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Preventive Care Coverage Guidelines Revised Effective April 1

Story Content Provided by: UnitedHealthcare, March 13, 2013

UnitedHealthcare’s Preventive Care Services Coverage Determination Guideline (CDG), that helps doctors identify and correctly code preventive services they deliver to our members, will receive updates effective April 1. The CDG defines the services, diagnoses, age, gender, and other requirements to ensure that certain services are paid with preventive benefits and covered without cost-share under most plans.

Under the health reform law, non-grandfathered health plans are required to cover certain preventive care services without cost-sharing as long as these services are provided by network doctors and health care professionals.  Remember, the expanded list of women’s preventive care services  is not effective until the health plan’s first renewal date on or after Aug. 1, 2012.

The CDG is updated when new guidance is received about services that must be covered as preventive services and whenever the applicable codes are revised. The U.S. Preventive Services Task Force (USPSTF) is one of the primary references driving changes to the CDG. Items that have an “A” or “B” rating must be covered without cost-share by non-grandfathered plans.

Here are some of the  updates that will be made to the CDG effective April 1 and will apply to dates of service on or after April 1, 2013. 

Expanded Women’s Preventive, Breast Pump Equipment & Supplies

  • Added V24.1 to list of applicable diagnosis codes. V24.1 indicates postpartum care and the supervision of a lactating mother. This code is now required for an electric breast pump (E0603), a hospital-grade electric breast pump (E0604) and breast pump tubing and supplies (A4281 – A4286).  

This means that a woman should have delivered her baby and be lactating when she receives a breast pump. Doctors should use the V24.1 code on the physician order for the durable medical equipment supplier before the pump is sent to the member. The member does not have to obtain a prescription prior to contacting a durable medical equipment breast pump supplier. Previously, members could request a breast pump from a network provider or supplier at any time throughout their pregnancy.  

Breast Pump Coverage Updates 

Women’s preventive benefits, defined under the Health Resources and Services Administration (HRSA) requirement, include the cost of renting onebreast pump per pregnancy in conjunction with childbirth.  

UnitedHealthcare believes some members may prefer to purchase a more portable and convenient electric breast pump rather than rent hospital-grade equipment. To offer a range of choices for our members, UnitedHealthcare will also cover the purchase of a personal, double-electric breast pump at no cost to the member. Additionally, we believe purchasing a personal breast pump is on average less expensive than renting a hospital-grade breast pump.

If more than one type of breast pump can meet the member’s needs, benefitsare available only for the most cost-effective pump. UnitedHealthcare will determine the following:

  • Which pump is the most cost-effective
  • Whether the pump should be purchased or rented
  • Duration of a rental
  • Timing of an acquisition 

Hospital Grade Breast Pump

Hospital-grade breast pumps (heavy-duty pumps designed for multiple users), and the personal use attachment kit, are covered for members who meet the following criteria:

  1. The woman is a lactating mother
  2. The breast pump is obtained within the first two months (60 days) following delivery
  3. The baby has one or more of the following criteria:
  • Hospitalized newborn
  • Congenital malformations or genetic abnormalities that impact feeding (e.g. cleft lip and palate, Down Syndrome) 

After 10 months of renting, hospital-grade pumps automatically convert to a purchase. Previously, there were no criteria to rent a hospital-grade pump.   

Personal Use Double-Electric Breast Pump
High-quality, personal use double-electric breast pumps have been shown to be as effective as hospital-grade pumps in outpatient settings. 

A personal use double-electrical pump may be covered for the members who meet the following criteria:

  1. The woman is a lactating mother

  2. The breast pump is obtained within one year (365 days) following delivery 

Previously, there were no criteria to purchase a personal, double-electric breast pump.  

Screening for Obesity in Adults

  • Updated to reflect the June 2012 USPSTF rating indicating that clinicians should offer or refer patients with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions
  • Added diagnosis codes for BMI of 30.0 – 39.0 (V85.30 – V85.39) 

UnitedHealthcare covers screening and counseling today for obese patients. The change is that the USPSTF clarified that it must be done for those with BMI of 30+.  

Note: Weight management programs, such as Weight Watchers,  are not covered under this benefit. 

Cervical Cancer Screening, Pap Smear

  • Added the March 2012 USPSTF rating that provides screening for all women (not just sexually active women as was previously covered) age 21 to 65 years. Coverage ends on the 66th birthday.
  • There remains no frequency limit. 

This information was shared with doctors and health care professionals in our January issue of the Network Bulletin newsletter. 

The Preventive Care Services CDG is posted on the United for Reform Resource Center and the link will automatically update on April 1 with the new coding information. 

Marketing materials on breast-feeding supplies are updated on the United for Reform Resource Center: Women's Preventive Care Services: Breast-feeding Support, Supplies & Counseling

For more information please contact your UniteHealthcare representative.