Currentblue cross blue shield - michiganPolicy N/A

Screening pelvic (well‑woman) examination — Medicare Plus Blue

Defines Medicare Plus Blue (Medicare Advantage PPO) coverage, frequency, billing and payment conditions for screening pelvic (well-woman/annual gynecological) examinations for Medicare beneficiaries under the plan.

Policy Summary

Payerblue cross blue shield - michigan

PolicyScreening pelvic (well‑woman) examination — Medicare Plus Blue

Policy CodePolicy N/A

Change TypeTemplate transition with no material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionIf coverage is uncertain, obtain a coverage determination from Medicare Plus Blue before providing the service.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Once/benefit yearMedicare Plus Blue enhanced benefit frequency

Every 24 monthsOriginal Medicare - normal risk

AnnuallyOriginal Medicare - high risk

Every 5 yearsHPV screening interval

10 codesPreventive CPT/HCPCS codes listed

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Coverage Criteria for Screening Pelvic (Well-Woman) Examination

Coverage for screening Pap test and pelvic examination

Covered when meeting the applicable Medicare or plan frequency and risk criteria:

Coverage paths: Either Original Medicare coverage rules or the Medicare Plus Blue enhanced benefit applies as described below

Original Medicare - normal risk: Asymptomatic female beneficiaries at normal risk: screening Pap test and pelvic examination every 24 months (at least 23 months after the most recent screening pelvic examination)

Chunk 2

Original Medicare - high risk: Female beneficiaries at high risk: screening Pap test and pelvic examination annually (at least 11 months after the most recent screening pelvic examination). High risk defined by medical history or other findings indicating increased risk for cervical or vaginal cancer, or female of childbearing age with prior abnormal screening within the preceding three years.

Chunk 2

Original Medicare - HPV screening: Asymptomatic female beneficiaries ages 30-65: HPV screening once every 5 years (at least 59 months after the most recent HPV screening)

Chunk 2

Medicare Plus Blue enhanced benefit frequency: Medicare Plus Blue PPO group plan (University of Michigan) provides coverage for a well-woman/gynecological exam once per benefit year (at least 11 months after the most recent exam)

Chunks 4,9

Noncovered services require a prior coverage determination from Medicare Plus Blue before being provided. Providers may not have members sign an Advance Beneficiary Notice of Noncoverage (ABN) to accept financial responsibility for noncovered items. If a provider issues a noncovered item without first obtaining a coverage determination, the member must be held harmless for all charges except any applicable cost share. Providers should verify benefits and cost share using the provider portal or by calling the number provided.

Policy history: the policy was transitioned to a new template effective 01/01/2026 with approval dated 11/25/2025. No changes were made to benefit or payment conditions during this transition.

Billing, Frequency and Code Guidance

Preventive medicine CPT/HCPCS codes (enhanced benefit)CPTCovered

99383	Initial comprehensive preventive medicine evaluation and management — new patient; late childhood (age 5 through 11 years)
99384	Initial comprehensive preventive medicine evaluation and management — new patient; adolescent (age 12 through 17 years)
99385	Initial comprehensive preventive medicine evaluation and management — new patient; 18-39 years
99386	Initial comprehensive preventive medicine evaluation and management — new patient; 40-64 years
99387	Initial comprehensive preventive medicine evaluation and management — new patient; 65 years and older
99393	Periodic comprehensive preventive medicine reevaluation — established patient; late childhood (age 5 through 11 years)
99394	Periodic comprehensive preventive medicine reevaluation — established patient; adolescent (age 12 through 17 years)
99395	Periodic comprehensive preventive medicine reevaluation — established patient; 18-39 years
99396	Periodic comprehensive preventive medicine reevaluation — established patient; 40-64 years
99397	Periodic comprehensive preventive medicine reevaluation — established patient; 65 years and older

ICD-10ICD-10

ICD-10 codes should be reported to the highest level of specificity consistent with Original Medicare rules

inv-06: HPV screening interval

IntervalOnce every 5 years for asymptomatic beneficiaries ages 30-65 (at least 59 months after prior HPV screening)

Age rangeAges 30-65

Minimum months since prior HPV testAt least 59 months (4 years, 11 months)

inv-07: Screening Pap/pelvic interval (normal risk)

Interval (normal risk)Every 24 months

Minimum months since prior screening pelvic examAt least 23 months after prior screening pelvic exam

Provider Responsibilities, Billing and Documentation

Prior Authorization

Coverage determination recommended

Coverage determination recommended when unsure. No routine prior authorization is specified for the screening pelvic exam; however, if there is any question about coverage the provider should obtain a prior determination from Blue Cross Blue Shield of Michigan before providing the service.

Note

Provider action

Follow provider-actions guidance from source: when unsure about coverage or billing, contact the payer or use the provider portal to confirm requirements prior to rendering services.

Documentation Required

Claim submission and documentation

Claim submission and documentation. Providers must report CPT/HCPCS and diagnosis codes to the highest level of specificity, include their National Provider Identifier (NPI) on all claims, and bill on the appropriate claim form (CMS-1500 (02/12), UB-04, or the 837 electronic equivalent). Use electronic billing where available and send claims to your local Blue Cross plan; Michigan providers may use the addresses and EDI guidance available at bcbsm.com/providers/help/edi/.

Background

A screening pelvic examination (also called an annual gynecological exam) is performed in asymptomatic women to evaluate pelvic organs, screen for cervical and vaginal disease and infections, detect precancers and genital cancers, identify fibroids and other reproductive abnormalities, and assess pelvic organ size and position. Screening may include a Pap test and HPV testing per Medicare intervals and may include a clinical breast exam.

Definitions

inv-14: Screening pelvic examination / annual gynecological exam

DefinitionAn examination performed when no specific complaint or symptom is present to evaluate pelvic organs, screen for cervical/vaginal disease and infections; terms 'screening pelvic exam' and 'annual gynecological exam' are used interchangeably in this policy.

PurposeDetect precancers, genital cancers, infections (including STIs), fibroids and other reproductive abnormalities; evaluate pelvic organ size and position.

May includeClinical breast examination and at least seven of the listed pelvic exam elements (inspection/palpation of breasts, rectal exam, inspection of external genitalia, cervix, uterus, adnexa, etc.).

inv-15: High-risk female beneficiary

DefinitionA beneficiary with medical history or findings indicating high risk for cervical or vaginal cancer, or a premenopausal female of childbearing age with a prior abnormal screening in any of the previous three years.