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Preventive Care CDG Changes Effective 2016

May 20, 2016

UnitedHealthcare’s Preventive Care Services Coverage Determination Guideline (CDG), which helps doctors identify and correctly code preventive services they deliver to our members, will making a few updates this year. The CDG defines the services, diagnoses, 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.  

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.

Changes to UnitedHealthcare Preventive Services CDG

The following updates will be made to the CDG in the upcoming months.

High Blood Pressure Screening in Adults The U.S. Preventive Services Task Force (USPSTF) recommends screening for high blood pressure in adults aged 18 years or older including obtaining measurements outside of the clinical setting for diagnostic confirmation prior to starting treatment.  Therefore, beginning October 1, 2016, UnitedHealthcare Preventive Care Services CDG will include codes for ambulatory blood pressure screening at home.

Abnormal Glucose and Type 2 Diabetes Mellitus in Adults Screening
The USPSTF recommends screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese. Beginning October 1, 2016, UnitedHealthcare adds the benefit for obese and overweight individuals aged 40 to 70.  UnitedHealthcare will continue to include screening for individuals with hypertensive diagnoses as a preventive services benefit – age limit applies.

There is a separate benefit for gestational diabetes that has no age limit.

Iron Deficiency Screening in Pregnant Women– Codes removed from CDG
The USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for iron deficiency anemia in pregnant women to prevent adverse maternal health and birth outcomes.  Therefore, UnitedHealthcare will remove this benefit from the Preventive Care Services CDG on October 1, 2016.  

Recent USPSTF Recommendations Where No Change is Required
The following USPSTF recommendations did not require changes to CDG:

Breast Cancer Screening for Women 50 to 74
USPSTF recommends screening mammography every two years for women ages 50 to 74 years. UnitedHealthcare already covers breast cancer screening in our Preventive Care Services CDG and are not making any changes at this time. Today UnitedHealthcare does not enforce any age or frequency limits on mammography screening.

Depression Screening, Adolescents
The USPSTF recommends screening for major depressive disorder in adolescents aged 12 to 18 years. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for major depressive disorder in children aged 11 years or younger.  UnitedHealthcare already includes these codes in the Preventive Care Services CDG and therefore no additional coding changes are necessary.

The Preventive Care Services CDG is available on the United for Reform Resource Center.

Contact your UnitedHealthcare representative if you have questions about the CDG changes or other health reform-related topics.

January 1, 2018 PDL Updates

The following updates will take effect for the OptumRx direct Prescription Drug Lists (PDLs) on January 1, 2018. Learn more

New Sales Automation Management Tool

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