| Medical Policy |
| Subject: Preventive Health Guidelines | |
| Document #: ADMIN.00002 | Publish Date: 06/28/2024 |
| Status: Reviewed | Last Review Date: 05/09/2024 |
| Description/Scope |
Preventive services span a broad range of care for individuals of all ages. Several national organizations produce evidence-based guidelines for these services.
Note: Please see the following document for information related to immunizations:
Note: Please see the following document for additional information related to specific screenings for colorectal cancer:
Note: For criteria related to specific screenings for breast cancer using MRI, refer to applicable guidelines used by the plan.
| Position Statement |
Medically Necessary:
The following lists of sources of preventive services recommendations created by the referenced organizations listed below are considered medically necessary.
When these recommendations are updated by their sponsoring organizations, the update is considered medically necessary as of the effective date of the update of the recommendation.
If there is a specific medical policy or clinical UM guideline that encompasses a topic addressed in any of these referenced guidelines, the specific medical policy or clinical UM guideline will take precedence.
| Rationale |
Preventive health recommendations from prominent national organizations are listed below.
American Academy of Family Physicians. Clinical Preventive Services Recommendations. 2024. Available at: https://www.aafp.org/family-physician/patient-care/clinical-recommendations/clinical-practice-guidelines/clinical-preventive-services-recommendations.html. Accessed on May 3, 2024.
American Academy of Pediatrics. 2024 Bright Futures/AAP Recommendations for Preventive Pediatric Health Care. Available at: https://brightfutures.aap.org/materials-and-tools/guidelines-and-pocket-guide/Pages/default.aspx. Accessed on May 3, 2024.
American Cancer Society. Cancer screening guidelines. Last updated November 1, 2023. Available at: https://www.cancer.org/healthy/find-cancer-early/cancer-screening-guidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer.html. Accessed on May 3, 2024.
American College of Cardiology. American Heart Association and National Heart, Lung and Blood Institute (ACC/AHA/NHLBI). ACC/AHA/NHLBI Clinical advisory on the use and safety of statins (2002). Available at: http://circ.ahajournals.org/content/106/8/1024.full. Accessed on May 3, 2024.
American College of Obstetricians and Gynecologists. Resources and Publications. Available at: https://www.acog.org/clinical/search#sort=relevancy&f:topic=[obstetric%20delivery]. Accessed on May 3, 2024.
American Heart Association. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Available at: https://professional.heart.org/en/guidelines-and-statements/guidelines-and-statements-search. Accessed on May 3, 2024.
Centers for Disease Control and Prevention. Vaccines and Immunizations. Advisory Committee on Immunizations Practices. Immunization schedules. Last Reviewed November 16, 2023. Available at: https://www.cdc.gov/vaccines/index.html. Accessed on May 3, 2024.
Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/. Accessed on May 3, 2024.
Health Resources and Services Administration (HRSA). Women’s preventive services guidelines. Last updated March 2024. Available at: http://hrsa.gov/womensguidelines/. Accessed on February 28, 2024.
U.S. Preventive Services Task Force (USPSTF). Published recommendations. Last updated 2024. Available at: http://www.uspreventiveservicestaskforce.org/BrowseRec/Index. Accessed May 3, 2024.
The above organizations generally have similar recommendations for a given condition. When recommendations from these organizations are discordant, the least restrictive recommendations are recognized.
| Background/Overview |
Disease prevention is integral to the practice of medicine. The construct of prevention has several components, depending on the context and the patient’s location on the spectrum of disease, which are described as follows (Katz 2009):
Primary Prevention: Refers to health promotion, which fosters wellness in general and thus reduces the likelihood of disease, disability, and premature death in a nonspecific manner, as well as specific protection against the inception of disease. Examples of the former include the promotion of physical activity and prudent dietary practices; smoking avoidance or cessation; and the mitigation of stress. Immunization is a clear example of the latter.
Secondary Prevention: Refers to the detection and management of presymptomatic disease, and the prevention of its progression to symptomatic disease. Screening is the dominant practice in this space, exemplified by cancer screening (e.g., mammography, colonoscopy), and cardiac risk screening (e.g., lipid testing, blood pressure screens).
Tertiary Prevention: Refers to the treatment of symptomatic disease in an effort to prevent its progression to disability, or premature death.
The preventive services recommendations referenced in this document refer to primary and secondary prevention strategies.
In determining the clinical appropriateness of a preventive service, a distinct set of principles must be critically considered. Recommendations must be evidence-based and clinically meaningful: there must be scientific evidence that persons who receive the preventive service experience better health outcomes than those who do not, and that the benefits are large enough to outweigh the harms. For a detailed example of the methodologic, scientific and administrative process of making evidence-based recommendations for preventive services, please refer to the USPSTF procedure manual or the National Academy of Medicine’s standards for developing trustworthy guidelines.
| References |
Government Agency, Medical Society, and Other Authoritative Publications:
| Index |
Abdominal Aortic Aneurysm
Abnormal Blood Glucose
Adult Immunizations
Alcohol Misuse
Abdominal Aortic Aneurysm Screening: men aged 65 to 75 years with history of smoking
Anemia
Anxiety Screening
Aspirin as Preventive Medication
Autism
Bacteriuria Screening in Pregnant Women
Behavioral Health Counseling
Blood Lead Screening
Blood Pressure Screening
Body Mass Index (BMI)
BRCA Risk Assessment and Genetic Counseling/Testing
Breast Cancer
Breast Cancer Preventive Medications
Breastfeeding Support, Supplies and Counseling
Cardiovascular Disease
Cervical Cancer Screening
Chlamydia
Child Development
Cholesterol/ Dyslipidemia Screening
Colorectal Cancer
Contraception Methods and Counseling
COVID-19
Dental Health/Prevention of dental caries in children younger than 5 years: screening and interventions/Fluoride Treatment
Depression Screening: Adolescents and Adults
Developmental and Behavioral Surveillance and Screening
Diabetes Screening & screening for diabetes mellitus after pregnancy
Falls Prevention
Family Planning
Firearm Safety
Folic Acid and Neural Tube Deficit
Genital Herpes Infection
Gestational Diabetes Mellitus Screening
Gonorrhea Prophylactic Medication/Gonococcal Ophthalmia Neonatorum
Group B Streptococcal Infection in Pregnancy
Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: Behavioral Counseling Interventions
Hearing Loss in Newborns, Toddlers and Young Children
Hemoglobin and Hematocrit
Hemoglobinopathies Screening: Newborns
Hepatitis A
Hepatitis B Screening in Pregnant Women, Nonpregnant Adolescents and Adults
Hepatitis C (HCV)
High Blood Pressure Screening
Human Immunodeficiency Virus (HIV) Preexposure Prophylaxis
HIV Screening
Human Papilloma Virus (HPV)
Hypertensive Disorders of Pregnancy
Hypothyroidism in Newborns
Immunizations
Influenza
Injury Prevention
Intimate Partner Violence
Iron Deficiency Anemia
Language Delay
Lead Exposure
Lipid Disorders in Children and Adolescents
Lung Cancer Screening
Neural Tube Defection Prevention
Obesity Screening and Counseling in Adults, Children and Adolescents
Obstructive Sleep Apnea in Adults
Oral Health
Osteoporosis Screening
Perinatal Depression
Phenylketonuria Screening in Newborns
Prediabetes and Type 2 Diabetes: screening
Preeclampsia Prevention
PrEP
Rh Blood Type
Rubella Immunity
Secondhand Smoke
Sexually Transmitted Infections Counseling
Skin Cancer
Smoking Cessation
Speech Delay
Substance Abuse
Syphilis Screening
Tobacco Abuse
Tobacco Cessation in Pregnancy
Tuberculosis Screening: Adults
Urinary Incontinence Screening
Vaccinations
Visual Acuity in Children
Ultraviolet Radiation
Well Visits for Infants, Children, and Adolescents
Well-woman visits
Women’s Health
The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.
| Document History |
| Status | Date | Action |
| Reviewed | 05/09/2024 | Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Rationale, References and Index sections. |
| Reviewed | 05/11/2023 | MPTAC review. Updated Description/Scope, Rationale, and References sections. |
| Reviewed | 05/12/2022 | MPTAC review. Updated Rationale, References, and Index sections. |
| Reviewed | 05/13/2021 | MPTAC review. Updated Rationale, References and Index sections. |
| Reviewed | 05/14/2020 | MPTAC review. Updated Rationale, References and Index sections. |
| Reviewed | 06/06/2019 | MPTAC review. Updated Rationale, References and Index sections. |
| Reviewed | 07/26/2018 | MPTAC review. Updated Rationale, Background/Overview and References sections. |
|
| 05/15/2018 | The document header wording updated from “Current Effective Date” to “Publish Date.” |
| Reviewed | 08/03/2017 | MPTAC review. Updated References section. |
| Reviewed | 08/04/2016 | MPTAC review. Updated the Rationale, References and Index sections. |
| Revised | 08/06/2015 | MPTAC review. Updated and reviewed hyperlinks; included IOM and HRSA citation hyperlinks. Updated the Rationale and Index sections. |
| Revised | 11/13/2014 | MPTAC review. Updated Rationale section to include websites of evidenced based organizations. Added Background and References sections. Updated the Index section. |
| Revised | 05/15/2014 | MPTAC review. Updated ACOG Practice Bulletin Gestational Diabetes Mellitus, 2013. Added USPSTF recommendation for Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA-Related Cancer in Women, 2013; added USPSTF recommendation Gestational Diabetes Mellitus, 2014; added USPSTF recommendation Screening for Lung Cancer, 2013. Updated Rationale. |
| Revised | 11/14/2013 | MPTAC review. Added USPSTF recommendation Primary Care Interventions To Prevent Tobacco Use in Children and Adolescents, 2013. |
| Revised | 08/08/2013 | MPTAC review. Added USPSTF recommendation Screening for HIV, 2013; added USPSTF recommendation for Hepatitis C screening in adults, 2013; added USPSTF recommendation Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse, 2013. |
| Revised | 05/09/2013 | MPTAC review. Added USPSTF Screening for Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults, 2013. Updated Index. |
| Revised | 02/14/2013 | MPTAC review. Updated USPSTF Guide to Preventive Clinical Services, 2012. Added American Academy of Pediatrics Policy Statement—Ultraviolet Radiation: A Hazard to Children and Adolescents, 2011. Added USPSTF Behavioral Counseling to Prevent Skin Cancer, 2012. Added ACOG Practice Bulletin Screening for cervical cancer, 2012. |
| Revised | 11/08/2012 | MPTAC review. Added Centers for Disease Control and Prevention Recommendations for the Identification of Chronic Hepatitis C Virus Infection Among Persons Born During 1945–1965, 2012. Updated Index. |
| Revised | 05/10/2012 | MPTAC review. Updated American Cancer Society Guidelines for the Early Detection of Cancer. Added ACOG Practice Bulletin Gestational Diabetes, 2001. Added USPSTF Primary Care Interventions to Promote Breastfeeding Recommendation Statement, 2008. Added ACOG Committee Opinion Intimate partner violence, 2012. Added reference for Epidemiologic and Statistical Considerations. Updated Rationale. |
| Revised | 11/17/2011 | MPTAC review. Removal of Immunizations from References and moved to ADMIN.00007. Updated ACOG Practice Bulletin on Breast Cancer Screening. Removed U.S. Department of Health and Human Services 2008 Physical Activity Guidelines for Americans, U.S. Department of Health and Human Services and U.S. Department of Agriculture. Dietary Guidelines for Americans, Centers for Disease Control and Prevention, Folic Acid and Prevention of Spina Bifida and Anencephaly, American Academy of Pediatrics Council on Sports Medicine and Fitness, Council on School Health. Active healthy living: prevention of childhood obesity through increased physical activity, American Heart Association Dietary recommendations for children and adolescents, and ACS/ADA/AHA Scientific Statement. Preventing Cancer, Cardiovascular Disease, and Diabetes. Updated Index. |
| Revised | 08/18/2011 | MPTAC review. American Academy of Pediatrics Recommendation for Preventive Pediatric Healthcare Reaffirmed January 2011, American Cancer Society Guidelines for the Early Detection of Cancer update. |
| Revised | 05/19/2011 | MPTAC review. Added updated US HHS and USDA Dietary Guidelines for Americans, 2010; CDC Guidelines for the Identification and Management of Lead Exposure in Pregnant and Lactating Women. 2010, AHA Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women: 2011 Update. |
| Revised | 02/17/2011 | MPTAC review. Added ACIP Adult and Childhood and Adolescent Immunization Schedules, 2011; CDC updated Sexually Transmitted Diseases Treatment Guidelines, CDC updated Recommendations for Use of Meningococcal Conjugate Vaccines, CDC updated Recommendations for Use of Tdap Vaccine, CDC updated Prevention of Perinatal Group B Streptococcal Disease guidelines, ACIP recommendations for Prevention of Invasive Pneumococcal Disease Among Infants and Children --- Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine and USPSTF updated Screening for Visual Impairment in Children Ages 1 to 5 Years and USPSTF updated Screening for Osteoporosis. |
| Revised | 11/18/2010 | MPTAC review. Added ACIP Updated Recommendations for Prevention of Invasive Pneumococcal Disease Among Adults Using the 23-Valent Pneumococcal Polysaccharide Vaccine (PPSV23), ACOG Committee opinion no. 463: Cervical cancer in adolescents: screening, evaluation, and management and AAP Clinical Report--Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0-3 Years of Age).Updated USPSTF Guide to Clinical Preventive Services, 2010-2011. |
| Revised | 08/19/2010 | MPTAC review. Removed the ACIP provisional HPV recommendations and replaced with the official published recommendations in the MMWR. Added ACIP Recommendations for Prevention and Control of Influenza with Vaccines. |
| Revised | 05/13/2010 | MPTAC review. Added ACIP Provisional Recommendations for the Use of Influenza Vaccines and Licensure of a 13-Valent Pneumococcal Conjugate Vaccine (PCV13) and Recommendations for Use Among Children --- ACIP. |
| Revised | 02/25/2010 | MPTAC review. Added ACIP Adult and Childhood and Adolescent Immunization Schedules, 2010; ACIP Provisional Recommendations for HPV Vaccine, ACOG Practice Bulletin on Cervical Cytology Screening and USPSTF recommendations for Screening for Obesity in Children and Adolescents. Recommendations reviewed and updated as indicated. |
| Reviewed | 11/19/2009 | MPTAC review. Added USPSTF recommendations for Screening for Breast Cancer, Screening of Infants for Hyperbilirubinemia and Using Nontraditional Risk Factors in Coronary Heart Disease Risk Assessment. Added ACIP provisional recommendation for Use of Combination Vaccines. Recommendations reviewed and updated as indicated. |
| Reviewed | 08/27/2009 | MPTAC review. Added USPSTF updated recommendation for Folic Acid for the Prevention of Neural Tube Defects and Screening for Impaired Visual Acuity in Older Adults. Added ACIP recommendations for Prevention and Control of Seasonal Influenza with Vaccines and Use of Influenza A (H1N1). Added ACIP Resolutions for Measles, Mumps, Rubella, and Varicella, Meningococcal Disease, and Poliomyelitis. |
| Reviewed | 05/21/2009 | MPTAC review. Added ACIP provisional recommendation for the 2009-2010 influenza season, the U.S. HHS 2008 Physical Activity Guidelines for Americans and Dietary Guidelines for Americans, 2005. Recommendations reviewed and updated as indicated. |
| Reviewed | 02/26/2009 | MPTAC review. Added ACIP resolution for Use of Pneumococcal Vaccines. Recommendations reviewed and updated as indicated. |
| Reviewed | 11/20/2008 | MPTAC review. Added USPSTF updated recommendation on Screening for Lipid Disorders in Adults and USPSTF updated recommendation on Screening for Colorectal Cancer Screening. Websites reviewed and updated. |
| Reviewed | 08/28/2008 | MPTAC review. Added USPSTF recommendation on Screening for Prostate Cancer, Treating Tobacco Use and Dependence: 2008 Update, and USPSTF recommendation on universal screening hearing loss in newborns. Updated Influenza and Rotavirus recommendations. Websites reviewed and updated. |
| Reviewed | 06/04/2008 | Added USPSTF recommendation on screening for type 2 diabetes in adults. Effective June 2008. Removed American Medical Association. Improving Colorectal Cancer: Screening reference – no longer available. |
| Reviewed | 05/15/2008 | MPTAC review. Added rationale on colorectal cancer screening and ACIP recommendation on Prevention of Pertussis, Tetanus, and Diphtheria Among Pregnant and Postpartum Women and Their Infants and Prevention of Herpes Zoster. |
| Reviewed | 03/03/2008 | Added ACIP resolution on influenza, adopted February 27, 2008 and effective July 1, 2008. |
| Revised | 02/21/2008 | MPTAC review. Clarified position statement for updating effective date for updated recommendations. Recommendations reviewed and updated. |
| Revised | 11/29/2007 | MPTAC review. ACIP resolutions for Meningococcus and Influenza Vaccines added. Websites reviewed and updated. |
| Revised | 08/23/2007 | MPTAC review. CDC guide on Screening Young Children for Lead Poisoning and CDC recommendation for varicella prevention added. Websites reviewed and updated. |
| Revised | 05/17/2007 | MPTAC review. Added AHA recommendation for Cardiovascular Disease Prevention in Women. Updated ACOG Committee Opinion on Primary and Preventive Care. Websites reviewed and updated. |
| Reviewed | 03/12/2007 | Provisional recommendation for Quadrivalent Human Papillomavirus Vaccine updated. |
| Reviewed | 01/05/2007 | The link for the 2007 Childhood and Adolescent Immunization Schedule and the link for the Recommendations for the Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine updated. |
| Revised | 12/07/2006 | MPTAC review. Recommendations for childhood obesity, HIV testing, prenatal care, hepatitis B, rotavirus, and “shingles” vaccination added. Websites reviewed and updated. |
| Revised | 09/14/2006 | MPTAC review. Websites updated for HPV, Rotavirus, Mumps, Pertussis and Varicella Vaccines. |
| Reviewed | 06/08/2006 | MPTAC review. Websites updated. |
| Revised | 07/14/2005 | MPTAC review. Revision based on Policy Harmonization: Pre-merger Anthem and Pre-merger WellPoint. |
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