Coverage Policy Manual
Policy #: 2011028
Category: PPACA Preventive
Initiated: May 2011
Last Review: June 2022
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: PHENYLKETONURIA SCREENING IN NEWBORNS

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 phenylketonuria (PKU) in newborns is covered for members of “non-grandfathered” plans without cost-sharing (i.e., deductible, co-insurance, or co-pay).
 
The appropriate ICD-10 code to report this service is Z13.228.
 
CPT Code 84030 may be used to report PKU screening. 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 USPSTF recommends screening for phenylketonuria (PKU) in newborns. (Grade A recommendation).
 
    • PKU is an inborn error of phenylalanine metabolism that occurs in from 1 per 13,500 to 1 per 19,000 newborns in the United States.  In the absence of treatment during infancy, most persons with this disorder will develop severe mental retardation.
    • Two approaches, fluorometry and tandem mass spectrometry, are in common use. The sensitivity and specificity of fluorometry are 100% and 51%, respectively, and of tandem mass spectrometry, 100% and 98%, respectively.
    • There is good evidence that detection by neonatal screening and early treatment of PKU substantially improve neurodevelopmental outcomes for affected persons.
    • False-positive tests could generate considerable parental anxiety.  
    • Screening for PKU is mandated in all 50 states, though methods of screening vary. There are three principal methods used for PKU screening in the United States: the Guthrie Bacterial Inhibition Assay (BIA), automated fluorometric assay, and tandem mass spectrometry. Screening tests are most accurate if performed after 24 hours of life but before the infant is 7 days old.  
    • It is essential that phenylalanine restrictions be instituted shortly after birth to prevent the neurodevelopmental effects of PKU.
    • Infants who are tested within the first 24 hours after birth should receive a repeat screening test by 2 weeks of age. Premature infants and those with illnesses should be tested at or near 7 days of age, but in all cases before newborn nursery discharge.
 

CPT/HCPCS:
84030Phenylalanine (PKU), blood

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

Screening for Osteoporosis.(2011) U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsspku.htm. Last accessed May 2011.


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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