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TRICARE Policy Manual 6010.60-M, April 1, 2015
Medicine
Chapter 7
Section 2.2
Clinical Preventive Services - TRICARE Prime And TRICARE Select
Issue Date:  May 15, 1996
Authority:  32 CFR 199.17
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-90, September 3, 2021
1.0  POLICY
1.1  TRICARE Prime enrollees may receive TRICARE Prime clinical preventive services from any network provider within their region of enrollment without referral or authorization. If a TRICARE Prime clinical preventive service is not available from a network provider (e.g., a network provider is not available within prescribed access parameters), an enrollee may receive the service from a non-network provider with a referral from the Primary Care Manager (PCM). If an enrollee uses a non-network provider without first obtaining a referral from the PCM, payment is made under the Point of Service (POS) option only for services that are otherwise covered under the TRICARE Basic Program. Payment will not be made under the POS option for clinical preventive services that are not otherwise covered under the TRICARE Basic Program. A temporary waiver of the referral requirement for TRICARE Prime enrollees, not including Active Duty Service Members (ADSMs), for the Coronavirus 2019 (COVID-19) vaccine is authorized. The COVID-19 vaccine is a clinical preventive service and under this waiver it may be obtained from any TRICARE Basic (medical) program authorized non-network provider without incurring POS charges, where applicable. See Chapter 1, Section 15.1.
1.2  Beginning January 1, 2018, TRICARE Select enrollees may receive TRICARE Prime clinical preventive services when furnished by a network provider. If a TRICARE Select enrollee uses a non-network provider, payment is made only for the clinical preventive services that are otherwise covered under the TRICARE Basic Program. See Section 2.1.
1.3  There shall be no copayments associated with the individually TRICARE reimbursable services listed below. The contractor shall apply all appropriate claims processing and rebundling edits before determining if the below listed Current Procedural Terminology (CPT) procedure code is individually reimbursable. A 30 day administrative tolerance will be allowed for any time interval requirements imposed on services covered by this policy, e.g., if an asymptomatic woman 40 years of age or older received a screening mammography on September 15, coverage for another screening mammography would be allowed on or after August 17 of the following year.
1.4  The services identified in this policy are applicable to beneficiaries six years of age and older. Health Promotion and Disease Prevention (HP&DP) annual examinations for those beneficiaries age 6-21 include those services recommended by the American Academy of Pediatrics and Bright Futures guidelines. This includes developmental observation, physical examination, screening, immunizations, and anticipatory guidance. For beneficiaries under age six, covered preventive services are identified in the TRICARE well-child care policy. See Section 2.5.
1.5  Covered services as identified in this policy are based on recommendations from the United States Department of Health and Human Services (HHS). This includes recommendations from the United States Preventive Services Task Force (USPSTF), the Health Resources and Services Administration, etc. For the benefits under this program, the effective date of coverage is the publication date of the corresponding recommendation from the HHS.
Services
Frequency or Age Interval
HEALTH PROMOTION AND DISEASE PREVENTION (HP&DP) EXAMINATIONS
For ages six year and or older: One HP&DP examination is covered annually.
WELL WOMAN EXAMINATIONS
HP&DP exams for the purpose of a well woman exam are covered annually for female beneficiaries under age 65. If the primary care clinician determines that a patient requires additional well woman visits to obtain all necessary recommended preventive services that are age and developmentally appropriate, these may be provided without copay and subject to reasonable medical management.
TARGETED CLINICAL PREVENTIVE SERVICES
The following clinical preventive services may be performed during either an HP&DP exam or a well woman exam.
Breast Cancer:
Clinical Breast Examination (CBE): A CBE may be performed during a covered HP&DP exam.
BRCA1 or BRCA2 Genetic Counseling and Testing: Genetic counseling rendered by a TRICARE-authorized provider that precedes BRCA1 or BRCA2 gene testing is covered for women who are identified as high risk for breast cancer by their primary care clinician.
BRCA1 or BRCA2 gene testing is covered for women who meet the coverage guidelines outlined in the TRICARE Operations Manual (TOM), Chapter 18, Section 3, Figure 18.3-1.
Screening Mammography: Covered annually for all women beginning at age 40. Covered annually beginning at age 30 for women who have a 15% or greater lifetime risk of breast cancer (according to risk assessment tools based on family history such as the Gail model, the Claus model, and the Tyrer-Cuzick model), or who have any of the following risk factors:
1. History of breast cancer, Ductal Carcinoma In Situ (DCIS), Lobular Carcinoma In Situ (LCIS), Atypical Ductal Hyperplasia (ADH), or Atypical Lobular Hyperplasia (ALH);
2. Extremely dense breasts when viewed by mammogram;
3. *Known BRCA1 or BRCA2 gene mutation;
4. *First-degree relative (parent, child, sibling) with a BRCA1 or BRCA2 gene mutation, and have not had genetic testing themselves;
5. Radiation therapy to the chest between the ages of 10 and 30 years; or
6. History of Li-Fraumeni, Cowden, or Bannayan-Riley-Ruvalcaba syndrome, or a first-degree relative with a history of one of these syndromes.
Note: The risk factors identified above for screening mammography are those established by the American Cancer Society.
Breast Screening Magnetic Resonance Imaging (MRI): Covered annually, in addition to the annual screening mammogram, beginning at age 30 for women who have a 20% or greater lifetime risk of breast cancer (according to risk assessment tools based on family history such as the Gail model, the Claus model, and the Tyrer-Cuzick model), or who have any of the following risk factors:
1. *Known BRCA1 or BRCA2 gene mutation;
2. First-degree relative (parent, child, sibling) with a BRCA1 or BRCA2 gene mutation, and have not had genetic testing themselves;
3. Radiation to the chest between the ages of 10 and 30; or
4. History of LiFraumeni, Cowden, or Bannayan-Riley-Ruvalcaba syndrome, or a first-degree relative with a history of one of these syndromes.
Note: The risk factors identified above for breast cancer screening MRI are those established by the American Cancer Society.
Cervical Cancer
Pelvic Examination: A pelvic examination should be performed as part of a well woman exam and in conjunction with Pap smear testing for cervical neoplasms and premalignant lesions.
Pap Smears: For dates of service prior to May 8, 2015, cancer screening Pap smears should be performed for women who are at risk for sexually transmittable diseases, women who have or have had multiple sexual partners (or if their partner has or has had multiple sexual partners), women who smoke cigarettes, and women 18 years of age and older when provided under the terms and conditions contained in the guidelines adopted by the Director, Defense Health Agency (DHA). The frequency of the screening Pap smears will be at the discretion of the patient and clinician but not less frequent then every three years.
For dates of service on or after May 8, 2015, cancer screening Pap smears are covered for female beneficiaries beginning at age 21. Women under age 21 should not be screened regardless of the age of sexual initiation or other risk factors. The frequency of screening Pap smears may be at the discretion of the patient and clinician; however, screening Pap smears should not be performed less frequently than once every three years.
Human Papillomavirus (HPV) Deoxyribonucleic Acid (DNA) Testing: HPV DNA testing is covered as a cervical cancer screening only when performed in conjunction with a Pap smear, and only for women aged 30 and older.
To be eligible for reimbursement as a cervical cancer screening, HPV DNA testing must be billed in conjunction with a Pap smear that is provided to a woman aged 30 or older.
Colorectal Cancer:
The following cancer screenings and frequencies are covered for individuals at average risk for colon cancer:
Fecal Occult Blood Testing (FOBT): Either guaiac-based or immunochemical-based testing of three consecutive stool samples once every 12 months for beneficiaries who have attained age 45 (i.e., at least 11 months must have passed following the month in which the last covered screening fecal-occult blood test was done).
Fecal Immunochemical Testing (FIT). FIT of one stool sample once every 12 months beginning at age 45.
Fecal Immunochemical Testing (FIT-DNA): FDA approved stool DNA tests (e.g., Cologuard™) once every one to three years beginning at age 45.
Flexible Sigmoidoscopy: Once every three to five years beginning at age 45.
Computed Tomographic Colonography (CTC): Once every five years beginning at age 45.
Optical (Conventional) Colonoscopy: Once every 10 years beginning at age 45.
Flexible Sigmoidoscopy with FIT. Flexible Sigmoidoscopy once every 10 years plus annual FIT beginning at age 45.
According to the American Cancer Society (ACS), for screening, people are considered to be at average risk if they do not have:
•  A personal history of colorectal cancer or certain types of polyps;
•  A family history of colorectal cancer or advanced adenomatous polyps in at least one first degree relative, or in multiple second degree relatives;
•  A personal history of inflammatory bowel disease (ulcerative colitis or Crohn’s disease);
•  A confirmed or suspected hereditary colorectal cancer syndrome, such as familial adenomatous polyposis (FAP) or Lynch syndrome (hereditary non-polyposis colon cancer or Hereditary Non-Polyposis Colorectal Cancer (HNPCC));
•  A personal history of getting radiation to the abdomen (belly) or pelvic area to treat a prior cancer; or
•  Signs or symptoms of colorectal cancer.
Note:  The ACS no longer maintains screening guidelines specifically for people at increased or high risk of colorectal cancer nor does the USPSTF have such recommendations. A discussion between the beneficiary and their provider to determine if they are at increased or high risk of colorectal cancer is encouraged in order to decide if they need to start colorectal cancer screening before age 45, be screened more often, and/or utilize personalized testing strategies.
Prostate Cancer:
Rectal Examination: Digital rectal examination will be offered annually for all men beginning at age 50 who have at least a 10 year life expectancy. It should also be offered to begin for men age 45 and over with a family history of prostate cancer in at least one other first- degree relative (father, brother, or son) diagnosed with prostate cancer at an early age (younger than age 65) and to all African American men aged 45 and over regardless of family history. Testing should be offered to start at age 40 for men with a family history of prostate cancer in two or more other family members.
Prostate-Specific Antigen (PSA): Annual testing for the following categories of males may be offered:
1. Men aged 50 years and older.
2. Men aged 45 years and over with a family history of prostate cancer in at least one other family member.
3. African American men aged 45 and over regardless of family history.
4. Men aged 40 and over with a family history of prostate cancer in two or more other family members.
A discussion between the beneficiary and his provider on the risks/benefits of PSA testing is encouraged.
Testicular Cancer:
Physical Examination: Examination of the testis should be performed annually for males age 13-39 with a history of cryptorchidism, orchiopexy, or testicular atrophy.
Skin Cancer:
Physical Examination: Examination of the skin should be performed for individuals with a family or personal history of skin cancer, increased occupational or recreational exposure to sunlight, or clinical evidence of precursor lesions.
Oral Cavity and Pharyngeal Cancer:
Physical Examination: A complete oral cavity examination should be part of routine preventive care for adults at high risk due to exposure to tobacco or excessive amounts of alcohol.
Thyroid Cancer:
Physical Examination: Palpation for thyroid nodules should be performed in adults with a history of upper body irradiation.
Lung Cancer:
Low-Dose Computed Tomography: Screening covered annually for persons 50 through 80 years of age with a 20 pack per year history of smoking who are currently smoking or have quit within the past 15 years. Screening should be discontinued once the individual has not smoked for 15 years or develops a health problem significantly limiting either life expectancy or the ability or willingness to undergo curative lung surgery.
Immunizations:
Coverage is extended for the age appropriate dose of vaccines that meet the following requirements:
1. The vaccine has been recommended and adopted by the Advisory Committee on Immunization Practices (ACIP) for use in the United States; and
2. The ACIP adopted recommendations have been accepted by the Director of the Centers for Disease Control and Prevention (CDC) and the Secretary of Health and Human Services (HHS) and published in a CDC Morbidity and Mortality Weekly Report (MMWR).
3. The effective date of coverage for CDC recommended vaccines is the date ACIP recommendations for the vaccine are published in an MMWR.
Refer to the CDC’s web site (http://www.cdc.gov) for a current schedule of CDC recommended vaccines for use in the United States.
Immunizations recommended specifically for travel outside the United States are NOT covered, EXCEPT for immunizations required by dependents of active duty military personnel who are traveling outside the United States as a result of an active duty member’s duty assignment, and such travel is being performed under orders issued by a Uniformed Service. Claims must include a copy of the travel orders or other official documentation verifying the official travel requirement.
Infectious Diseases:
Tuberculosis (TB) Screening: Screen annually, regardless of age, all individuals at high risk for tuberculosis (as defined by the CDC using Mantoux tests).
Rubella Antibodies: Test females, once, between the ages of 12 and 18, unless documented history of adequate rubella vaccination with at least one dose of rubella vaccine on or after the first birthday is documented.
Hepatitis B Virus (HBV) Screening: Screen for HBV in individuals at high risk for infection.
Hepatitis C Virus (HCV) Screening: Screen for HCV in individuals at high risk for infection and as a one-time screening for adults born between 1945 and 1965.
Human Immunodeficiency Virus (HIV) Infection Screening: Screen for HIV in individuals ages 15-65. Younger adolescents and older adults who are at increased risk should also be screened.
Syphilis Infection Screening: Screen at risk individuals for syphilis infection.
Chlamydia and Gonorrhea Screening: Screen sexually active women age 24 years and younger and older women who are at increased risk for infection.
Diabetes Mellitus (Type II):
Diabetes Mellitus (Type II) Screening: Screen adults with a sustained blood pressure (treated or untreated) greater than 135/80 mmHg. Screen adults aged 40-70 who are overweight or obese.
Cardiovascular Diseases:
Cholesterol Screening: Screen children once between the ages of 9 and 11 and again between the ages of 17 and 21. Screen men age 35 and older. Screen men and women age 20 and older who are at increased risk for coronary heart disease.
Blood Pressure Screening: At least every two years after age six.
Abdominal Aortic Aneurysm (AAA): One time AAA screening by ultrasonography for men, age 65 - 75, who have ever smoked.
Osteoporosis:
Osteoporosis Screening: Screen women for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older and in post-menopausal women younger than 65 years who are at increased risk of osteoporosis as determined by a formal clinical assessment tool, including but not limited to, the Simple Calculated Osteoporosis Risk Estimation (SCORE).
Intensive Behavioral Counseling for Sexually Transmitted Infections (STIs):
Intensive Behavioral Counseling for STIs: Intensive behavioral counseling (counseling that lasts more than 30 minutes) for all sexually active individuals who are at increased risk for STIs is covered when rendered by a TRICARE authorized provider.
Intensive, Multicomponent Behavioral Interventions for Obesity:
For adults with a Body Mass Index (BMI) of 30 kg/m2 or higher and for children/adolescents with a BMI value greater than the 95th percentile, intensive, multicomponent behavioral interventions to promote sustained weight loss (12 to 26 sessions in a year) are covered when rendered by a TRICARE authorized provider. Intensive, multicomponent behavioral interventions include, but are not limited to: behavioral management activities such as setting weight-loss goals; diet and physical activity guidance; addressing barriers to change; active self-monitoring; and, strategies to maintain lifestyle changes.
Prenatal Screening Tests:
Breast Pumps, Breast Pump Supplies, and Breastfeeding Counseling:
Well-Child Care:
Other:
School Physicals: Physical examinations required in connection with school enrollment are covered.
Physical Examinations Required for Travel Outside the United States – Orders Required: A physical examination provided when required in the case of a family member who is traveling outside the United States as a result of the member’s assignment and such travel is being performed under orders issued by a Uniformed Service is covered. Claims must include a copy of the travel orders or other official documentation verifying the official travel requirement.
Body Measurement: For children and adolescents: Height and weight typically is measured and BMI-for-age calculated and plotted at each primary care visit using the CDC “Data Table of BMI-for-age Charts”. Children/adolescents with a BMI value greater than the 85th percentile typically receive appropriate nutritional and physical activity counseling as part of the primary care visit. Head circumference typically is measured through age 24 months.
For adults: Height and weight typically is measured and BMI calculated at each primary care visit. Individuals identified with a BMI of 25 or above typically receive appropriate nutritional and physical activity counseling as part of primary care visit.
Vision Care: Routine eye exam once every two years for retirees and eligible family members who are enrolled in TRICARE Prime. Routine eye exams are not a covered benefit for retirees and eligible family members who are enrolled in TRICARE Select. Active Duty Family Members (ADFMs) who are enrolled in TRICARE Prime or TRICARE Select may receive a routine eye exam annually (see Section 6.1).
Note:  Routine eye examinations are meant to be more than the standard visual acuity screening test conducted by the member’s primary care physician through the use of a standard Snellen wall chart. Self-referral will be allowed for routine eye examinations since PCMs are incapable of providing this service (i.e., a TRICARE Prime beneficiary will be allowed to set up his or her own appointment for a routine eye examination with any network optometrist or ophthalmologist).
Note:  TRICARE diabetic beneficiaries may receive medically necessary eye exams IN ADDITION to the routine eye exams they receive as a preventive benefit.
Note:  When a beneficiary’s eligibility status changes from ADSM or TRICARE Prime ADFM to TRICARE Prime retiree or retiree family member, the two-year time requirement between routine eye examinations will start on the date of the eligibility status change. That is, a TRICARE Prime retiree or retiree family member will be eligible for a routine eye examination in the first year of the status change regardless of whether or not an examination was performed in the previous year under ADFM eligibility status. The eligibility status of the beneficiary will dictate the coverage parameters of the eye examination.
Hearing Screening: A hearing evaluation should be a part of routine examinations for all children, and those with possible hearing impairment should be referred for appropriate testing.
Patient & Parent Education And Counseling:
•  Accident & Injury Prevention;
•  Cancer surveillance;
•  Depression, stress, bereavement, & suicide risk assessment;
•  Dietary assessment & nutrition;
•  Intimate partner violence and abuse;
•  Physical activity & exercise;
•  Promoting dental health;
•  Risk reduction for skin cancer;
•  Safe sexual practices; and
•  Tobacco, alcohol and substance abuse.
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