Medical Policy

Effective Date:03/01/2009

Title:HPV Testing

Revision Date:09/01/2019

Document:BI238:00

CPT Code(s):87623-87625, 0096U

Public Statement

Effective Date:

a) This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1) Testing for human papillomavirus (HPV) can assist with prevention of cervical cancer. This testing is covered every 60 months as routine screening for women age thirty or over (see BI062), and is covered as part of the medical benefit in women of any age with certain types of abnormal Papanicolaou tests,

2) Tumor cell testing for HPV for men and women with diagnosis of head and neck cancer or urinary HPV testing for men are covered under medical benefit.

Medical Statement

1) Routine HPV DNA testing is covered as an adjunct to Pap smear in women ≥30 years of age once every five years under the preventive benefit.

2) Additional testing (87623 or 87624) to determine the genotype of the HPV is covered under the medical benefit, only for follow up of women with abnormal pap smears: Dysplasia of cervix, ASCUS, ASC-H, LSIL or AGC NOS.

3) Stratification into high or low risk types is appropriate with HPV high-risk type (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68) OR HPV low-risk type (e.g., 6, 11, 42, 43, and 44) testing.

4) CPT 87625 Testing for HPV types 16 & 18 only, incl type 45, is not covered, as these types are included in HPV high-risk type testing.

5) (HPV) DNA testing in tumor cells is eligible for coverage for Head and Neck cancer.(NCCN guidelines)

Codes Used In This BI:

87623	HPV, low risk types (e.g., 6, 11, 42, 43, 44) (new 1-1-15)
87624	HPV, high risk types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) (new 1-1-15)
87625	HPV, types 16 & 18 only, incl type 45, if performed (new 1-1-15)
0096U	Human papillomavirus (HPV), high-risk types (ie, 16,18,31,33,35,39,45,51,52,56,58,.59,66,68), male urine

Limits

QualChoice considers HPV DNA testing experimental and investigational for the following indications:

Use as a primary screening test for cervical cancer in women younger than 30 years of age. According to evidence-based guidelines from the U.S. Preventive Services Task Force (2003), the medical literature does not support HPV testing as a screening test for cervical cancer for younger individuals whose cervical cytology is normal or is unknown. Hayes C
For selecting candidates for cervical cancer vaccine. The Centers for Disease Control and Prevention`s Advisory Committee on Immunization Practices does not recommend HPV testing to select persons for cervical cancer vaccine.

Reference

1) Centers for Disease Control and Prevention (CDC). Human Papillomavirus: HPV Information for Clinicians. CS110004. Atlanta, GA: CDC; April 2007. at: http://www.cdc.gov/std/Hpv/common-clinicians/ClinicianBro-fp.pdf

2) Hayes Inc. Medical Technology Directory; HPV testing for cervical cancer Feb. 6 2004

3) NCCN Guidelines Index Head and Beck cancer. http://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf

Application to Products

This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.