Medical Policy



Subject: Preventive Health Guidelines
Document #: ADMIN.00002 Current Effective Date:    09/27/2017
Status: Reviewed Last Review Date:    08/03/2017

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 documents for additional information related to specific screenings for colorectal cancer:

Note: Please see the following document for additional information related to specific screenings for breast cancer:

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

American Academy of Family Physicians. Summary of recommendations for clinical preventive services, June 2017. Available at: http://www.aafp.org/dam/AAFP/documents/patient_care/clinical_recommendations/cps-recommendations.pdf. Accessed on June 26, 2017.

American Academy of Pediatrics. Bright Futures guidelines. February 2017. Available at: https://brightfutures.aap.org/materials-and-tools/guidelines-and-pocket-guide/Pages/default.aspx . Accessed on June 26, 2017.

American Cancer Society. Cancer screening guidelines. Available at: http://www.cancer.org/healthy/findcancerearly/cancerscreeningguidelines/. Accessed on June 26, 2017.

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 June 26, 2017.

American College of Obstetricians and Gynecologists. Resources and Publications. Available at: http://www.acog.org/Resources-And-Publications. Accessed on June 26, 2017.

American Heart Association. Clinical practice guidelines for prevention. 2013. Available at: http://professional.heart.org/professional/ScienceNews/UCM_457211_Clinical-Practice-Guidelines-for-Prevention.jsp. Accessed on June 26, 2017.

Centers for Disease Control and Prevention. Advisory Committee on Immunizations Practices. Immunization schedules. Available at: http://www.cdc.gov/vaccines/acip/. Accessed on June 26, 2017.

Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/. Accessed on June 26, 2017.

Health Resources and Services Administration (HRSA). Women's preventive services guidelines. 2016. Available at: http://hrsa.gov/womensguidelines/. Accessed on June 26, 2017.

National Academies of Sciences, Engineering and Medicine (formerly the Institute of Medicine [IOM]). Recommendations for preventive services for women that should be considered by United States Department of Health and Human Services (HHS). 2011. Available at: http://nationalacademies.org/hmd/~/media/files/report%20files/2011/clinical-preventive-services-for-women-closing-the-gaps/preventiveservicesforwomenreportbrief_updated2.pdf. Accessed on June 26, 2017.

U.S. Preventive Services Task Force (USPSTF). Published recommendations. Available at: http://www.uspreventiveservicestaskforce.org/BrowseRec/Index. Accessed on June 26, 2017.

Background/Overview

According to Katz (2009), "All physician and other health professional activities have the goal of prevention. What is to be prevented depends on the context, and the patient's position on the spectrum from health to disease." The construct of prevention is described as follows:

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.

References
  1. Katz, D, Ali A. Preventive Medicine, Integrative Medicine and the Health of the Public. 2009. Available at: http://www.nationalacademies.org/hmd/~/media/Files/Activity%20Files/Quality/IntegrativeMed/Preventive%20Medicine%20Integrative%20Medicine%20and%20the%20Health%20of%20the%20Public.pdf. Accessed on June 26, 2017.
  2. U.S. Preventive Services Task Force. U.S. Preventive Services Task Force Procedure Manual. Available at: https://www.uspreventiveservicestaskforce.org/Page/Name/methods-and-processes . Accessed on June 26, 2017.
Index

Abdominal Aortic Aneurysm
Adult Immunizations
Alcohol Misuse
Aspirin Preventive Medication
Autism
Bacteriuria Screening in Pregnant Women
Behavioral Health Counseling
Blood Lead Screening
Blood Pressure Screening
Body Mass Index (BMI)
BRCA Testing
Breast Cancer
Breast Cancer Preventive Medications (tamoxifen or raloxifene)
Breastfeeding
Cardiovascular Disease
Cervical Cancer
Chlamydia|
Cholesterol/ Dyslipidemia Screening
Colorectal Cancer
Contraception Methods and Counseling
Dental Health/Caries/Fluoride Treatment
Depression Screening
Diabetes Screening
Falls Prevention
Family Planning
Firearm Safety
Folic Acid and Neural Tube Deficit
Gestational Diabetes Mellitus
Gonorrhea Prophylactic Medication/Gonococcal Ophthalmia Neonatorum
Group B Streptococcal Infection in Pregnancy
Healthy Diet and Physical Activity
Hearing Loss in Newborns
Hemoglobin and Hematocrit
Hepatitis A
Hepatitis B
Hepatitis C (HCV)
Human Immunodeficiency Virus (HIV)
Human Papilloma Virus (HPV)
Hypothyroidism in Newborns
Immunizations
Influenza
Injury Prevention
Intimate Partner Violence
Iron Deficiency Anemia
Lead Exposure
Lung Cancer
Obesity in Adults, Children and Adolescents
Osteoporosis
Phenylketonuria Screening in Newborns
Preeclampsia Prevention
Rh Blood Type
Rubella Immunity
Secondhand Smoke
Sexually Transmitted Diseases
Skin Cancer
Smoking Cessation
Substance Abuse
Syphilis
Tobacco Abuse
Tobacco Cessation in Pregnancy
Vaccinations
Visual Acuity in Children
Ultraviolet Radiation
Well Visits for Infants, Children, and Adolescents
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 08/03/2017 Medical Policy & Technology Assessment Committee (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.