| Coverage Policy Manual | |
| Policy #: | 2015036 |
| Category: | PPACA Preventive |
| Initiated: | January 2016 |
| Last Review: | January 2025 |
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| PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: SCREENING FOR HYPERTENSIVE DISORDERS AND PREVENTION OF PREECLAMPSIA IN PREGNANCY | |
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| 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.
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Policy/ Coverage: |
Effective January 2025
Screening for hypertensive disorders in pregnancy with blood pressure measurements is covered for biologic females throughout pregnancy for members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay).
The use of low-dose aspirin (81 mg per day) when prescribed by a health care provider with prescribing authority is covered as a preventive medication after 12 weeks gestation in biologic females who are high risk for preeclampsia for members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay).
The appropriate ICD-10 codes to report these services are Z00.00, Z00.01, Z33.1, Z34.00-Z34.93, O09-O09.40; O09.519, O09.529-O09.93.
This service is included as part of a preventative office visit, 99384, 99385, 99386. 99394, 99395, 99396, 99401, 99402, 99403 or 99404. 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.
Effective January 2019 – December 2024
Screening for preeclampsia in pregnant women with blood pressure measurements is covered throughout pregnancy for members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay).
The use of low-dose aspirin (81 mg per day) when prescribed by a health care provider with prescribing authority is covered as a preventive medication after 12 weeks gestation in women who are high risk for preeclampsia for members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay).
The appropriate ICD-10 codes to report these services are Z00.00, Z00.01, Z33.1, Z34.00-Z34.93, O09-O09.40; O09.519, O09.529-O09.93.
This service is included as part of a preventative office visit, 99384, 99385, 99386. 99394, 99395, 99396, 99401, 99402, 99403 or 99404. 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.
EFFECTIVE PRIOR TO JANUARY 2019
The use of low-dose aspirin (81 mg per day) when prescribed by a health care provider with prescribing authority is covered as a preventive medication after 12 weeks gestation in women who are high risk for preeclampsia for members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay).
The appropriate ICD-9 codes to report these services are V22.0-V22.2, V23.0- V23.9, V70.0.
The appropriate ICD-10 codes to report these services are Z00.00, Z00.01, Z33.1, Z34.00-Z34.93, O09-O09.40; O09.519, O09.529-O09.93.
This service is included as part of a preventative office visit, 99384, 99385, 99386. 99394, 99395, 99396, 99401, 99402, 99403 or 99404. 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-9 and CPT or HCPCS codes are also required.
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| Rationale: |
The USPSTF recommends the use of low-dose aspirin (81 mg/d) as preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia (Grade B Recommendation).
The USPSTF recommendation (LeFevre, 2014) includes the following information:
Preeclampsia is one of the most serious health problems affecting pregnant women. It is a complication in 2% to 8% of pregnancies worldwide and contributes to both maternal and infant morbidity and mortality. Preeclampsia also accounts for 15% of preterm births in the United States. The disorder is defined by the onset of hypertension (blood pressure greater than 140/90 mm Hg) and proteinuria (greater than or equal to 0.3 g of protein in the urine within a 24-hour period) during the second half of pregnancy (greater than 20 weeks). In the absence of proteinuria, preeclampsia is classified as hypertension with any of the following: thrombocytopenia, impaired liver function, renal insufficiency, pulmonary edema, or cerebral or visual disturbances.
Important risk factors for preeclampsia include history of preeclampsia (including early-onset preeclampsia), intrauterine growth restriction (IUGR), or preterm birth; placental abruption or fetal death; maternal comorbid conditions (including type 1 or 2 pre-gestational diabetes, chronic hypertension, renal disease, and autoimmune diseases); and multifetal gestation.
The USPSTF found adequate evidence of a reduction in risk for preeclampsia, preterm birth, and IUGR in women at increased risk for preeclampsia who received low-dose aspirin, thus demonstrating substantial benefit. Low-dose aspirin (range, 60 to 150 mg/d) reduced the risk for preeclampsia by 24% in clinical trials and reduced the risk for preterm birth by 14% and IUGR by 20%.
The USPSTF found adequate evidence that low-dose aspirin as preventive medication does not increase the risk for placental abruption, postpartum hemorrhage, or fetal intracranial bleeding. In a meta-analysis of randomized, controlled trials (RCTs) and observational studies of women at low/average or increased risk for preeclampsia, there was no significantly increased risk for these adverse events. In addition, there was no difference in the risk for placental abruption by aspirin dosage.
The USPSTF also found adequate evidence that low-dose aspirin as preventive medication in women at increased risk for preeclampsia does not increase the risk for perinatal mortality. Evidence on long-term outcomes in offspring exposed in utero to low-dose aspirin is limited, but no developmental harms were identified by 18 months of age in the one study reviewed. The USPSTF concludes that the harms of low-dose aspirin in pregnancy are no greater than small.
Preeclampsia is a complex, multisystem inflammatory syndrome that can originate from multiple causes. It is believed to evolve from changes in placental development that result in placental ischemia. Poor placental perfusion may produce inflammation and oxidative stress. Preeclampsia may also develop as a result of overactive inflammatory responses to normal placentation. Preexisting inflammatory conditions are also believed to trigger systemic inflammatory and oxidative stress processes. The antiinflammatory, antiangiogenesis, and antiplatelet properties of low-dose aspirin are believed to account for its preventive effect on preeclampsia.
2024 Update
The USPSTF recommends screening for hypertensive disorders in pregnant persons with blood pressure measurements throughout pregnancy.
Hypertensive disorders of pregnancy include gestational hypertension, preeclampsia and eclampsia, and chronic hypertension with superimposed preeclampsia (Henderson, 2023; ACOG, 2020; DeSisto, 2021).
Hypertensive disorders of pregnancy are among the leading causes of maternal morbidity and mortality in the US (CDC, 2023). The rate of hypertensive disorders of pregnancy has been increasing from approximately 500 cases per 10,000 deliveries in 1993 to 1021 cases per 10,000 deliveries in 2016 to 2017 (CDC, 2023). Serious maternal morbidities associated with hypertensive disorders of pregnancy, in particular preeclampsia, include cerebrovascular accidents, retinal detachment, organ damage or failure, and eclamptic seizures. Hypertensive disorders of pregnancy (including preeclampsia) were responsible for 6.8% of pregnancy-related deaths in the US during 2014 to 2017 (Petersen, 2019). Most deaths attributed to hypertensive disorders of pregnancy (65%) occur in the 6 weeks following delivery (Ananth, 2006). Adverse perinatal outcomes for the fetus and newborn include intrauterine growth restriction, low birth weight, and stillbirth (Henderson, 2023; ACOG, 2020; DeSisto, 2021). Many of the complications associated with preeclampsia lead to early induction of labor or cesarean delivery and preterm birth. Preeclampsia has been estimated to account for 6% of preterm births and 19% of medically indicated preterm births in the US (Giorgione, 2021). Having any hypertensive disorder of pregnancy (particularly preeclampsia) is associated with an increased risk of maternal chronic hypertension and cardiovascular disease later in life (Honigberg, 2019; Melamed, 2014; Bryant, 2014).
In the US, Black persons experience higher rates of maternal and infant morbidity and perinatal mortality than other racial and ethnic groups and are at greater risk for developing hypertensive disorders of pregnancy than other pregnant persons (Henderson, 2023; CDC, 2023; Hoyert, 2021). In 2019, the maternal mortality rate (maternal deaths during and up to 42 days postpartum) was higher among Black persons than among White persons (44.0 per 100,000 live births vs 17.9 per 100,000 live births, respectively) (Petersen, 2019). Hypertensive disorders of pregnancy account for a larger proportion of pregnancy-related morbidity and mortality among Black populations than White populations (Grobman, 2018; Gyamfi, 2020; Fingar, 2017; MacDorman, 2021; Creanga, 2017; Hitti, 2018). Approximately two-thirds of Black persons with preeclampsia are diagnosed with having severe symptoms, compared with fewer than half of White persons developing preeclampsia (Grobman, 2018; Gyamfi, 2020; Fingar, 2017; MacDorman, 2021). These disparities in disease severity contribute to the higher overall maternal mortality rates observed in Black populations (USPSTF, 2021). The risk of dying of eclampsia and preeclampsia is about 5 times greater for Black individuals (3.93 maternal deaths per 100,000 live births) than for White individuals (0.78 maternal deaths per 100,000 live births) (Henderson, 2023; Creanga, 2017).
Pregnancy-related mortality among Native American/Alaska Native persons is also elevated compared with White persons (29.7 maternal deaths vs 12.7 maternal deaths per 100,000 live births in 2007 to 2016, respectively), with hypertensive disorders of pregnancy accounting for 12.8% of pregnancy-related deaths (Grobman, 2018). Native American/Alaska Native individuals have significantly higher severe maternal morbidity rates compared with other racial and ethnic groups (11.7% vs 3.9% for White individuals) (USPSTF, 2021).
The US Preventive Services Task Force (USPSTF) concludes with moderate certainty that screening for hypertensive disorders in pregnancy with blood pressure measurements has substantial net benefit.
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| References: |
. LeFevre ML.(2014) Low-Dose Aspirin Use for the Prevention of Morbidity and Mortality From Preeclampsia: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2014;161:819-826. doi:10.7326/M14-1884 |
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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.
CPT Codes Copyright © 2025 American Medical Association. |
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