Cervical Cancer Screening — Coverage Criteria for Pap cytology, high‑risk HPV testing, and co‑testing
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Defines coverage criteria for cervical cancer screening methods (Pap cytology, high-risk HPV testing, and co-testing) including frequency and special-population rules for BlueCross BlueShield of Tennessee members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Cervical Cancer Screening
Covered screening by age and risk
Covered when ALL of the following age- and risk-based conditions are met as specified:
From policy: immunocompromised or immunosuppressed individuals
High-risk defined in policy (history of high-grade precancerous lesion or cervical cancer, in utero DES exposure)
Reflex and annual screening exceptions
Additional covered and not-covered conditions:
Policy statement: nucleic acid testing for high-risk strains 16 and 18
From policy: annual screening allowed for prior abnormal or high-risk individuals
Not Medically Necessary / Not Covered
Not covered situations
Adequate history defined in policy
From policy exclusions: low-risk strains and other technologies not supported
The policy explicitly excludes the inclusion of low-risk HPV strains in co-testing approaches and excludes use of other unspecified technologies for cervical cancer screening due to insufficient supporting evidence. This means assays or co-testing panels that report or rely on low-risk HPV types (eg, types typically associated with benign disease rather than cervical cancer) are not considered to meet coverage criteria under this policy.
Routine cervical cancer screening is subject to age- and risk-based limits. Screening does not meet coverage criteria for individuals under 21 years. For individuals >65 years who are not high-risk and who have an adequate screening history (for example, three consecutive negative Pap smears), routine screening is not covered. The policy also permits exceptions to more frequent screening: for individuals ≤65 years, annual Pap or HPV testing meets coverage criteria only when there is a prior abnormal cytology or positive HPV result, or the individual is at high risk (for example, organ transplant or in utero DES exposure). Finally, technologies that include low-risk HPV strains or other unspecified screening methods are listed among approaches that do not meet coverage criteria.
Procedure and Billing Codes
| 87623 | Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44). |
| 87624 | Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68). |
| 87625 | Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed. |
| 88141 | Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician. |
| 88142 | Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision. |
| 88143 | Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with manual screening and rescreening under physician supervision. |
| 88147 | Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision. |
| 88148 | Cytopathology smears, cervical or vaginal; screening by automated system with manual rescreening under physician supervision. |
| 88150 | Cytopathology, slides, cervical or vaginal; manual screening under physician supervision. |
| 88152 | Cytopathology, slides, cervical or vaginal; with manual screening and computer- assisted rescreening under physician supervision. |
| 0500T | Infectious agent detection by nucleic acid (DNA or RNA), Human Papillomavirus (HPV) for five or more separately reported high-risk HPV types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) (ie, genotyping). |
| G0476 | Infectious agent detection by nucleic acid (DNA or RNA); human papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) for cervical cancer screening, must be performed in addition to pap test. |
| Q0091 | Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory. |
Provider Actions — Authorization, Documentation, and Denial Risks
Bill listed cytology/HPV procedure codes only at policy‑specified intervals
Coverage for cervical cytology and high‑risk HPV procedure codes is allowed only at the intervals and for the age/risk groups specified in the policy (e.g., Pap every 3 years for ages 21–29; Pap every 3 years OR HPV alone every 5 years OR co‑testing every 5 years for ages 30–65; annual cytology for immunocompromised individuals). The listed CPT/HCPCS/G codes in the policy are the procedure codes to use when billing these covered services.
No policy‑mandated prior authorization specified
The policy does not specify any universal prior authorization requirement for the listed cervical cytology or high‑risk HPV screening codes; coverage is determined by meeting the age‑ and risk‑based criteria in the policy and the member’s benefit rules.
- Prior authorization may still be required per the member’s benefit plan; the policy text itself does not mandate prior authorization for the listed screening codes.
No step‑therapy sequencing — modality and interval options allowed
The policy does not impose step‑therapy sequencing for cervical cancer screening; it defines allowable screening modalities and intervals (e.g., Pap, HPV alone, or co‑testing) rather than requiring one test before another.
- Providers may select an approved modality per the member’s age and risk status without following a step‑therapy progression.
Step therapy not specified in reference listings
Confirmatory: the policy contains no step‑therapy requirements in its listings — step therapy is not specified as a requirement for cervical cancer screening services.
- The policy references clinical guidance and technologies but does not direct a required sequence of tests.
Document age, risk status, prior abnormal results, DES exposure, hysterectomy and screening history
Document the member’s age, immunocompromised/high‑risk status (including organ transplant or in utero DES exposure), prior abnormal cytology or positive HPV results, dates and results of prior Pap/HPV tests, and history of high‑grade precancer or cervical cancer to support that the service meets the policy’s age‑ and risk‑based intervals or exceptions.
- Record dates/results of prior Pap and HPV tests to demonstrate adequate screening history when assessing cessation criteria for those >65.
- Document any history of high‑grade precancer or cervical cancer or DES exposure to justify continued screening when indicated.
No additional documentation specifics provided in code listings
Some reference/listing sections of the policy do not specify additional documentation requirements beyond clinical history and test results; there is no separate, detailed documentation checklist provided for every listed code.
- Providers should rely on the clinical documentation described in the policy (age, risk, prior results) because separate documentation instructions are not provided in the code listings.
Denial risk: routine screening <21 or routine screening >65 with adequate history
Routine cervical cancer screening for individuals under 21 years and routine screening for individuals over 65 who have an adequate prior negative screening history do not meet coverage criteria and may be denied if billed as routine screening.
- Under 21: routine screening is not covered.
- Over 65 with adequate screening history (three consecutive negative Pap smears OR two consecutive negative HPV tests within 10 years, most recent within 5 years): routine screening is not covered.
Denial risk: screening after total hysterectomy without history not covered
Cervical cancer screening for individuals who have had surgical removal of the uterus and cervix (total hysterectomy) and who have no history of cervical cancer or precancer does not meet coverage criteria and may be denied.
- Do not bill routine cervical screening for members post‑hysterectomy with cervix removed and no history of cervical cancer/pre‑cancer.
No procedural authorization requirements specified in listings
The policy’s code listings and reference sections do not impose separate procedural authorization requirements or identify additional denial triggers beyond the age‑ and risk‑based coverage criteria.
- Follow the policy’s coverage criteria and the member’s benefit plan rules; the policy itself does not add procedural authorization steps in the listings.
Background and Clinical Rationale
Cervical cancer screening aims to detect precancerous lesions and early cancer through cytology (Pap testing) and detection of high-risk HPV types. This policy supports evidence-based screening intervals and modalities: ages 21–29 are eligible for Pap testing once every 3 years; individuals 30–65 may receive Pap every 3 years, high-risk HPV testing alone every 5 years, or co-testing every 5 years. Reflex testing for HPV-positive/cytology-negative patients is covered for high-risk HPV types (HPV-16 and HPV-18). The policy excludes use of low-risk HPV types in co-testing and other unvalidated technologies because they lack adequate literature support, and it limits routine screening in younger (<21) and certain older (>65 with adequate history) populations to align coverage with accepted clinical guidance.
Key Definitions
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