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Modifiedharvard pilgrim health carePolicy N/A

Cervical cancer screening — coverage criteria

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Policy governing coverage of cervical cancer screening tests (Pap cytology, high-risk HPV testing, and co-testing) for individuals with a cervix under Harvard Pilgrim Health Care commercial products.

Policy Summary

Payerharvard pilgrim health care

PolicyCervical cancer screening — coverage criteria

Policy CodePolicy N/A

Change TypeAdded CPT code 87626initial policy creation

Effective DateNov 1, 2025

Next Review DateApr 1, 2026

Key ActionEnsure submitted cervical cancer screening tests and codes match the covered indications and intervals.

SourceLink

POLICY UPDATE CHANGES

Added code 87626, effective for dates of service beginning June 1, 2026.

Policy created to support coverage guidelines, effective for dates of service beginning Nov. 1, 2025.

3yPap 21–29 interval

3–5yAccepted intervals 30–65

annualImmunocompromised screening

NoNot covered: low-risk HPV

87626New code added

Nov 1, 2025Policy effective (DOS)

Coverage Criteria: When Cervical Cancer Screening Is Covered

General coverage criteria by age and risk

Covered when ANY of the following age- and risk-specific criteria are met

Immunocompromised individuals: For immunocompromised or immunosuppressed individuals, any one of the following meets coverage criteria: (a) annual cervical cytology testing for individuals of all ages; (b) co-testing (cervical cytology and high-risk HPV testing) once every 3 years for individuals 30 years of age or older.immunocompromised status

based on guideline sources

Individuals 21-29: Individuals 21 to 29 years of age: cervical cancer screening once every 3 years using conventional or liquid-based Papanicolaou (Pap) smears meets coverage criteria.age 21-29

Pap only

Individuals 30-65: Individuals 30 to 65 years of age: any one of the following meets coverage criteria: (a) conventional or liquid-based Pap smear once every 3 years; (b) high-risk HPV test alone once every 5 years; (c) co-testing (cytology with concurrent high-risk HPV testing) once every 5 years.age 30-65

three acceptable strategies

High-risk over 65: Individuals over 65 who are considered high-risk (history of high-grade precancerous lesion or cervical cancer, or in utero DES exposure) should be screened at the frequency described for individuals 30–65 and this meets coverage criteria.age>65 and high-risk

follow criterion for ages 30-65

HPV 16/18 reflex testing: For individuals who are pooled high-risk HPV positive and cytology negative, nucleic acid testing for high-risk strains HPV-16 and HPV-18 meets coverage criteria (reflex genotyping).pooled hr-HPV positive with negative cytology

reflex genotyping

Annual screening for <=65 with prior abnormal results or high risk: For individuals 65 years of age or younger, annual cervical cancer screening by Pap smear or high-risk HPV testing meets coverage criteria if there was a prior abnormal cytology result and/or prior positive HPV, or if the individual is at high risk (e.g., organ transplant, DES exposure).<=65 with prior abnormal or high-risk

enhanced surveillance

Not covered

The following do not meet coverage criteria

Under 21: Cervical cancer screening for individuals less than 21 years of age does not meet coverage criteria.age<21

explicit exclusion

Over 65 with adequate history: Individuals over 65 who are not immunocompromised or high-risk and who have an adequate screening history — defined as either three consecutive negative Pap smears OR two consecutive negative HPV tests within 10 years with the most recent test within 5 years — routine cervical cancer screening does not meet coverage criteria.age>65 with adequate history

defines adequate history

Post-hysterectomy: 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 does not meet coverage criteria.hysterectomy without history

Testing for low-risk HPV does not meet coverage criteria. The policy explicitly excludes inclusion of low-risk strains of HPV in co-testing and states that other technologies for cervical cancer screening not discussed in the policy also do not meet coverage due to lack of evidence. Providers should therefore not bill for or expect coverage for assays that report only low-risk HPV types or for screening technologies that are not described in this policy.

This policy is a coverage guideline and is not a guarantee of payment. Actual payment depends on the member’s benefits and eligibility on the date of service, any required prior authorization or utilization management rules, coordination of benefits, referral requirements, provider network participation, and claims-editing logic. An authorization, when obtained, also is not a guarantee of payment.

Routine cervical cancer screening is not covered for certain groups. Screening for individuals younger than 21 years does not meet coverage criteria. Individuals over 65 years who are not immunocompromised or high-risk and who have an 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) do not meet coverage criteria for routine screening. Additionally, individuals who have had a hysterectomy with removal of the cervix and no history of cervical cancer or pre-cancer do not meet coverage criteria for cervical cancer screening at any age.

Procedure and Billing Codes

Applicable CPT/HCPCS Procedure Codesmixed

87623	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (e.g., 6, 11, 42, 43, 44)
87624	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) pooled result
87625	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed
87626	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), separately reported high- risk types (e.g., 16, 18, 31, 45, 51, 52) and high-risk pooled result(s) (Effective for DOS beginning June 1, 2026)
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

1–10 of 32

1/4

Covered CPT/HCPCS Codes (added)CPTCovered

87626

added to policy (exact description not provided in this excerpt)

Provider Actions, Authorization, and Billing Guidance

Prior Authorization

Coverage requires matching test to covered indication

Coverage is determined by matching the specific test ordered to the covered indication(s) in this policy. Before submitting services, confirm the test performed corresponds to a covered screening indication (for example: age-based intervals, immunocompromised status, prior abnormal results, or high‑risk exposure) and document the clinical rationale on the claim and in the medical record.

Ensure submitted test code and test type reflect the covered indication (screening vs diagnostic).
Do not submit low‑risk HPV testing codes — testing for low‑risk HPV DOES NOT MEET COVERAGE CRITERIA.
For individuals <21 years or routine screening >65 with adequate history, screening may be denied; include clinical rationale if screening outside standard intervals is performed.

Definitions and Background

Cervical cancer screening is intended to detect precancerous lesions and cancer in individuals with a cervix. The principal screening method is the Pap (Papanicolaou) smear, which samples cervical cells for cytologic interpretation. High-risk HPV testing targets viral DNA from oncogenic HPV strains associated with cervical intraepithelial neoplasia and cervical cancer and may be used as an adjunct to cytology or as a primary screening strategy.

Pap smear (Papanicolaou smear)

DefinitionSampling of cervical cells from the cervix during a pelvic examination sent to an accredited laboratory for cytologic staining, observation, and interpretation (Papanicolaou or Pap smear).

PurposePrincipal screening test to detect cervical cancer in asymptomatic individuals with a cervix.

Specimen handlingCells are scraped, spread onto a slide (or collected in preservative for liquid-based cytology), and submitted to a laboratory for interpretation.

High-risk HPV (hr-HPV) testing

Policy Revision History

2026-04-01administrative_editLatest

Annual review with administrative edits and addition of CPT code 87626 effective for dates of service beginning 2026-06-01.

2025-09-01policy_creation

Initial policy creation recorded; policy effective for dates of service beginning 2025-11-01.

Policy Summary

Payerharvard pilgrim health care

PolicyCervical cancer screening — coverage criteria

Policy CodePolicy N/A

Change TypeAdded CPT code 87626initial policy creation

Effective DateNov 1, 2025

Next Review DateApr 1, 2026

Key ActionEnsure submitted cervical cancer screening tests and codes match the covered indications and intervals.

SourceLink

On This Page

Low-risk HPV testing: Testing for low-risk HPV does not meet coverage criteria.low-risk HPV tests

explicit

Other unspecified technologies: Other technologies for cervical cancer screening not discussed in the policy do not meet coverage criteria due to lack of published evidence.unspecified technologies

catch-all

Procedure codes listed in this policy are provided for reference and may not be all‑inclusive. Use the appropriate, current CPT/HCPCS codes when submitting claims and follow the latest coding guidelines.

Verify and report the most current CPT/HCPCS code for the test performed.
If submitting alternative technologies or codes not discussed in this policy, confirm coverage status — many other technologies DO NOT MEET COVERAGE CRITERIA.

Documentation Required

Documentation and audit risk

Maintain documentation to support medical necessity for the service rendered. This includes member eligibility, clinical indications (age, immunocompromised status, prior abnormal cytology or positive hr‑HPV, high‑risk exposures), prior screening history, and any required referrals/authorizations. Be prepared for audit requests — lack of appropriate documentation may result in denial and recoupment.

Confirm member eligibility and benefits on date of service.
Obtain and retain referrals/authorizations when required by the member’s benefit plan; an authorization is not a guarantee of payment.
Retain records showing why screening outside standard intervals was indicated (e.g., immunocompromised, prior abnormal results).
Comply with any post‑payment audit requests; if noncompliance is identified, the plan may seek repayment.

Note

Authorization and payment considerations

Claims payment is subject to member eligibility, benefits, coordination of benefits, referral/authorization, utilization management, and adherence to plan policies and claims editing logic. An authorization, when required, does not guarantee payment. Providers should verify requirements prior to testing.

Point32Health may update coding and policy; use current CPT/HCPCS guidance.
Audits may be conducted and repayments required if services do not comply with policy.

DefinitionFDA‑approved tests that detect viral DNA from high‑risk HPV strains associated with cervical precancer and cancer; used as adjunctive or primary screening (hr‑HPV testing).

Clinical roleValidated high‑risk HPV assays are used as an adjunct to cytology or as a primary screening method per contemporary guidelines.

Guidance sourcesReferenced guideline sources include ASCCP, ACOG, and interim guidance on primary hr‑HPV testing.

Adequate screening history

DefinitionAn adequate screening history is either three consecutive negative Pap smears OR two consecutive negative HPV tests within the prior 10 years, with the most recent test performed within the last 5 years.

Use in age-based decisionsAdequate screening history is the threshold used to determine when routine screening may stop for individuals over 65 who are not high‑risk.

ApplicabilityApplies when assessing routine screening exclusions for individuals over 65 and not immunocompromised or high‑risk.

HPV testing modalities

Primary hr‑HPV testingPrimary high‑risk HPV testing (hr‑HPV alone) is an accepted screening strategy for individuals 30–65 years of age, performed once every 5 years per the policy and guideline references.

Co‑testingConcurrent cytology plus hr‑HPV testing (co‑testing) is an accepted strategy for individuals 30–65; frequency per policy is once every 5 years (or every 3 years for some immunocompromised scenarios).

Self‑collected vaginal specimensSelf‑collected vaginal specimens for HPV testing are referenced in contemporary guidelines and supported by evidence summaries cited in the policy.

Reflex genotypingFor pooled hr‑HPV positive with negative cytology, reflex nucleic acid testing for HPV‑16 and HPV‑18 (genotyping) meets coverage criteria.