Coverage Policy Manual - Arkansas Blue Cross and Blue Shield

Coverage Policy Manual
Policy #:	2011011
Category:	PPACA Preventive
Initiated:	September 2010
Last Review:	January 2025

PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: ABDOMINAL AORTIC ANEURYSM 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 abdominal aortic aneurysm by ultrasonography is covered for members of “non-grandfathered” plans on a one-time basis, without cost-sharing (i.e., deductible, co-insurance, or co-pay):

in men 65 to 75 who have ever smoked;

The appropriate ICD-10 codes to report these services are Z87.891 or Z13.6.

The code that is used to report this procedure is CPT 76706. 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-10 and CPT or HCPCS codes are also required.

Rationale:

The U.S. Preventive Services Task Force (USPSTF) recommends one-time screening for abdominal aortic aneurysm in men aged 65-75 who have ever smoked (Grade B recommendation).

The USPSTF found good evidence that screening for AAA and surgical repair of large AAAs (5.5 cm or more) in men aged 65 to 75 who have ever smoked (current and former smokers) leads to decreased AAA-specific mortality. There is good evidence that abdominal ultrasonography, performed in a setting with adequate quality assurance (i.e., in an accredited facility with credentialed technologists), is an accurate screening test for AAA. There is also good evidence of important harms of screening and early treatment, including an increased number of surgeries with associated clinically-significant morbidity and mortality, and short-term psychological harms. Based on the moderate magnitude of net benefit, the USPSTF concluded that the benefits of screening for AAA in men aged 65 to 75 who have ever smoked outweigh the harms.

The USPSTF recommendations include the following information:

The major risk factors for abdominal aortic aneurysm (AAA) include age (being 65 or older), male sex, and a history of ever smoking (at least 100 cigarettes in a person's lifetime). A first-degree family history of AAA requiring surgical repair also elevates a man's risk for AAA; this may also be true for women but the evidence is less certain. There is only a modest association between risk factors for atherosclerotic disease and AAA.
Screening for AAA would most benefit those who have a reasonably high probability of having an AAA large enough, or that will become large enough, to benefit from surgery. In general, adults younger than age 65 and adults of any age who have never smoked are at low risk for AAA and are not likely to benefit from screening. Among men aged 65 to 74, an estimated 500 who have ever smoked—or 1,783 who have never smoked—would need to be screened to prevent 1 AAA-related death in the next 5 years. As always, clinicians must individualize recommendations depending on a patient's risk and likelihood of benefit. For example, some clinicians may choose to discuss screening with male nonsmokers nearing age 65 who have a strong first-degree family history of AAA that required surgery.
The potential benefit of screening for AAA among women aged 65 to 75 is low because of the small number of AAA-related deaths in this population. The majority of deaths from AAA rupture occur in women aged 80 or older. Because there are many competing health risks at this age, any benefit of screening for AAA would be minimal. Individualization of care, however, is still required. For example, a clinician may choose to discuss screening in the unusual circumstance in which a healthy female smoker in her early 70s has a first-degree family history for AAA that required surgery.
Operative mortality for open surgical repair of an AAA is 4 to 5 percent, and nearly one-third of patients undergoing this surgery have other important complications (e.g., cardiac and pulmonary). Additionally, men having this surgery are at increased risk for impotence.
Endovascular repair of AAAs (EVAR) is currently being used as an alternative to open surgical repair. Although recent studies have shown a short-term mortality and morbidity benefit of EVAR compared with open surgical repair, the long-term effectiveness of EVAR to reduce AAA rupture and mortality is unknown. The long-term harms of EVAR include late conversion to open repair and aneurysmal rupture. EVAR performed with older-generation devices is reported to have an annual rate of rupture of 1 percent and conversion to open surgical repair of 2 percent. The conversion to open surgical repair is associated with a peri-operative mortality of about 24 percent. The long-term harms of newer generation EVAR devices are yet to be reported.
For most men, 75 years may be considered an upper age limit for screening. Patients cannot benefit from screening and subsequent surgery unless they have a reasonable life expectancy. The increased presence of comorbidities for people aged 75 and older decreases the likelihood that they will benefit from screening.
Ultrasonography has a sensitivity of 95 percent and specificity of nearly 100 percent when performed in a setting with adequate quality assurance. The absence of quality assurance is likely to lower test accuracy. Abdominal palpation has poor accuracy and is not an adequate screening test.
One-time screening to detect an AAA using ultrasonography is sufficient. There is negligible health benefit in re-screening those who have normal aortic diameter on initial screening.
Open surgical repair for an AAA of at least 5.5 cm leads to an estimated 43-percent reduction in AAA-specific mortality in older men who undergo screening. However, there is no current evidence that screening reduces all-cause mortality in this population.
In men with intermediate-sized AAAs (4.0-5.4 cm), periodic surveillance offers comparable mortality benefit to routine elective surgery with the benefit of fewer operations. Although there is no evidence to support the effectiveness of any intervention in those with small AAAs (3.0-3.9 cm), there are expert opinion-based recommendations in favor of periodic repeat ultrasonography for these patients.

CPT/HCPCS:

References:

Bright Futures-Guidelines for Health Supervision of Infants, Children and Adolescents. Bright Futures.

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

U.S. Preventive Services Task Force. Screening for Abdominal Aortic Aneurysm: Recommendation Statement. AHRQ Publication No. 05-0569-A, February 2005. http://www.uspreventiveservicestaskforce.org/uspstf05/aaascr/aaars.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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