I Statements and C and D Recommendations of the U.S. Preventive Services Task Force (USPSTF)

In a resource-constrained environment, employers must carefully consider which preventive services to offer. Some are known to be effective. Others are known to be relatively ineffective or even harmful; others may be effective but are lacking proof.

By assessing the grades given to each clinical preventive service reviewed by the USPSTF, employers can better determine the services with proven benefit (the "A" and "B" recommendations).

In addition to adding coverage for services recommended in the Purchaser's Guide, employers should evaluate their current preventive service benefits for those services that, for one reason or another, do not have sufficient evidence to make a recommendation or are not recommended.

The USPSTF has labeled these services:
D EMPLOYER ACTION:
Employers are discouraged from providing coverage for clinical preventive services that received a "D" rating from the USPSTF, as these services have been found to be ineffective or to have more harms than benefits.


D Recommendations of the USPSTF
Explanation: The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.1

Employers should not provide coverage for these clinical preventive services for their general asymptomatic beneficiary population. However, employers may choose to cover these services on a case-by-case basis as determined by beneficiary risk or medical necessity criteria. Further, these services should be covered when part of the diagnostic work-up of a symptomatic patient or part of a medical treatment plan for an existing condition/disease or when an individual is determined to be at high-risk for the respective condition/disease.
IMPORTANT NOTE: "D"-rated services are not recommended for the general asymptomatic population and therefore should not be covered as preventive services within a medical benefit plan. However, these services may play an important role in the diagnostic work-up of symptomatic patients and in the treatment or management of existing conditions and should be covered as indicated for all populations under the health plan's treatment benefit.
Non-Recommended Clinical
Preventive Service		 Explanation
Abdominal Aortic Aneurysm in women, Screening The USPSTF recommends against routine screening for AAA in women.
Aspirin Therapy for the Primary Prevention of Cardiovascular Disease for specific populations, Counseling The USPSTF recommends against the use of aspirin for stroke prevention in women younger than 55 years and for myocardial infarction prevention in men younger than 45 years.
Aspirin Therapy for the Primary Prevention of Colorectal Cancer, Counseling The USPSTF recommends against the routine use of aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) to prevent colorectal cancer in individuals at average risk for colorectal cancer.
Asymptomatic Bacteriuria in men and nonpregnant women, Screening The USPSTF recommends against the routine screening of men and nonpregnant women for asymptomatic bacteriuria.
Bacterial Vaginosis among low-risk pregnant women, Screening The USPSTF recommends against screening for bacterial vaginosis in asymptomatic pregnant women at low risk for preterm delivery.
Bladder Cancer, Screening The USPSTF recommends against routine screening for bladder cancer in adults.
Breast Cancer, Preventive medication for low or average-risk women The USPSTF recommends against routine use of tamoxifen or raloxifene for primary prevention of breast cancer for women at low or average risk for breast cancer.
Breast Cancer, Screening The USPSTF recommends against teaching breast self-examination (BSE).
Carotid Artery Stenosis, Screening The U.S. Preventive Services Task Force (USPSTF) recommends against screening for asymptomatic carotid artery stenosis (CAS) in the general adult population.
Cervical Cancer in women over 65 years, Screening The USPSTF recommends against routinely screening women older than age 65 for cervical cancer if they have had adequate recent screening with normal Pap smears and are not otherwise at high risk.
Cervical Cancer in women with hysterctomy, Screening The USPSTF recommends against routine Pap smear screening in women who have had a total hysterectomy for benign disease.
Colorectal Cancer in adults over age 85, Screening The USPSTF recommends against screening for colorectal cancer in adults older than age 85 years.
COPD Screening using Spirometry, Screening The USPSTF recommends against screening adults for chronic obstructive pulmonary disease (COPD) using spirometry.
Coronary Heart Disease, Screening The USPSTF recommends against screening with resting electrocardiography (ECG), exercise treadmill test (ETT), or electron-beam computerized tomography (EBCT) scanning for coronary calcium for either the presence of severe coronary artery stenosis (CAS) or the prediction of coronary heart disease (CHD) in adults at low risk for CHD events.
Gonorrhea, Screening The USPSTF recommends against routine screening for gonorrhea infection in men and women who are at low risk for infection.
Genetic Risk Assessment and BRCA Mutation Testing for Breast and Ovarian Cancer Susceptibility USPSTF recommends against routine referral for genetic counseling or routine breast cancer susceptibility gene (BRCA) testing for women whose family history is not associated with an increased risk for deleterious mutations in breast cancer susceptibility gene 1 (BRCA1) or breast cancer susceptibility gene 2 (BRCA2).
Hemochromatosis, Screening The USPSTF recommends against routine genetic screening for hereditary hemochromatosis in the asymptomatic general population.
Hepatitis B Virus Infection, Screening The USPSTF recommends against routinely screening the general asymptomatic population for chronic hepatitis B virus infection.
Hepatitis C, Screening The USPSTF recommends against routine screening for hepatitis C virus (HCV) infection in asymptomatic adults who are not at increased risk (general population) for infection.
Herpes (Genital), Screening The USPSTF recommends against routine serological screening for HSV in asymptomatic adolescents and adults or in asymptomatic pregnant women at any time during pregnancy to prevent neonatal HSV infection.
Hormone Therapy in postmenopausal women, Preventive Medication The USPSTF recommends against the routine use of combined estrogen and progestin for the prevention of chronic conditions in postmenopausal women. The USPSTF recommends against the routine use of unopposed estrogen for the prevention of chronic conditions in postmenopausal women who have had a hysterectomy.
Idiopathic Scoliosis, Screening The USPSTF recommends against the routine screening of asymptomatic adolescents for idiopathic scoliosis.
Lead Levels in average-risk children, Screening The USPSTF recommends against routine screening for elevated blood lead levels in asymptomatic children aged 1 to 5 years who are at average risk.
Ovarian Cancer, Screening The USPSTF recommends against routine screening for ovarian cancer.
Pancreatic Cancer, Screening The USPSTF recommends against routine screening for pancreatic cancer in asymptomatic adults using abdominal palpation, ultrasonography, or serologic markers.
Peripheral Arterial Disease, Screening The USPSTF recommends against routine screening for peripheral arterial disease (PAD).
Prostate Cancer in men over age 75, Screening The USPSTF recommends against screening for prostate cancer in men age 75 years or older.
Syphilis Infection in average-risk adults, Screening The USPSTF recommends against routine screening of asymptomatic persons who are not at increased risk for syphilis infection.
Testicular Cancer, Screening The USPSTF recommends against routine screening for testicular cancer in asymptomatic adolescent and adult males. Vitamin Supplementation, Preventive Medication The USPSTF recommends against the use of beta-carotene supplements, either alone or in combination, for the prevention of cancer or cardiovascular disease.

RETURN TO TOP


C EMPLOYER ACTION:
Employers should provide coverage for "C"-rated services only if there is a compelling reason to do so in an individual patient. The USPSTF issues a "C" rating to services in which the net benefit is small and the USPSTF recommends against routinely providing the services in the general population. Therefore, the provision of coverage for "C"-rated services should be secondary to the provision of coverage for all recommended services featured in the Purchaser's Guide.


C Recommendations of the USPSTF
Explanation: The USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is moderate or high certainty that the net benefit is small.1

Employers have discretion to cover "C"-services if they choose. However, the provision of coverage for "C"-rated services should be secondary to the provision of coverage for all recommended services featured in the Purchaser's Guide ("A" and "B"-rated services).
IMPORTANT NOTE: Several Services on the following pages are recommended by the U.S. Preventive Services Task Force (USPSTF) for a different population and have been included in the Purchaser's Guide for the proper demographic. In some instances, the USPSTF recommendation has been superceded by the recommendations of other respected organizations and recommended for inclusion in benefit plans. Such services are notated with an asterisk (*).
Clinical Preventive Services
with No Recommendation		 Explanation
Abdominal Aortic Aneurysm in low-risk men, Screening The USPSTF makes no recommendation for or against screening for AAA in men aged 65 to 75 who have never smoked.
Breast Cancer in women aged 40 - 49, Screening The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including patient's values regarding specific benefits and harms.
Chlamydial Infection in low or average-risk women, Screening The USPSTF recommends against routinely providing screening for chlamydial infection for women aged 25 and older, whether or not they are pregnant, if they are not at increased risk.
Colorectal Cancer among adults aged 76-85 years, Screening The USPSTF recommends against routine screening for colorectal cancer in adults age 76 to 85 years. There may be considerations that support colorectal cancer screening in an individual patient.
Depression, Screening The USPTF recommends against routinely screening adults for depression when staff-assisted depression care supports are not in place. There may be considerations that support screening for depression in an individual patient.
*Human Immunodeficiency Virus (HIV) Infection among low or average-risk adults, Screening The USPSTF makes no recommendation for or against routinely screening for HIV adolescents and adults who are not at increased risk for HIV infection.
Lipid Disorders in low-risk adults, Screening The USPSTF makes no recommendation for or against routine screening for lipid disorders in men aged 20 to 35, or in women aged 20 and older who are not at increased risk for coronary heart disease.
Osteoporosis in postmenopausal women, Screening The USPSTF makes no recommendation for or against routine osteoporosis screening in postmenopausal women who are younger than 60 or in women aged 60 to 64 who are not at increased risk for osteoporotic fractures.

*Recommended for coverage in the Purchaser's Guide
RETURN TO TOP


I EMPLOYER ACTION:
Employers have discretion as to whether to provide coverage for services with limited or conflicting evidence (services that received an "I" rating). The provision of coverage for "I" rated services should be secondary to the provision of coverage for all recommended services featured in the Purchaser's Guide.


It is important to remember that "insufficient evidence" means just that: the evidence is not currently adequate for evidence-based decisions. On occasion, employers may need to resort to the informed opinions of unbiased experts about such interventions. There are several reasons why an intervention may have insufficient evidence.
  • There may have been insufficient time to conduct and publish the large, rigorous studies needed to assess a new intervention.

  • In some instances, such as with vaccines that have been widely used for decades, observational studies of current use support its continued effectiveness and it is generally agreed that it would be unethical to conduct controlled studies, where a vaccine would be tested against a placebo.

  • It may be imprudent to test in the United States an intervention that has made a condition so rare that it almost never occurs and experience suggests that removing the preventive intervention from use would threaten the health of people.

  • The intervention may have minimal effectiveness and, despite considerable study, its small effects have been insufficient to allow a decision about its value.
I Statements of the USPSTF
Explanation: The USPSTF concludes that the evidence is insufficient to assess the balance of benefits and harms of the service. Evidence that [the service] is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.1

Employers have discretion to cover these services if they choose. However, the provision of coverage for "I"-rated services should be secondary to the provision of coverage for all recommended services featured in the Purchaser's Guide ("A" and "B"-rated services and equivalencies.)
IMPORTANT NOTE: Several services on the following pages are recommended by the U.S. Preventive Services Task Force (USPSTF) for a different population and have been included in the Purchaser's Guide for the proper demographic. In some instances, the USPSTF recommendation has been superseded by recommendations of other respected organizations and recommended for inclusion in benefit plans. Such services are notated with an asterisk (*).
Clinical Preventive Services with Insufficient Evidence Available to Make a Recommendation Explanation
*Alcohol Misuse among adolescents, Screening and behavioral counseling interventions The USPSTF concludes that the evidence is insufficient to recommend for or against screening and behavioral counseling interventions to prevent or reduce alcohol misuse by adolescents in primary care settings.
Aspirin Therapy for the Primary Prevention of Cardiovascular Disease in adults aged 80 or older, Counseling The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years or older.
Bacterial Vaginosis in high-risk pregnant women, Screening The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for bacterial vaginosis in asymptomatic pregnant women at high risk for preterm delivery.
Breast Cancer, Screening The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.
Breast Cancer, Screening The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer.
Breast Cancer in women aged 75 and older, Screening The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.
Breastfeeding, Behavioral interventions to promote The USPSTF found insufficient evidence to recommend for or against the following interventions to promote breastfeeding: brief education and counseling by primary care providers; peer counseling used alone and initiated in the clinical setting; and written materials, used alone or in combination with other interventions.
Cervical Cancer, Screening The USPSTF concludes that the evidence is insufficient to recommend for or against the routine use of new technologies to screen for cervical cancer.
Cervical Cancer, Screening The USPSTF concludes that the evidence is insufficient to recommend for or against the routine use of human papillomavirus (HPV) testing as a primary screening test for cervical cancer.
Colorectal Cancer, Screening with Computed Tomographic Colonography and Fecal DNA Testing The USPSTF concludes that the evidence is insufficient to assess the benefits and harms of computed tomographic colonography and fecal DNA testing as screening modalities for colorectal cancer.
Coronary Heart Disease, Screening The USPSTF found insufficient evidence to recommend for or against routine screening with electrocardiography (ECG), exercise treadmill test (ETT), or electron-beam computerized tomography (EBCT) scanning for coronary calcium for either the presence of severe Coronary Artery Stenosis (CAS) or the prediction of Coronary Heart Disease (CHD) events in adults at increased risk for CHD events.
Chlamydial Infection in men, Screening The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydial infection for men.
*Dental Caries in preschool children, Preventive medication The USPSTF concludes that the evidence is insufficient to recommend for or against routine risk assessment of preschool children by primary care clinicians for the prevention of dental disease.
Dementia in older adults, Screening The USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for dementia in older adults.
Depression Disorder in children, Screening The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening of children (7-11 years of age).
Developmental Dysplasia of the Hip, Screening The USPSTF concludes that evidence is insufficient to recommend routine screening for developmental dysplasia of the hip in infants as a means to prevent adverse outcomes.
Diabetes Mellitus Type 2 in asymptomatic average-risk adults, Screening The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for type 2 diabetes in asymptomatic adults with blood pressure of 135/80 mm Hg or lower.
Diet, Behavioral counseling The USPSTF concludes that the evidence is insufficient to recommend for or against routine behavioral counseling to promote a healthy diet in unselected patients in primary care settings.
Family and Intimate Partner Violence, Screening The USPSTF found insufficient evidence to recommend for or against routine screening of parents or guardians for the physical abuse or neglect of children, of women for intimate partner violence, or of older adults or their caregivers for elder abuse.
Gestational Diabetes Mellitus, Screening The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for gestational diabetes mellitus (GDM), either before or after 24 weeks gestation.
Glaucoma, Screening The U.S. Preventive Services Task Force (USPSTF) found insufficient evidence to recommend for or against screening adults for glaucoma.
Gonorrhea in men, Screening The USPSTF found insufficient evidence to recommend for or against routine screening for gonorrhea infection in men at increased risk for infection.
Gonorrhea in low-risk pregnant women, Screening The USPSTF found insufficient evidence to recommend for or against routine screening for gonorrhea infection in pregnant women who are not at increased risk for infection.
Hepatitis C, Screening The USPSTF found insufficient evidence to recommend for or against routine screening for hepatitis C virus (HCV) infection in adults at high risk for infection.
High Blood Pressure in children and adolescents, Screening The USPSTF concludes that evidence is insufficient to recommend for or against routine screening for high blood pressure in children and adolescents to reduce the risk of cardiovascular disease.
Illict Drug Use, Screening The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening adolescents, adults, and pregnant women for illicit drug use.
*Iron Deficiency Anemia in children, Screening The U.S. Preventive Services Task Force (USPSTF) concludes that evidence is insufficient to recommend for or against routine screening for iron deficiency anemia in asymptomatic children aged 6 to 12 months.
Iron Supplementation for children and pregnant women, Preventive medication The USPSTF concludes that evidence is insufficient to recommend for or against routine iron supplementation for asymptomatic children aged 6 to 12 months who are at average risk for iron deficiency anemia. The USPSTF concludes that evidence is insufficient to recommend for or against routine iron supplementation for non-anemic pregnant women.
*Lead Levels in high-risk children, Screening The U.S. Preventive Services Task Force (USPSTF) concludes that evidence is insufficient to recommend for or against routine screening for elevated blood lead levels in asymptomatic children aged 1 to 5 who are at increased risk.
Lipid Disorders in children, Screening The USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for lipid disorders in infants, children, adolescents, or young adults (up to age 20).
Low Back Pain, Preventive Intervention The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against the routine use of interventions to prevent low back pain in adults in primary care settings.
Lung Cancer, Screening The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against screening asymptomatic persons for lung cancer with either low dose computerized tomography (LDCT), chest x-ray (CXR), sputum cytology, or a combination of these tests.
*Motor Vehicle Safety, Counseling The USPSTF concludes that the current evidence is insufficient to assess the incremental benefit, beyond the efficacy of legislation and community-based interventions, of counseling in the primary care setting, in improving rates of proper use of motor vehicle occupant restraints (child safety seats, booster seats, and lap-and-shoulder belts). The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine counseling of all patients in the primary care setting to reduce driving while under the influence of alcohol or riding with drivers who are alcohol-impaired.
Obesity, Counseling The USPSTF concludes that the evidence is insufficient to recommend for or against the use of moderate- or low-intensity counseling together with behavioral interventions to promote sustained weight loss in obese adults.
Oral Cancer, Screening The USPSTF concludes that the evidence is insufficient to recommend for or against routinely screening adults for oral cancer.
Overweight Children and Adolescents, Screening The USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for overweight in children and adolescents as a means to prevent adverse health outcomes.
Overweight Adults, Counseling The USPSTF concludes that the evidence is insufficient to recommend for or against the use of counseling of any intensity and behavioral interventions to promote sustained weight loss in overweight adults.
Physical Activity, Behavioral counseling The USPSTF concludes that the evidence is insufficient to recommend for or against behavioral counseling in primary care settings to promote physical activity.
Prostate Cancer, Screening The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years.
Skin Cancer, Counseling The USPSTF concludes that the evidence is insufficient to recommend for or against routine counseling by primary care clinicians to prevent skin cancer.
Skin Cancer, Screening The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of using a whole-body skin examination by a primary care clinician or patient skin self-examination for the early detection of cutaneous melanoma, basal cell cancer, or squamous cell skin cancer in the adult general population.
*Speech and Language Delay in preschool children, Screening The USPSTF concludes that the evidence is insufficient to recommend for or against routine use of brief, formal screening instruments in primary care to detect speech and language delay in children up to 5 years of age.
Suicide Risk, Screening The USPSTF concludes that the evidence is insufficient to recommend for or against routine screening by primary care clinicians to detect suicide risk in the general population.
Thyroid Disease, Screening The USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for thyroid disease in adults.
*Tobacco Use among children and adolescents, Screening, counseling, and intervention The USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for tobacco use or interventions to prevent and treat tobacco use and dependence among children and adolescents.
Vitamin Supplementation to Prevent Cancer and Cardiovascular Disease, Preventive medication The USPSTF concludes that the evidence is insufficient to recommend for or against the use of supplements of vitamins A, C, or E; multivitamins with folic acid; or antioxidant combinations for the prevention of cancer or cardiovascular disease.

*Recommended for coverage in the Purchaser's Guide
RETURN TO TOP


Citations:

1 Agency for Healthcare Research and Quality. The Guide to Clinical Preventive Services: Recommendations of the U.S. Preventive Services Task Force. Rockville, MD: Agency for Healthcare Research and Quality; 2009.