CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB002

Cervical Cancer Screening

Reimbursement and coding criteria for cervical cancer screening tests for individuals with a cervix, specifying when screening is reimbursable and which tests and frequencies are supported for BCBSOK products.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyCervical Cancer Screening

Policy CodePolicy CPCPLAB002

Change TypeMaterial revision — coverage expanded for certain <21 high-risk individuals

Effective DateNov 1, 2023

Next Review Date

Key ActionSubmit accurate documentation and use valid HIPAA-approved codes; prior authorization rules are determined by plan documents and provider contracts.

SourceLink

POLICY UPDATE CHANGES

Cervical cancer screening for individuals under age 21 changed from 'not reimbursable' to 'may be reimbursable' when specific high-risk conditions are present (HIV, other immunocompromise, prior cervical cancer or dysplasia, organ transplant).

Language changed from 'women' to 'individuals' throughout the reimbursement information section and a clarifying note added about the evidence sources informing criteria.

21-29Pap every 3 years reimbursable

30-65Pap / hrHPV / co-testing reimbursable

>65Routine screening not reimbursable if adequate prior screening

codes listed

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Coverage criteria for cervical cancer screening

Age- and risk-based coverage criteria

Covered when the specific age and risk-based criteria below are met

Under 21: Cervical cancer screening may be reimbursable only when ANY of the following are present: history of HIV and/or other non-HIV immunocompromised conditions; previous diagnosis of cervical cancer; previous diagnosis of cervical dysplasia; history of organ transplant.

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Immunosuppressed individuals (without HIV): Any one of the following cervical cancer screening techniques may be reimbursable: (a) annual cytology testing for individuals 30 years or younger; OR (b) co-testing (cytology and HPV) every 3 years for individuals 30 years or older.

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Ages 21-29: Conventional or liquid-based Papanicolaou (Pap) smear reimbursable at a frequency of every 3 years.

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Ages 30-65: Any one of the following reimbursable: (a) Pap smear every 3 years; (b) high-risk HPV test alone every 5 years; or (c) co-testing (cytology with concurrent high-risk HPV testing) every 5 years.

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HPV positive / cytology negative: For individuals who are HPV positive and cytology negative, testing for high-risk strains HPV16 and HPV-18 may be reimbursable.

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Over 65 high risk: Individuals >65 years who are high-risk (history of high-grade precancerous lesion or cervical cancer; in-utero DES exposure; immunocompromised) may be reimbursable for screening.

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Repeat screening at 1 year: Repeat Pap smear or HPV testing in one year may be reimbursable for: (a) individuals with prior abnormal cytology and/or positive HPV; or (b) individuals at high risk for cervical cancer (organ transplant, DES exposure, immunocompromised).

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Over 65 routine stopping: For individuals >65 years who are not high risk and have an adequate screening history, routine cervical cancer screening is not reimbursable. Adequate screening history: either three consecutive negative Pap smears OR two consecutive negative HPV tests within 10 years with the most recent within 5 years.

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Explicit not reimbursable items

Post-hysterectomy without history: Individuals who have undergone surgical removal of the uterus and cervix and who have no history of cervical cancer or pre-cancer: cervical cancer screening (at any age) is not reimbursable.

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Specific tests not reimbursable: Inclusion of low-risk HPV strains in co-testing and other technologies for cervical cancer screening are not reimbursable.

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For individuals >65 years who are not high risk and who have an adequate screening history, routine cervical cancer screening is not reimbursable. Adequate screening history is defined as either: (a) three consecutive negative Pap smears, or (b) two consecutive negative HPV tests within 10 years with the most recent test within 5 years prior to stopping screening. This exclusion applies regardless of age once the specified screening history is met.

Routine screening for low-risk individuals over age 65 with an adequate prior screening history is considered not medically necessary / not reimbursable. The policy specifies the two acceptable criteria for an adequate screening history: three consecutive negative Pap smears, or two consecutive negative high‑risk HPV tests within the prior 10 years with the most recent within 5 years.

Procedure, laboratory codes and screening-history definitions

Procedure and lab codes referencedmixed

0500T
87623
87624
87625
88141
88142
88143
88147
88148
88150

1–10 of 30

1/3

inv-06: Adequate screening history

DefinitionAdequate screening history for stopping routine cervical cancer screening in individuals >65 years

Option 1Three consecutive negative Pap smears

Option 2Two consecutive negative high-risk HPV tests within the 10 years before cessation of screening, with the most recent test occurring within 5 years

Provider responsibilities and billing considerations

Documentation Required

Provider documentation responsibility

If a conflict arises between a Payment and Coding Policy and any plan document under which a member is entitled to Covered Services, the plan document governs. If a conflict arises between a PCP and any provider contract pursuant to which a provider participates in and/or provides Covered Services to eligible member(s) and/or plans, the provider contract governs. "Plan documents" include, but are not limited to, Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents. BCBSOK may use reasonable discretion interpreting and applying this policy to services being delivered in a particular case. BCBSOK has full and final discretionary authority for their interpretation and application to the extent provided under any applicable plan documents.

Providers are responsible for submission of accurate documentation of services performed and may be asked to provide additional documentation upon request.
Claims must be submitted using valid HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, UB, DRG guidelines, CMS NCCI, CCI edits, etc.).
Claims are subject to code edit protocols and may be reviewed against benefit coverage, provider contract language, medical/payment/coding policies, and coding software logic.

Key definitions used in this policy

inv-12: individual(s) with a cervix

Termindividual(s) with a cervix

MeaningTerminology used throughout the reimbursement criteria to denote persons with a cervix eligible for cervical cancer screening

Policy noteLanguage was changed from 'women' to 'individuals' throughout the reimbursement information to clarify inclusion of all persons with a cervix

Clinical background

Cervical cancer screening is explicitly not reimbursable after surgical removal of the uterus and cervix when there is no history of cervical cancer or pre‑cancer. The policy also lists specific non‑reimbursable items, including the inclusion of low‑risk HPV strains in co‑testing and other technologies for cervical cancer screening. For details on HPV testing, the policy cross‑references CPCPLAB51 (Diagnostic Testing of Common Sexually Transmitted Infections).