Cervical Cancer Screening — Coverage Criteria for Pap, HPV, and Cotesting
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Coverage criteria for cervical cancer screening tests (Pap cytology, high-risk HPV testing, co-testing, and related reflex testing) for individuals with a cervix, including age- and risk-based frequency and limitations of coverage.
No material clinical or coverage changes in this revision.
Coverage Criteria
Immunocompromised / High-risk individuals
Covered when ANY of the following high-risk conditions apply (criteria summarized from policy):
Per policy: annual cytology for immunocompromised individuals; see ASCCP guidance for transplant/HSCT specifics.
Age-based screening: 21–29 years
Covered when ALL of the following are met:
Policy specifies Pap every 3 years for ages 21–29.
Age-based screening: 30–65 years
Covered when ANY one of the following is selected:
Options align with USPSTF and ACS recommendations summarized in policy.
HPV-positive / cytology-negative reflex testing
Policy supports HPV-16/18 genotyping as reflex in HPV-positive/cytology-negative cases.
Cessation of screening: >65 years
Policy defines adequate screening history for cessation at >65.
Hysterectomy without history of cervical disease
Policy explicitly excludes screening after hysterectomy for benign disease when no prior cervical neoplasia exists.
Not covered / Experimental tests
Policy lists these technologies/tests as not meeting coverage criteria.
General exclusion: <21 years
Policy states screening <21 does not meet coverage criteria.
Age-based screening
USPSTF and ACS age-based screening recommendations (as summarized in the document):
USPSTF Grade A; reflected in policy.
USPSTF Grade A; ACS 2020 prefers primary HPV every 5 years starting at age 25 per ACS summary.
USPSTF Grade D; policy aligns with USPSTF/ACS guidance.
Special-population screening (immunocompromised)
Immunocompromised and special-population screening guidance (ASCCP/SGO summary):
ASCCP guidance summarized in policy.
ASCCP recommendations per policy.
ASCCP summary in policy.
Primary hrHPV screening and reflex management
Primary hrHPV screening considerations and management:
Policy cites interim guidance that primary hrHPV screening should not be initiated before 25.
Policy cites guidance that negative hrHPV allows at least 3‑year interval.
ACOG/ASCCP guidance summarized in policy.
Screening, triage, and follow-up criteria
Coverage and clinical criteria are guided by professional society recommendations and FDA approvals; use the following guideline-based criteria for screening, triage, and follow-up.
Policy requires FDA‑approved assays for primary use and restricts non‑FDA‑approved assays to cotesting unless evidence supports otherwise.
Policy summarizes HIV‑specific screening intervals.
Policy provides alternative management pathways for WWH ≥30.
ASCO resource‑stratified guidance summarized in policy.
ASCO enhanced‑resource strategy described in policy.
ASCO limited/basic recommendations included in policy.
The policy explicitly states that inclusion of low‑risk HPV strains in co-testing and use of unspecified "other technologies for cervical cancer screening" do not meet coverage criteria because published scientific literature does not confirm these tests are required and beneficial. These items are listed among the tests that are not covered by the policy and should not be used as substitutes for guideline-recommended cytology or high‑risk HPV assays. (See policy list of tests that do not meet coverage criteria.)
The policy follows guideline recommendations that screening is not helpful for individuals who no longer have a cervix following hysterectomy for a benign condition: do not screen these individuals at any age unless there is a prior history of cervical cancer or precancer. The policy also states that cervical cancer screening for individuals younger than 21 years does not meet coverage criteria (screening younger than 21 is discouraged due to low prevalence of progressive lesions and harms from overtreatment).
Use of HPV mRNA or HPV DNA assays that lack FDA approval for primary screening alone is restricted by this policy: such assays should be used only as cotesting with cytology unless there are sufficient, rigorous data supporting their standalone primary‑screening performance. The policy therefore prioritizes FDA‑approved HPV NAATs for primary screening and requires reflex or cotesting for non‑FDA‑approved assays.
No additional explicit coverage exclusions beyond those listed elsewhere in the policy are stated in the referenced material; the cited pages largely list bibliographic references and related resources and include an item heading that reads "Screening for cervical cancer in patients with HIV" without adding new exclusion language.
Summarizing the coverage stance: screening individuals younger than 21 years does not meet coverage criteria; routine screening for those older than 65 years with an adequate screening history does not meet coverage criteria; screening after hysterectomy for benign disease does not meet coverage criteria at any age; and use of tests that include low‑risk HPV strains or other nonstandard technologies is not covered. Additionally, HPV mRNA/DNA assays without FDA approval for primary screening are limited to cotesting with cytology unless sufficient evidence supports primary use.
The policy reiterates that screening individuals under 21 years confers limited benefit and potential harms (false positives, overtreatment) and thus does not meet coverage criteria. It also echoes USPSTF/NCI guidance that routine screening is not recommended for individuals older than 65 years with an adequate prior screening history and that screening after hysterectomy for benign disease is not helpful. Additionally, inclusion of low‑risk HPV strains in co-testing is specifically listed as not meeting coverage criteria.
The policy notes that screening individuals younger than 21 years offers small absolute benefit while increasing harms from unnecessary diagnostic procedures and treatment; this is supported by NCI guidance emphasizing higher false‑positive rates and spontaneous regression of low‑grade lesions in younger persons, so screening in this age group is discouraged.
Within the cited reference material there are no explicit additional statements declaring services "not medically necessary." The referenced pages primarily list bibliographic sources and note topics such as screening for cervical cancer in patients with HIV, without providing new formal noncoverage language.
Coding
| 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. |
Provider Actions & Billing Guidance
Age/risk-based screening frequency & age limits (USPSTF-aligned)
Age- and risk-based screening frequencies must be followed. Routine screening is not indicated for individuals <21 years. For ages 21–29, Pap (cytology) every 3 years meets coverage. For ages 30–65, any one of: Pap every 3 years, high-risk HPV testing alone every 5 years, or cotesting (Pap + high-risk HPV) every 5 years meets coverage. Individuals >65 who are not high-risk with an adequate screening history (three consecutive negative Pap tests or two consecutive negative HPV tests within 10 years, with most recent within 5 years) do not meet coverage for routine screening. Individuals >65 who are high-risk (history of high-grade precancer or DES exposure) should continue screening per ages 30–65 intervals. Individuals who have had hysterectomy with no history of cervical cancer or precancer do not meet coverage for screening at any age.
- Do not screen <21 years (may be denied).
- 21–29 years: Pap every 3 years (covered).
- 30–65 years: Pap q3y OR hrHPV alone q5y OR cotest q5y (covered).
- >65 years: stop if adequate prior negative screening and not high-risk; continue if high-risk.
- Post-hysterectomy (benign disease, no history of CIN/cancer): screening not covered.
HPV assay regulatory / usage requirement
HPV assays used for primary screening should be FDA-approved for that indication. HPV mRNA and HPV DNA assays that do not have FDA approval for primary screening should only be used as cotests with cytology unless rigorous evidence supports primary use. Use assays according to their regulatory approval and intended use.
- Use FDA-approved primary screening HPV assays for primary-screening-only workflows.
- Non-FDA-approved HPV mRNA/DNA assays: use only as cotest with cytology unless strong evidence supports primary use.
Applicable procedure codes
Applicable CPT/HCPCS procedure codes for HPV testing and cervical cytology are listed and should be used for claims submission as appropriate.
Reflex testing and colposcopy workflow (ACOG/WHO/ISS guidance)
Reflex testing and colposcopy workflow: positive primary HPV screening tests should have reflex triage testing (eg, reflex cytology or genotyping for HPV16/18 ±45) performed on the same specimen when feasible. If reflex testing on the same specimen is not possible and HPV16/18 is positive, proceed directly to colposcopy. Negative triage may prompt repeat HPV testing per guidance (eg, 12 months) rather than immediate colposcopy.
- Perform reflex cytology and/or genotyping (HPV16/18 ±45) from same specimen for all positive primary HPV tests.
- If reflex not feasible and HPV16/18 positive → proceed to colposcopy.
- If triage negative → repeat HPV testing at 12 months; refer to colposcopy if persistently positive.
Triage after positive HPV test
Triage after a positive HPV test should follow guideline-recommended algorithms: reflex genotyping for HPV16/18 (with or without 45) and/or reflex cytology to determine need for colposcopy. Abnormal triage (≥ ASC-US or HPV16/18 positive) warrants colposcopy and biopsy. If triage is negative, repeat HPV testing at 12 months and refer to colposcopy if positive on repeat.
- Reflex genotyping and/or cytology is required for positive HPV results.
- Abnormal triage (≥ASC-US or HPV16/18 [+/-45]) → colposcopy and biopsy.
- Negative triage → repeat HPV at 12 months; refer if persistent positivity.
Deferral of colposcopy for low-risk abnormalities (ACOG)
Colposcopy may be deferred for certain low-risk abnormalities per ACOG: repeat HPV testing or cotesting at 1 year is recommended for patients with minor screening abnormalities indicating HPV infection with low risk of underlying CIN3+.
- HPV-positive with low-grade cytology after documented negative prior screen → repeat HPV or cotest at 1 year rather than immediate colposcopy.
Prior authorization / Step therapy / Documentation expectations
No prior authorization, step therapy, or additional documentation specific to these screening intervals and tests is specified in this section. Follow applicable government (LCD/NCD) or state Medicaid policies where they differ.
- No prior authorization requirement stated in these policy excerpts.
- No step therapy sequence described for screening tests.
- If conflict with government policy (eg, LCD/NCD), government policy governs.
Background
Cervical cancer screening is intended to detect precancerous lesions and invasive cancer using cytology (Papanicolaou smear) and high‑risk HPV testing, with colposcopy and further diagnostic evaluation when indicated. The policy highlights that high‑risk HPV types (notably HPV‑16 and HPV‑18) are causally linked to cervical neoplasia and that HPV‑based screening provides greater protection against invasive cervical cancer than cytology alone, while recognizing different specificity and false‑positive profiles. Reflex genotyping for HPV‑16/18 is supported for HPV‑positive/cytology‑negative results to guide triage and colposcopy decisions.
Definitions
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