TRANSMITTAL #:  128

DATE:  12/23/2011

TRICARE CHANGE #:  N/A

CHAMPVA POLICY MANUAL

ADDENDUM 1

PREVENTIVE SERVICES

Covered Benefit

Summary

Location of

Policy Guidance

Body Measurements (Adult)

Periodic height and weight as a component of good clinical practice that is integrated into the office visit at no additional charge. (*)

Chapter 2, Section 23.1

Body Measurements (Well-Child)

Height and weight measurements are covered throughout infancy and childhood. Head circumference should be measured for children through 24 months at the physician’s discretion. (Reimbursement is for the office visit only)

Chapter 2, Section 12.1

Blood Pressure (Adult)

Reimbursement is for the office visit only.

Chapter 2, Section 23.1

Blood Pressure (Well-Child)

Annual blood pressure screening for children between 3 and to 6 years of age.

Chapter 2, Section 12.1

Blood Lead Test (Well-Child)

Blood lead test.  Assessment of risk for lead exposure by structured questionnaire based on Center for Disease Control

(CDC) publication, Preventing Lead Poisoning in Young, during each well-child visit from age 6 months to under 6 years of age.

Chapter 2, Section 12.1

Cancer Screening - Breast Cancer (Mammography)

Mammography is covered as a diagnostic or screening procedure when provided in accordance with referenced policy.  See criteria for asymptomatic women and indicators for those women considered high risk.

Chapter 2, Section 2.1 and Section 23.1

Cancer Screening - Colorectal Cancer

Digital rectal examination, fecal occult blood testing, proctosigmoidoscopy or sigmoidoscopy and colonoscopy.

Chapter 2, Section 3.2 and Section 23.1

Cancer Screening – Oral Cavity and Pharyngeal Cancer

A complete oral cavity examination is a part of routine preventive care for adults at high risk due to exposure to tobacco or excessive amounts of alcohol and is normally integrated into the office visit at no additional charge (*)

Chapter 2, Section 23.1

Cancer Screening – Prostate Cancer

Annual digital rectal examinations are covered for men age 40-49 who have a family history of prostate cancer, and for all men over 50.  Annual PSA (Prostate-Specific Antigen) testing is covered for all men age 50 and older; men age 40 and over who have a family history of prostate cancer; men who have had a vasectomy at least 20 years previously or who had their vasectomy at age 40 or older.  Discontinue screening at age 70.

Chapter 2, Section 3.5 and Section 23.1

Cancer Screening - Screening PAP Test

Women age 18 and over women who are at risk for sexually transmissible diseases; or women who have or have had multiple sexual partners; or if their partner has or has had multiple sexual partners; women who smoke. Frequency of PAP tests will be at the discretion of the clinician but should not be less frequent than every 3 years.

Chapter 2, Section 23.1 and Section 35.2

Cancer Screening – Skin Cancer

Physical skin examination is a covered service if certain criteria are met however, reimbursement costs usually integrated

into the office visit (*)

Chapter 2, Section 23.1

Cancer Screening – Testicular Cancer

Annual physical examination for males age 13-39 with history of cryptorchidism, orchipexy, or testicular atrophy.  (*)

Chapter 2, Section 23.1

Cancer Screening – Thyroid Cancer

Palpation for thyroid nodules is covered for adults with a history of upper body irradiation.  (*)

Chapter 2, Section 23.1

Cholesterol Screening

Cholesterol. Non-fasting total blood cholesterol at least once every 5 years. (*)

Chapter 2, Section 23.1

Chromosome analysis

In cases of habitual abortion or infertility is considered a diagnostic service and is not subject to the genetic testing criteria.

Chapter 2, Section 23.1

Communicable diseases

(Hepatitis b meningococcal, meningitis, etc.)

Covered if provided to individuals with verified exposure to a potentially life-threatening medical condition.

Chapter 2, Section 23.1 and Section 23.3

Counseling Services (i.e., patient and parent education counseling for dietary assessment and nutrition; physical activity and exercise; cancer surveillance; safe sexual practices; tobacco, alcohol and substance abuse; promoting dental health; accident and injury prevention; and stress, bereavement and suicide risk assessment.)

Reimbursement is for the office visit only.

Chapter 2, Section 23.1

Dental Screening (Adult)

CHAMPVA does not include a dental screening benefit. Under very limited circumstances, benefits are available when adjunctive to otherwise covered medical treatment. Fillings or extractions do not qualify as adjunctive dental care and therefore are not covered.

Chapter 2, Section 5.1

Dental Screening (Well-Child)

Dental screening by primary physician during routine exams at birth, approximately 6 months, 3 years, and 5 years of age. Adjunctive dental care requires preauthorization. Routine fillings and extractions do not qualify as adjunctive dental care and therefore are not covered.

Chapter 2, Section 5.1 and Section 12.1

Electrocardiograms

Covered when patient is being admitted for a surgical procedure involving general anesthesia.

Chapter 2, Section 4.4 and 23.1

Genetic testing and counseling

Covered under certain circumstances for a pregnant beneficiary and those certain circumstances as defined within benefit policy.

Chapter 2, Section 23.1

Genetic testing for Marfan Syndrome and chromosome analysis for children

Testing and analysis (includes karyotyping and/or high-resolution chromosome analysis) of children are considered a diagnostic service and are not subject to the genetic testing criteria.

Chapter 2, Section 23.1

Health Counseling (Well-Child)

Health guidance and counseling, including breast-feeding and nutrition counseling are covered.

Chapter 2, Section 12.1

Hearing Screening (Well-Child) (Audiology)

Evaluate hearing of all well-child participants as part of routine examinations and refer those with possible hearing impairments as appropriate.

Chapter 2, Section 12.1 and Section 23.1

Heredity and Metabolic Screening (Well-Child)

Includes the routine testing of newborns (hypothyroidism, phenylketonuria (PKU), hemoglobinopathies

Chapter 2, Section 12.1

HIV Testing

Service may be provided during acute and chronic care visits or during preventive care visits.

Chapter 2, Section 14.1, Section 16.3, and Section 23.1

Immunizations

Covered when administered in accordance with current CDC (Center for Disease) Immunization guidelines.

Chapter 2, Section 12.1, Section 23.1, and Section 23.3

Infectious Diseases

(Tuberculosis screening, Isoniazid therapy, Rubella)

TB Screening: Conducted annually, regardless of age, all individuals at high risk.

Isoniazid Therapy: for high-risk individuals

Rubella Antibodies: Females once during are 12-18

Chapter 2, Section 23.1 and Section 23.3

Rabies: Administration of Antirabies Serum/Rabies Vaccine; Laboratory examination of the brain of an animal suspected of having rabies.

Covered following an animal bite. Pre-exposure prophylaxis for persons with high risk of exposure to rabies is not covered. Lab exam of the animal's brain is covered. Charges for boarding, collection of brain specimen and animal destruction are not covered.

Chapter 2, Section 23.1

Tetanus immunoglobulin and tetanus toxoid

Covered as medically determined.

Chapter 2, Section 23.1 and Section 23.3

Vision Screening (Adult)

Eye examinations are excluded except when rendered in connection with medical or surgical treatment of a covered illness or injury. Purchase of eyeglasses, spectacles, contact lenses and prescriptions for or other optical devices are not covered unless the medical need meets the criteria of policy guidance.

Chapter 2, Section 10.6 and Section 23.1

Vision Screening  (Well-Child)

Eye and vision screening by primary provider during routine examinations at birth, approximately 6 months, 3 years, and 5 years of age and are referred if medically appropriate. Additionally, ages 3 to 6: comprehensive eye examinations for amblyopia and strabismus. Purchase of eyeglasses, spectacles, contact lenses and or other optical devices are not covered unless medically necessary.

Chapter 2, Section 12.1 and Section 23.1

Well-Child  Care Policy

Well-Child care from birth to age 6 when services are provided by the attending physician, certified nurse practitioner, or certified physician assistant. (In some cases, reimbursement is for the office visit only.)

 

X-rays (Routine Chest)

Covered when patient is admitted for a surgical procedure that involves general anesthesia.

Chapter 2, Section 23.1 and Section 26.2

NOTE: (*) Denotes covered preventive services when provided in connection with immunizations, pap smears, mammograms, or colon and prostate examinations. Refer to CHAMPVA PM Chapter 2, Section 23.1 for clarification. (Although a particular service may be covered, in some cases, such services may be considered a component of the office visit and therefore reimbursement is for the office visit only.)