Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 09|01|2003 POLICY LAST UPDATED: 02|16|2022 OVERVIEW This policy addresses state mandated coverage guidelines for the venipuncture for blood specimen collection to be sent to a state-approved laboratory for lead screening (Rhode Island General Law 23-24.6-9). MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION Prior Authorization is not required. POLICY STATEMENT Commercial Products Venipuncture for blood specimen collection for lead testing is covered and separately reimbursed when filed with a -32 modifier. Medicare Advantage Plans Not applicable Rhode Island-mandated benefits generally do not apply to Medicare Advantage Plans members. This mandate is for children under age 6 who are not eligible for Medicare.
COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable physician services/lab coverage/benefits. BACKGROUND Lead is a heavy gray metal that has many uses and can be harmful if it gets into the body. Before 1978, lead was used to make paint. Many old houses are painted with lead-based paint. Lead can get into the body in various ways, including by ingesting or breathing dust from lead paint, ingesting lead chips, drinking tap water that has lead in it, eating fruits or vegetables that have lead on them from the soil, and eating food that has been prepared or stored in dishes made with lead. Lead can be found in many places around a home, such as in peeling and chipping lead paint, dust from lead paint, soil and dirt in the yard, tap water from lead pipes, and pottery, crystal, or ceramic dishes. The most prevalent exposure in Rhode Island comes from lead-based paint and paint dust found in residences built before 1978. Lead is most dangerous to children younger than six years old. Young children put their hands, toys and other things in their mouths. Any of these objects could have lead dust on them. Lead poisoned children are likely to suffer life-long consequences. Even a small amount of lead can have a negative effect on a child's development and can cause serious health problems, including learning disabilities, loss of IQ, and reduced attention span.
Payment Policy | Venipuncture for State Mandated Lead Screening d

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

According to the American Academy of Pediatrics, one million U.S. children have elevated lead levels in their blood. Even low levels of lead can cause a range of chronic conditions, including everything from anemia, hearing loss, and kidney problems, to physical and developmental delays; severe exposure to lead can cause seizures, coma, and even death.

Some states require pediatricians to regularly screen children under age three for lead exposure; however, many states do not. Lead poisoning is an environmental problem that can be prevented and treated. Often, however, exposure to lead goes undetected until the child’s physical or developmental symptoms are evident.

Developmental delays and behavioral problems can be a symptom of lead poisoning. A child who mouths many objects, or may put non-food items in the mouth, may be at risk of lead poisoning. Because of the range of risks involved, lead screenings are routinely performed when a child shows the signs of a developmental delay or disorder. This screening should be conducted immediately in order to rule out lead poisoning and, if detected, to minimize the negative effects of lead exposure.

A lead screening is conducted by a simple blood test. A health professional may complete this test with a finger prick or by taking blood from a vein. Generally, physicians prefer to test blood from a vein in a child’s arm. If a stick test shows a significant elevation of lead levels in a child’s blood, another sample will be taken from the child’s vein to confirm the results.

Lead exposure may come from a number of sources, as detailed by the following list from the Centers for Disease Control and Prevention (CDC): • Lead-based paint in older homes that is deteriorating, creating dust and paint chips easily ingested by young children. • Lead-based paint in homes that is disturbed during renovation or remodeling. • Lead-based paint in homes that is exposed, on a surface easily chewed by a young child (such as a window sill). • Lead-contaminated soil. • Operating or abandoned industrial sites and smelters. Although lead pollution has been greatly reduced, some soil and dust contamination can still result. • Occupations and hobbies. Children can be exposed to lead-contaminated dust on parents’ clothes. • Use of lead-containing ceramics for cooking, eating or drinking. • Use of traditional home remedies or cosmetics that contain lead.

§ 23-24.6-9 Reimbursement by third party payers. – Screening for lead poisoning and lead screening related services for children under six (6) years of age as required by department regulations and diagnostic evaluations for lead poisoning for children under six (6) years of age, including but not limited to confirmatory blood lead testing, shall be a covered health benefit and be reimbursable under any general or blanket policy of accident or health insurance offered by an insurer except for supplemental policies which only provide coverage for specific diseases, hospital indemnity Medicare supplements, or other supplemental policies. The department of human services shall pay for the lead screening and lead screening related and diagnostic evaluation services where the patient is eligible for medical assistance under the provisions of chapter 8 of title 40. The department of health shall pay for the lead screening and lead screening related and diagnostic evaluation services where the patient is not covered by any health insurance. All companies which are self insured for health care services will be encouraged by the department to participate as other insurers.

CODING Commercial Products The following codes are covered: 36415-32 Collection of venous blood by venipuncture
36416-32 Collection of capillary blood specimen (e.g., finger, heel, ear stick)

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

RELATED POLICIES Preventive Services for Commercial Members

PUBLISHED Provider Update, February 2021 Provider Update, January 2020 Provider Update, September 2018 Provider Update, October 2017 Provider Update, July 2016

REFERENCES

1. Rhode Island General Law (RIGL). 23-24.6-9 Lead Poisoning Prevention Act. http://webserver.rilin.state.ri.us/Statutes/TITLE23/23-24.6/23-24.6-9.HTM

2. Lead Screening. http://www.firstsigns.org/screening/lead.htm

3. Blood Test: Lead. http://kidshealth.org/parent/system/medical/test_lead.html

4. State of Rhode Island Department of Health (DOH). Lead Poisoning. http://health.ri.gov/healthrisks/poisoning/lead/

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   This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS