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    v1.0.28
    OpenPayerPolicy UpdatesGastroenterologyPremera Bluecross HRA Coverage Update | OpenPayer
    Ask Trek AI about this page
    CurrentPremera BluecrossPolicy N/A

    High-Resolution Anoscopy (HRA)

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    This policy governs when high-resolution anoscopy (HRA) may be considered medically necessary for diagnostic evaluation, management, treatment-related use, and surveillance of anal dysplasia and related findings. It applies to providers treating members enrolled in Individual Plans, subject to the member’s benefit contract.

    Policy Summary
    PayerPremera Bluecross
    PolicyHigh-Resolution Anoscopy (HRA)
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOct 1, 2026
    Last ReviewSep 21, 2026
    Next Review DateN/A
    Key ActionDocument the referral indication, relevant anal symptoms or examination findings, applicable anal cytology or hrHPV results, and the clinical rationale for HRA.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2Covered HRA CPT codes
    Not routine screeningHRA coverage limitation
    12–24 monthsRepeat screening interval
    High-riskPopulation focus

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    HRA-trained
    Provider qualification

    Medical Necessity Criteria

    Initial evaluation and referral indications

    HRA may be considered medically necessary for referred individuals when at least one of the following indications is present.

    Clinical indications

    • Symptoms, findings, or procedures: Initial evaluation of rectal bleeding; obtaining cytology samples to screen for anal squamous lesions, particularly in high-risk individuals with HIV infection; evaluation of intra-anal condyloma; anal or perianal pain; anal fistula; anal trauma; a mass palpated on digital rectal examination; perianal itching; abdominal pain; change in bowel habit; anal discharge or prolapse; retrieval of a foreign body; evaluation of fecal impaction; diagnosis of low-grade or high-grade squamous lesions; treatment of prolapsing hemorrhoids by rubber band ligation using a slotted anoscope; or post-treatment surveillance for anal carcinoma.
    • Anal cytology findings: Anal cytology shows ASC-US or worse (ASC-US+), ASC-H, or HSIL; or LSIL with a negative hrHPV test.
    • hrHPV testing findings: hrHPV testing with HPV16 genotyping shows hrHPV positive with HPV16 positive regardless of cytological diagnosis; hrHPV positive with ASC-US or ASC-US+ cytology; or hrHPV positive with NILM cytology.
    • Cytology and hrHPV co-testing findings: Co-testing shows ASC-US+ cytology with hrHPV positive; ASC-H or HSIL cytology regardless of hrHPV result; HPV16 positive regardless of cytology; NILM cytology with hrHPV positive; or LSIL cytology with hrHPV negative.

    Follow-up when HRA capacity is low

    If the wait for HRA referral is greater than 6 months because of low HRA capacity, follow-up screening is recommended according to the screening modality and result.

    Cytology as primary screening: Repeat screening based on the cytology and triage result.NILM: 12–24 months; ASC-US or worse/LSIL: 12 months; ASC-US/hrHPV-negative: 24 months; LSIL/hrHPV-negative: 12 months; ASC-US/LSIL/hrHPV-positive non-16: 12 months
    hrHPV testing with HPV16 genotyping as primary screening: Repeat screening based on the hrHPV and triage result.hrHPV-negative: 24 months; hrHPV-positive non-16: 12 months; NILM/hrHPV-positive non-16: 12 months; ASC-US or worse/LSIL/hrHPV-positive non-16: 12 months
    Cytology/hrHPV co-testing with HPV16 genotyping: Repeat screening based on the co-test result.NILM/hrHPV-negative: 24 months; ASC-US/hrHPV-negative: 24 months; NILM/hrHPV-positive non-16: 12 months; LSIL/hrHPV-negative: 12–24 months; ASC-US/LSIL/hrHPV-positive non-16: 12 months

    High-risk populations

    A high-risk population includes an individual with any of the following conditions or characteristics.

    Increased risk for anal cancer: Sexual-related acquired disease; HIV disease; history of cervical or vulvar HSIL or cervical or vulvar cancer; HPV infection, especially a history of internal or external genital warts or persistent cervical HPV16; solid organ transplantation; or other immunosuppression such as rheumatoid arthritis, lupus, Crohn disease, ulcerative colitis, or systemic steroid therapy.

    Case-by-case HRA referral

    HRA referrals for anal symptoms suspicious of dysplastic progression when anal cytopathology is unavailable are reviewed on a case-by-case basis.

    Case-by-case referral

    • Suspicious symptoms: Anal symptoms suspicious of dysplastic progression.
    • Qualifying condition or circumstance: The individual is a solid organ transplant candidate who is immunosuppressed; or the individual is a woman with high-grade genital dysplasias or a history of vulvar and cervical cancer.

      Reviewed case by case.

    • Unavailable cytopathology: Anal cytopathology is not available.

    Routine screening without an abnormality detected during screening is not covered. HRA is indicated for diagnostic use after an abnormal screening finding.

    HRA is contraindicated when the individual cannot tolerate the examination because of discomfort, apprehension, or significant active bleeding. It is also contraindicated when a known mass could be damaged, bleed, or become irritated by insertion of the rigid anoscope.

    Covered Codes and Operational Coding Rules

    Covered CPT CodesCPTCovered
    46601Anoscopy; diagnostic, with high-resolution magnification (HRA) (e.g., colposcope, operating microscope) and chemical agent enhancement, including collection of specimen(s) by brushing or washing, when performed.
    46607Anoscopy; with high-resolution magnification (HRA) (e.g., colposcope, operating microscope) and chemical agent enhancement, with biopsy, single or multiple.
    ICD-10 Diagnosis Codes - Covered if Selection Criteria are MetICD-10Covered
    A63.0Anogenital (venereal) warts.
    B20Human immunodeficiency virus (HIV) disease.
    B97.35Human immunodeficiency virus, type 2 (HIV 2).
    B97.7Papillomavirus as the cause of diseases classified elsewhere.
    C20-C21.8Malignant neoplasm of rectum, anal canal, and anus.
    D12.8-D12.9Benign neoplasm of rectum, anus, and anal canal.
    D01.3Carcinoma in situ of anus and anal canal.
    K62.0-K62.1Anal and rectal polyp.
    K62.5Hemorrhage of anus and rectum.
    K62.6Ulcer of anus and rectum.
    1–10 of 26
    1/3
    Low HRA capacity
    Capacity triggerUse this follow-up pathway when the wait for HRA referral is greater than 6 months because of low HRA capacity.
    Cytology-primary screeningRepeat screening intervals range from 12 to 24 months: NILM 12–24 months; ASC-US or worse/LSIL 12 months; ASC-US with hrHPV-negative 24 months; LSIL with hrHPV-negative 12 months; and ASC-US/LSIL with hrHPV-positive non-16 12 months.
    hrHPV-primary screeningRepeat screening is recommended at 24 months for hrHPV-negative results and 12 months for hrHPV-positive non-16 results, NILM/hrHPV-positive non-16 results, or ASC-US or worse/LSIL with hrHPV-positive non-16 results.
    Co-testingRepeat screening is recommended at 24 months for NILM/hrHPV-negative or ASC-US/hrHPV-negative results; 12 months for NILM/hrHPV-positive non-16 or ASC-US/LSIL/hrHPV-positive non-16 results; and 12–24 months for LSIL/hrHPV-negative results.
    Repeat screening after abnormal cytology

    Documentation, Qualification, and Billing Requirements

    Documentation Required

    Document the clinical indication and test results

    Document the referral indication, relevant anal symptoms or examination findings, anal cytology and/or hrHPV results when applicable, the individual’s high-risk condition when applicable, and the clinical rationale for HRA.

    Documentation Required

    Support case-by-case review

    For case-by-case review when anal cytopathology is unavailable, document suspicious anal symptoms, the applicable qualifying condition, and the reason cytopathology is unavailable. Qualifying examples include an immunosuppressed solid organ transplant candidate or a woman with high-grade genital dysplasia or a history of vulvar or cervical cancer.

    Documentation Required

    Document HRA clinician training

    Document that the performing physician or advanced practice clinician has completed comprehensive HRA training.

    Clinical Background

    Anal dysplasia consists of abnormal cells or tissue lesions in the anal canal and is associated with human papillomavirus (HPV). These lesions may progress to anal cancer. High-resolution anoscopy (HRA) uses a lubricated anoscope, acetic acid enhancement, and high-resolution magnification to identify, sample, manage, or treat abnormal anal lesions; the policy primarily supports diagnostic HRA after abnormal screening findings or for specified symptoms, risk factors, and surveillance indications.

    Clinical Terms and Abbreviations

    High-resolution anoscopy (HRA)
    ProcedureHigh-resolution anoscopy (HRA) is a minimally invasive procedure.
    TechniqueA lubricated anoscope containing a cotton swab wrapped in gauze and soaked in acetic acid is inserted into the anus.
    PurposeHigh-resolution magnification and acetic acid enhancement help identify, manage, and treat anal dysplasia and abnormal cells that may turn into cancer.
    Anal dysplasia
    DefinitionAnal dysplasia consists of abnormal cells or tissue growths called lesions.
    LocationThe abnormal cells or lesions are in the lining of the anal canal.
    Policy Summary
    PayerPremera Bluecross
    PolicyHigh-Resolution Anoscopy (HRA)
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateOct 1, 2026
    Last ReviewSep 21, 2026
    Next Review DateN/A
    Key ActionDocument the referral indication, relevant anal symptoms or examination findings, applicable anal cytology or hrHPV results, and the clinical rationale for HRA.
    SourceLink
    On This Page
    Medical Necessity CriteriaCovered Codes and Operational Coding RulesDocumentation, Qualification, and Billing RequirementsClinical BackgroundClinical Terms and Abbreviations
    NILM cytologyRepeat screening in 12–24 months.
    ASC-US or worse/LSILRepeat screening in 12 months.
    ASC-US with hrHPV-negative resultRepeat screening in 24 months.
    LSIL with hrHPV-negative resultRepeat screening in 12 months.
    ASC-US/LSIL with hrHPV-positive non-16 resultRepeat screening in 12 months.
    Repeat screening after abnormal hrHPV testing
    hrHPV-negative resultRepeat screening in 24 months.
    hrHPV-positive non-16 resultRepeat screening in 12 months.
    NILM with hrHPV-positive non-16 resultRepeat screening in 12 months.
    ASC-US or worse/LSIL with hrHPV-positive non-16 resultRepeat screening in 12 months.
    Denial Risk

    Avoid routine-screening HRA

    HRA is not covered for routine screening without an abnormality detected during screening. HRA is indicated for diagnostic use after an abnormality is detected during screening.

    Prior Authorization

    Use a comprehensively trained HRA clinician

    Coverage is limited to physicians or advanced practice clinicians who have completed comprehensive training in HRA, such as through the ASCCP/AMC/ACTG HRA certification process.

    Billing Rule

    Do not separately bill global HRA treatment services

    When HRA is performed in conjunction with treatment or destruction of anal dysplastic lesions, the HRA service is considered global to the primary procedure.

    Denial Risk

    Assess contraindications before HRA

    The examination may not be appropriate when the individual cannot tolerate it because of discomfort, apprehension, or significant active bleeding, or when a known mass could be damaged, bleed, or become irritated by insertion of the rigid anoscope.

    Clinical significance
    Anal dysplasia is associated with human papillomavirus (HPV) and can lead to anal cancer.
    hrHPV
    Full termhrHPV means high-risk human papillomavirus.
    TestingThe policy refers to hrHPV testing as a screening result used with cytology or as a primary screening test.
    GenotypingThe testing includes HPV16 genotyping.
    ASC-US
    Full termASC-US means atypical squamous cells of undetermined significance.
    Cell typeThe finding involves squamous cells.
    InterpretationThe cells are atypical, but their significance is undetermined.
    ASC-H
    Full termASC-H means atypical squamous cells in which a high-grade lesion cannot be excluded.
    Cell typeThe finding involves atypical squamous cells.
    InterpretationA high-grade lesion cannot be ruled out.
    HSIL
    Full termHSIL means high-grade squamous intraepithelial lesion.
    GradeThe lesion is classified as high-grade.
    Tissue classificationThe lesion is squamous and intraepithelial.
    NILM
    Full termNILM means no intraepithelial lesion or malignancy.
    Lesion findingNo intraepithelial lesion is identified.
    Malignancy findingNo malignancy is identified.