Basically, if you already have a condition (even if it's being treated and is controlled), or if you have symptoms, then lab work ordered is not preventive.
Here's some information that we share with our patients:
The Affordable Care Act of 2009 requires that most insurance companies pay 100% for Preventive Care. It is important to understand that not all services and visits provided or ordered by your doctor are considered preventive. You need to be aware when you schedule your annual Preventive Care Visit (or annual checkup, as they are sometimes called) and your doctor orders lab work in advance so that the results will be available for him to discuss with you at your checkup, some of these labs may not be covered at 100%. If your doctor orders lab work at the same time you are receiving your Preventive Care Visit, some of it may not be covered at 100%. The reason is that your doctor must order your lab work based on the reason why you need the lab work, and not based on the kind of visit you were having at that time.
If you already have a condition or disease, even if it is well-controlled with the medication you take, and your doctor orders a lab test to see how you are doing, this is called a “surveillance” lab. It is not considered preventive care and you will have to pay your deductible and co-insurance.
If you are having symptoms and your doctor orders lab work to rule out some sort of illness or disease, this is a called a diagnostic lab. It is also not considered preventive and you will have to pay your deductible and co-insurance.
If you are symptom or disease free, and your doctor orders lab work or other tests as a precaution, then you are receiving preventive care.
Your insurance company agrees. Here are their comments (taken from patient education publications).
Aetna: Services are not preventive if you get them as part of any visit to diagnose, monitor or treat an illness or injury. Then co-pays, co-insurance and deductibles apply.
Anthem: Preventive care is precautionary. Diagnostic care is used to find the cause of existing symptoms.
Cigna: Preventive care includes services for symptom-free or disease-free individuals.
Harvard: Diagnostic careinvolves treating an existing symptom and may be subject to cost sharing. It's different from preventive care, which involves services you receive to identify potential health risks.
Medicare: In providing good care, your doctor or health care provider may do exams or tests that Medicare doesn't cover. A diagnostic test may be recommended when a screening test or exam shows an abnormality. In some cases, you may have to pay for these services.
