Coverage Policy Manual - Arkansas Blue Cross and Blue Shield

PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: FOLIC ACID FOR PREVENTION OF NEURAL TUBE DEFECTS

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:

Counseling for folic acid supplementation for all women planning or capable of pregnancy is covered for members of “non-grandfathered” plans on an annual basis, without cost-sharing (i.e., deductible, co-insurance, or co-pay). Over the counter folic acid supplementation is not covered.

The appropriate ICD-10 code to report these services is Z32.2-Z32.3, Z71.89 or Z00.00-Z00.01.

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 that all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid. (A recommendation)

This recommendation applies to women who are planning or capable of pregnancy, but it does not apply to women who have had a previous pregnancy affected by neural tube defects or women taking certain antiseizure medicines.

The use of certain antiseizure medicines and a personal or family history of neural tube defects are well-established risk factors. Other reported risk factors include mutations in folate-related enzymes, maternal diabetes, and obesity.

Most studies indicate the need to start folic acid supplementation at least 1 month before conception and to continue daily supplements through the first 2 to 3 months of pregnancy. Studies also indicate that 50% of pregnancies in the United States are unplanned, and clinicians should therefore advise all women who are capable of pregnancy to take folic acid supplements.

Good evidence from randomized trials in settings without fortification of food suggests that a multivitamin with 0.8 mg (800 µg) of folic acid reduces the risk for neural tube defects. Observational studies done before fortification report a reduction of neural tube defects in women taking a supplement with 0.4 mg (400 µg) of folic acid (the generally available dose). Evidence indicates that most women in the United States are not ingesting fortified foods at a level thought to provide optimal benefit. In a setting in which food is fortified with folic acid, the effective amount of additional folic acid supplementation is unclear.

References:

Folic Acid for the prevention of neural tube defects. May 2009: U.S. Preventive Services Task Force http://www.uspreventiveservicestaskforce.org/uspstf09/folicacid/folicacidrs.htm#rationale

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

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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