CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB032

Oral Cancer Screening and Testing

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Defines reimbursement criteria for laboratory testing related to oral/oropharyngeal cancer screening and establishing HPV tumor status for members covered by Blue Cross and Blue Shield of New Mexico products.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyOral Cancer Screening and Testing

Policy CodePolicy CPCPLAB032

Change TypeCodes addedreimbursement detail revised

Effective DateApr 15, 2025

Last ReviewJan 23, 2024

Next Review Date

Key ActionProviders must submit accurate documentation and may be asked to provide additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

Added code 87626.

Revised reimbursement information to state intent of test and added code 0429U; removed code 87623.

1primary reimbursement statement

87626

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CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB032

Oral Cancer Screening and Testing

Customize your policy alerts

Sign up for Blue Cross Blue Shield - New Mexico Policy CPCPLAB032 alerts

Get alerted when Policy CPCPLAB032 changes without checking for updates manually.

Monitor payer policy activity

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Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyOral Cancer Screening and Testing

Policy CodePolicy CPCPLAB032

Change TypeCodes addedreimbursement detail revised

Effective DateApr 15, 2025

Last ReviewJan 23, 2024

Next Review Date

Key ActionProviders must submit accurate documentation and may be asked to provide additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

Added code 87626.

Revised reimbursement information to state intent of test and added code 0429U; removed code 87623.

1primary reimbursement statement

87626

Coverage Criteria

HPV tumor-status testing

Reimbursement is available under specified conditions for establishing HPV tumor status in oropharyngeal squamous cell carcinoma.

Testing is intended to establish tumor HPV status for individuals with oropharyngeal squamous cell carcinoma.

The test method must be either high-risk HPV mRNA expression testing for E6/E7 or immunohistochemistry.

Not all requirements apply to every product; providers should review applicable plan documents to determine eligible coverage.

Plan documents and provider contracts govern when conflicts arise.

Coding and Reimbursement Codes

Policy code changes and examplesmixed

87626	Code added to policy (specific descriptor not listed in document).
0429U	PLA code added per update (specific descriptor not listed in document).
87623	Code removed per policy update.

Code list completeness (limitations)

Scope of code listThe procedure code list provided is not all-encompassing; it does not include every potentially related code.

No guarantee of coverageInclusion of a code in the list does not guarantee it is a covered service or eligible for reimbursement.

Use as reference onlyCodes are presented for reference and should be validated against applicable plan benefits and billing rules.

Provider responsibilityProviders must ensure correct code selection and appropriate documentation when submitting claims.

Provider Documentation & Claims

Documentation Required

Documentation, coding, and claim review requirements

Providers are responsible for submission of accurate documentation of services performed and must submit claims using valid, industry-standard code combinations; upon request, providers should supply additional documentation for claim review. Claims are subject to code edit protocols and may be reviewed against benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and coding software logic.

Submit claims using valid HIPAA-approved code sets and appropriate industry coding guidelines (e.g., UB, CPT, HCPCS, ICD-10-CM/PCS).
Claims are subject to code edit protocols and claim review; provide additional documentation upon request to support billed services.
When conflicts arise, plan documents or provider contracts govern over this policy.

Definitions and Precedence

Definition — HPV tumor-status testing

DefinitionTesting to establish HPV tumor status for individuals with oropharyngeal squamous cell carcinoma using high-risk HPV mRNA E6/E7 expression testing or immunohistochemistry.

Methods referencedHigh-risk HPV mRNA E6/E7 expression testing (mRNA) and immunohistochemistry (IHC) are identified as methods to determine tumor HPV status.

PurposeTo establish tumor HPV status which may be used to inform diagnosis and treatment decisions and may be reimbursable when criteria are met.

Precedence — Plan documents and provider contracts

Governing documentsWhen a conflict exists, the member's plan documents (e.g., Certificates of Benefits, benefit booklets, Summary Plan Descriptions) govern over this policy.

Provider contracts