CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB032

Oral Screening Lesion Identification Systems and Genetic Screening

Defines BCBSOK reimbursement stance for oral screening/lesion identification systems, salivary biomarker tests, and certain HPV/genetic tests; applies to providers submitting claims to Blue Cross Blue Shield of Oklahoma.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyOral Screening Lesion Identification Systems and Genetic Screening

Policy CodePolicy CPCPLAB032

Change TypeNo material change

Effective DateNov 1, 2022

Next Review DateN/A

Key ActionSubmit accurate documentation and claims using valid HIPAA-approved code sets and review plan documents for product-specific coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3non-reimbursable examples

2reimbursable HPV methods

7procedure codes referenced

1version

Coverage Criteria

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ALL of the following

ONE of
- High-risk HPV testing for individuals with oropharyngeal squamous cell carcinoma may be reimbursable by HPV E6/E7 mRNA expression testing.
- High-risk HPV testing for individuals with oropharyngeal squamous cell carcinoma may be reimbursable by detection of p16 expression by immunohistochemistry (p16 IHC).

ALL of the following

Oral screening and lesion identification systems and genetic testing are not reimbursable for all uses; examples include OraRisk HPV Complete Genotyping Test, OraRisk HPV 16/18/HR Test (OralDNA Labs), MOP testing, and SaliMark OSCC (PeriRx).
Use of salivary biomarkers to screen, detect, or diagnose oral cancer is not reimbursable; examples include salivary peptides and proteins (e.g., protein 14, Mac-2 binding protein, profilin 1, CD59, defensin-1, IL-1ß, IL-8, lactate dehydrogenase, catalase).
Salivary nucleic acids are not reimbursable for these purposes; examples include methylated DNA testing, mRNAs, modified nucleotides (such as 8-OHdG), and microRNA (miRNAs).
Salivary metabolites are not reimbursable for these purposes; examples include valine, lactic acid, and phenylalanine.

Claims Submission and Plan-Specific Review

Documentation Required

Claims submission and plan‑specific review

Providers must submit accurate documentation of services performed and file claims using valid HIPAA‑approved code sets; claims are subject to code edit protocols and plan-specific review, and providers may be asked to supply additional documentation upon request. Reimbursement criteria and applicability vary by product and the member's plan, so providers should review applicable plan documents and provider contracts for coverage determinations.

Submit claims using valid code combinations from HIPAA‑approved code sets (CPT, HCPCS, ICD‑10, NDC, DRG, etc.).
Claims are subject to code edit protocols and review against benefit coverage, provider contract terms, medical policies, CPCPs, and coding software logic.
Upon request, submit any additional documentation to support the claim.

Definitions

HPV E6/E7 mRNA testing

DefinitionHPV E6/E7 mRNA expression testing

Reimbursable contextMay be reimbursable for individuals with oropharyngeal squamous cell carcinoma as a method of high-risk HPV testing

Policy limitationNot intended for oral screening or general salivary biomarker use; reimbursement limited to indicated OPSCC testing per policy

p16 IHC

DefinitionImmunohistochemical detection of p16 protein expression

Reimbursable contextExpression of p16 detected by immunohistochemistry may be reimbursable as a method of high-risk HPV testing for individuals with oropharyngeal squamous cell carcinoma

Coding noteRelevant CPT codes referenced in policy include 88341 and 88342 for surgical pathology and IHC procedures