseases); and multifetal gestation.
 
The USPSTF found adequate evidence of a reduction in risk for preeclampsia, preterm birth, and IUGR in women at increased risk for preeclampsia who received low-dose aspirin, thus demonstrating substantial benefit. Low-dose aspirin (range, 60 to 150 mg/d) reduced the risk for preeclampsia by 24% in clinical trials and reduced the risk for preterm birth by 14% and IUGR by 20%.
 
The USPSTF found adequate evidence that low-dose aspirin as preventive medication does not increase the risk for placental abruption, postpartum hemorrhage, or fetal intracranial bleeding. In a meta-analysis of randomized, controlled trials (RCTs) and observational studies of women at low/average or increased risk for preeclampsia, there was no significantly increased risk for these adverse events. In addition, there was no difference in the risk for placental abruption by aspirin dosage.
 
The USPSTF also found adequate evidence that low-dose aspirin as preventive medication in women at increased risk for preeclampsia does not increase the risk for perinatal mortality. Evidence on long-term outcomes in offspring exposed in utero to low-dose aspirin is limited, but no developmental harms were identified by 18 months of age in the one study reviewed. The USPSTF concludes that the harms of low-dose aspirin in pregnancy are no greater than small.
 
Preeclampsia is a complex, multisystem inflammatory syndrome that can originate from multiple causes. It is believed to evolve from changes in placental development that result in placental ischemia. Poor placental perfusion may produce inflammation and oxidative stress. Preeclampsia may also develop as a result of overactive inflammatory responses to normal placentation. Preexisting inflammatory conditions are also believed to trigger systemic inflammatory and oxidative stress processes. The antiinflammatory, antiangiogenesis, and antiplatelet properties of low-dose aspirin are believed to account for its preventive effect on preeclampsia.
 

CPT/HCPCS:
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)
99385Initial 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; 18-39 years
99386Initial 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; 40-64 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)
99395Periodic 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; 18-39 years
99396Periodic 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; 40-64 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

References: . LeFevre ML.(2014) Low-Dose Aspirin Use for the Prevention of Morbidity and Mortality From Preeclampsia: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2014;161:819-826. doi:10.7326/M14-1884


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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