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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements

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Preventive Health Guidelines


Medicare Advantage

Preventive Screening and Immunizations Recommendations for Medicare Beneficiaries: 


Height, weight, vision and hearing

Every 1-2 years

Blood Pressure

Every 1-2 years

Pap Test

Discuss frequency with physician

Total cholesterol and HDL cholesterol test

Discuss frequency and testing options with your physician, but at least every 5 years.

Mammography screening with or without clinical breast examination for women age 40 and older

Every 1-2 years. Discuss with your physician after age 75.

Colorectal cancer screening (age 50-80):
Fecal Occult Blood Test (FOBT)
Or Flexible Sigmoidoscopy
Or Colonoscopy
Or Double Contrast Barium Enema

Every 5 years
Every 10 years
Every 5 years

TB screening

High risk - to be performed based on risk

Variella (chicken pox)

High risk - 2 doses, 4-8 weeks apart

TD booster (tetanus, diptheria)

Once every 10 years

Pneumococcal (polysaccharide)

Once, booster may be required


Annually, each fall season

Hepatitus A (for high risk individuals)

2 doses - second dose 6 months after first

Hepatitus B (for high risk individuals)

At current visit, then at 1 and 6 months

Osteoporosis screening


Men should discuss the know risks and benefits of prostate cancer screening with their physician. 
Women should discuss the risk factors for osteoporosis with physician. 
Discuss risk factors for stroke and coronary artery disease for prevention with physician. 
Assess cardiovascular disease risk and discuss aspirin therapy periodically to prevent CVD events. 
Nutrition, Physical Activity, Injury Prevention, Drug and Alcohol Use, Sexually Transmitted Diseases, Medication Use, Hormone Replacement Therapy, Dental Health, Mental Health (Depression), Sun Exposure, Tobacco Cessation. 


The Guide to Clinical Preventive Services, 3rd Edition, U.S. Preventive Services Taskforce (2000-2002).


Centers for Disease Control and Prevention (2003, October) Notice to Readers: Revised Standards for Adult Immunization Practices and Child and Adolescent Immunization Practices, 2003. MMWR 52(40); 969-970


Centers for Disease Control and Prevention (2004, May). Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP) 53 (RR-6) MMWR Recommendations and Reports.


Institute for Clinical Systems Improvement. (2003, September) Health Care Guidelines: Preventive Services for Adults.


American Cancer Society. . (2002, November). New Cervical Cancer Early Detection Guidelines Released

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