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I had a routine physical recently, thinking it would all be full covered as Preventative Care (I have a metal plan in NY)
Then I got a bill from the lab showing Lipid panel (CPT 80061) being covered but Comprehensive metabolic panel (CPT Code 80053) only partially covered. I called the insurance company and they said that CPT 80053 doesn't fall under preventative care. Can anyone confirm whether this is accurate? Who decided that this code isn't for preventative care?
I'm finding little official resources online regarding this. I see the list of preventative care benefits on healthcare.gov, but they don't list corresponding CPT codes.
The link below lists the CPT codes. Although the link is to CIGNA, these CPT codes apply to all ACA compliant plans. These are the minimum requirements under the ACA as identified by the U. S. Preventive Services Task Force (USPSTF). Plans have the option of covering additional services under their preventive benefit.
Preventive care in "their" minds and in our minds are like day and night. I see an integrative MD and she's for years done out of the normal labs and for years a LOT was covered and more and more it's showing up that insurance is not paying. We are on our own a lot for a lot of those tests for prevention.
It sounds like only a small portion of 80053, Comprehensive metabolic panel is covered as preventative care. Had I know that during my evaluation, I would have asked for it to be left out since I'm generally in good health. The NP seemed completely in the dark as to what was covered as preventative care, which may be understandable since they're not medical billers, but it's during the evaluation that the tests get ordered. So I guess patients need to get more educated.
This may not be correct, so kindly double-check with your insurance: CPT code 80048 is a Basic Metabolic Panel and should be covered as Preventative. But that is only 8 tests and does not include the liver and protein components. Unfortunately, because these are pretty important. But next year, discuss with your physician as to why s/he is ordering these. Perhaps the coding could be separated, but that might actually end up most expensive for you if the "other tests" are not covered.
This may not be correct, so kindly double-check with your insurance: CPT code 80048 is a Basic Metabolic Panel and should be covered as Preventative. But that is only 8 tests and does not include the liver and protein components.
CPT 80048 is not an ACA mandated preventive service but, as noted above, plans have the option of including additional services in their preventive benefit design. This code has 2 configurations when unbundled. Only the Glucose test (82947) is an ACA mandated preventive service.
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