CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB032

Oral Cancer Screening and Testing

Governs reimbursement criteria for oral cancer screening and testing, including reimbursement for high-risk HPV testing to establish tumor status in oropharyngeal squamous cell carcinoma; applies to providers submitting claims to Blue Cross and Blue Shield of New Mexico.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyOral Cancer Screening and Testing

Policy CodePolicy CPCPLAB032

Change TypeCoding and reimbursement updates

Effective DateApr 15, 2025

Next Review DateN/A

Key ActionSubmit appropriate test codes and supporting pathology/pathologist report when requesting reimbursement to establish HPV tumor status.

SourceLink

POLICY UPDATE CHANGES

Revised reimbursement information: clarified intent of test and added 'To establish HPV tumor status…' and added code 0429U; removed code 87623.

Added code 87626.

Document updated with literature review.

1Primary reimbursement criterion item

1.0Policy version

04/15/2025Effective date

87626Recent coding update

Coverage Criteria

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyOral Cancer Screening and Testing

Policy CodePolicy CPCPLAB032

Change TypeCoding and reimbursement updates

Effective DateApr 15, 2025

Next Review DateN/A

Key ActionSubmit appropriate test codes and supporting pathology/pathologist report when requesting reimbursement to establish HPV tumor status.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

HPV testing for oropharyngeal squamous cell carcinoma

Reimbursement may be available for testing performed to establish HPV tumor status in oropharyngeal squamous cell carcinoma.

ALL of the following

The test is performed to establish tumor HPV status for a diagnosed or suspected oropharyngeal squamous cell carcinoma (documentation must support the diagnosis and clinical intent).
Test method
- mRNA expression testing for HPV E6/E7.
- Immunohistochemistry.

ALL of the following

Submit appropriate test codes and supporting pathology/pathologist report to demonstrate clinical indication and test performed.
Providers should review applicable Plan documents for product-specific coverage rules and are responsible for submission of accurate documentation; additional documentation may be requested.

Provider Actions and Claim Review

Documentation Required

Documentation and claims review

Providers are responsible for submission of accurate documentation of services performed and must submit additional documentation upon request. Claims should be coded using valid HIPAA-approved code sets and industry-standard coding guidelines; providers are urged to provide supporting documentation when requested for claim review.

Submit claims using valid HIPAA-approved code sets and appropriate code combinations.
Provide supporting documentation (e.g., pathology/pathologist report) upon request to substantiate medical necessity and diagnosis.
Follow industry coding guidelines (UB, CPT, HCPCS, ICD-10-CM/PCS, NDC, DRG, CCI edits).

Billing Rule

Claim review and coding edits

Claims are subject to code edit protocols and claim review, including evaluation against benefit coverage, provider contract terms, medical policies, and coding software logic; edits may affect payment.

Claims may be reviewed for compliance with plan documents, provider contracts, and medical/clinical payment policies.
Coding software logic and CCI/table edits may be applied to submitted claims.
Payment decisions will follow applicable plan documents where conflicts exist.

Definitions

HPV tumor status testing — key facts

DefinitionHPV tumor status testing — testing for high-risk HPV via mRNA expression testing for HPV E6/E7 or immunohistochemistry to establish tumor HPV status in oropharyngeal squamous cell carcinoma.

Clinical intentPerformed to establish HPV tumor status for individuals with oropharyngeal squamous cell carcinoma.

Supported methodsmRNA expression testing for HPV E6/E7; immunohistochemistry.

Reimbursement stanceMay be reimbursable when performed to establish tumor HPV status and supported by medical documentation and applicable plan coverage rules.

Provider guidanceReview applicable Plan documents for product-specific eligibility and submit supporting pathology/pathologist reports with claims as required.

OpenPayer

Oral Cancer Screening and Testing

Coverage Criteria

Coding and Reimbursement

Provider Actions and Claim Review

Definitions

87626	HPV testing code added to policy (document history notes addition).
0429U	Added previously per document history as a test code for HPV-related testing.
87623	Code removed per document history.