Pap Smears
The following diagnoses/conditions are those justifying payment for pap smears. (This is not intended to be an all-inclusive list.)

Abnormal vaginal discharge
Cervical ulcerations
Cervicitis
Condyloma
Endometriosis
Fibroma of cervix
Follow up to previous or suspicious pap smear
Menopausal syndrome
Neoplastic disease
Pelvic malignancy
Polyps or cysts, cervical or uterine
Post-menopausal bleeding
Pregnancy
Vaginal bleeding of unknown origin (abnormal)
Vaginal or vulvar lesions, any type
Vaginitis, any type
Vulvitis and vulvovaginitis
Women exposed to DES (Diethylstilbestrol) prior to birth

Payment may be made for pap smears performed to "rule out" a suspected condition that may be the cause of the patient's symptoms.

Cyto-hormonal study (88155) is used primarily to determine the need for, or possible response to, estrogen therapy and to evaluate the hormonal status in patients who have certain types of endocrine problems (e.g., failure to ovulate, possible abnormal sexual development, infertility, etc.) Payment may be made for the cyto-hormonal study (88155) in addition to the pap smear (88142-88154, 88164-88167, 88174, 88175).

Claims for pap smears with diagnoses/conditions other than those listed above should be denied on the basis of medical necessity. Individual consideration can be given if this decision is questioned.  Effective January 26, 2009, a participating, preferred or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost.  The member must agree in writing to assume financial responsibility, in advance of receiving the service.  The signed agreement should be maintained in the provider's records.

Pap smears using the ThinPrep method of slide preparation are eligible for payment under codes 88142, 88143, 88174, 88175, G0123, G0124, G0143, G0144, G0145.

Pap smears supplemented with the PapNet or AutoPap computerized rescreening are eligible for payment under codes 88147, 88148, 88152, 88154, 88166, 88167, as appropriate.

When reported, payment may be made for the physician interpretation (G0124, G0141, P3001, 88141) in addition to the pap smear codes (88142-88154, 88164-88167, 88174, 88175, G0123, G0143, G0144, G0145, G0147, G0148, P3000).

When a provider obtains a specimen for a pap smear, then refers that specimen to a laboratory for examination, the cost of obtaining the specimen is included in the allowance for the gynecological examination or evaluation and management service. Payment should be made to the laboratory for the actual pap smear examination.

However, if there is a billing arrangement whereby the provider reimburses the laboratory for the pap smear examination, payment can be made to the provider for the pap smear. No payment should be made to the laboratory in this case.

See Medical Policy Bulletin V-35 for guidelines on routine/screening pap smears.

Speculoscopy

Speculoscopy (58999) is considered experimental/investigational. There is insufficient scientific evidence to support the use of speculoscopy in the triage of low grade atypical pap smears or for routine screening for cervical cancer. The clinical role of speculoscopy as a screening device remains undefined. A participating, preferred, or network provider may bill the member for the denied service.

Date Last Reviewed:  11/2010

HPV Testing
HPV testing of pap smears that have an interpretation of atypical cells of undetermined significance (ASCUS) (795.00-795.09) is considered medically necessary.  HPV testing of pap smears is not indicated for those with a definitive interpretation of cervical cancer. 

HPV testing of pap smears with normal results for asymptomatic women is considered screening.  Payment for screening HPV testing is limited to one test per calendar year for women age 30 or older.  Coverage for HPV screening is determined according to individual or group customer benefits.

HPV testing is not intended to substitute for regular routine pap smear screening for cervical cancer. Nor is it intended to screen for women under 30 who have normal pap tests.  Although the rate of HPV infection in this group is high, most infections are short-lived and not associated with cervical cancer.

Description

Pap Smears
The pap smear is used as the primary screening test to detect cervical cancer in asymptomatic women.  It can also detect premalignant and malignant changes of the cervix or vagina and some changes due to noncancerous conditions such as inflammation from infections.

Speculoscopy
Most cases of invasive cervical cancer occur in the unscreened population. However, approximately one third can be attributed to screening failure (i.e., false-negative pap smear results). Speculoscopy (PapSure) is a technology employed to augment conventional cervical cytological screening to reduce the 30% false-negative rate. Speculoscopy uses a chemoluminescent light to illuminate the cervix to aid naked-eye or minimally magnified visualization of acetowhite changes on the cervix. In addition to its use as an adjunct to the pap smear for cervical cancer screening, speculoscopy has been used as a triage method to identify which patients with low grade atypical pap smears need further evaluation by colposcopy and biopsy.

HPV Testing
Human papillomavirus (HPV) has been associated with the development of cervical intraepithelial neoplasia (CIN) that can then progress to invasive cervical cancer.  Studies show that abnormal pap smears which are also HPV positive are more likely to be associated with abnormal colposcopic exams than abnormal pap smears that are HPV negative.  Women with normal pap smear results and no HPV infection are at a very low risk for developing cervical cancer. 

HPV testing (87620, 87621 or 87622) can be performed on the remaining liquid media used as part of the preparation of monolayer slides (e.g., ThinPrep pap smears).  This eliminates the need for the patient to return to the provider’s office for another visit to obtain another sample for HPV testing.  In addition, further testing (e.g., colposcopy) and treatment can be initiated sooner.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

This medical policy may not apply to FEP.  Medical policy is not an authorization, certification, explanation of benefits or a contract.  Benefits are determined by the Federal Employee Program.

PRN References

02/1998, New pap smear reporting adopted
08/2003, Coverage guidelines for HPV testing

Twu N, Chen Y, Wang, P, Y B, Lai C, Chao K, Yuan C, et al. Improved cervical cancer screening in premenopausal women by combination of Pap smear and speculoscopy, Eur J Obstet Gynecol Reprod Biol.2007;133:114-118

Mahboobeh, Solomon D, Castle P. Cervical Cancer Prevention - Cervical Screening: Science in Evolution. Obstet Gynecol. 2007;34(4). www.mdconsult.com/das/article/body/101266660-5/jorg-journal&source-MI&sp. Accessed August 4, 2008.

Almog B, Gutman G, Lessing JB, Grisaru D. Prediction of cervical involvement in endometrial cancer by hysteroscopy. Arch Gynecol Obstet. 2007 Jan;275(1):45-8.