Clinical UM Guideline

 

Subject: Cervical Cancer Screening and Human Papillomavirus Testing
Guideline #:  CG-MED-53 Publish Date:    12/27/2017
Status: Revised Last Review Date:    08/03/2017

Description

This document addresses the use of cervical cancer screening and testing for human papillomavirus (HPV) for assessment of cervical cancer risk. Currently cervical cancer screening comprises cervical cytology with Papanicolaou testing (also known as a 'Pap test'), and testing for HPV DNA. Pap tests are used to identify pre-cancerous or cancerous tissues present on the cervix. Screening for HPV aids in identifying individuals at higher risk for developing cervical cancer.

Note: This document addresses the use of cervical cancer screening in the general population. It does not address the use of cervical cancer screening technologies or procedures for the work-up or surveillance of either individuals with known precancerous lesions or a known history of cervical cancer.

Note: For additional information on cervical cancer screening, please see:

Clinical Indications

Medically Necessary:

Cervical cancer screening with cytology is considered medically necessary for individuals* who meet either of the following criteria:

  1. 21 years of age or older; or
  2. Who are chronically immunosuppressed (for example, organ transplant recipients or seropositive for the human immunodeficiency virus [HIV]) regardless of age.

HPV testing is considered medically necessary for individuals* who meet either of the following criteria:

  1. 30 years of age or older; or
  2. Who are chronically immunosuppressed (for example, organ transplant recipients or seropositive for HIV) regardless of age.

Not Medically Necessary:

Cervical cancer screening with cytology for is considered not medically necessary for all other indications including, but not limited to when the criteria above have not been met.

HPV testing is considered not medically necessary for all other indications including, but not limited, to when the criteria above have not been met.

*The term 'individual' in this document refers to any person with an intact cervix, regardless of gender identity.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT

 

87623

Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44)

87624

Human Papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68)

87625

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

88153

Cytopathology, slides, cervical or vaginal; with manual screening and rescreening under physician supervision

88164

Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision

88165

Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and rescreening under physician supervision

88166

Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer-assisted rescreening under physician supervision

88167

Cytopathology, slides, cervical or vaginal (the Bethesda System); with manual screening and computer-assisted rescreening using cell selection and review under physician supervision

88174

Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by automated system, under physician supervision

88175

Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; with screening by automated system and manual rescreening or review, under physician supervision

0500T

Infectious agent detection by nucleic acid (DNA or RNA), human papillomavirus (HPV) for five or more separately reported high-risk HPV types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) (ie, genotyping)

 

 

HCPCS

 

G0123

Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision

G0124

Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician

G0141

Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician

G0143

Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening by cytotechnologist under physician supervision

G0144

Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system, under physician supervision

G0145

Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening under physician supervision

G0147

Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision

G0148

Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening

P3000

Screening Papanicolaou smear, cervical or vaginal, up to 3 smears, by technician under physician supervision

P3001

Screening Papanicolaou smear, cervical or vaginal, up to 3 smears, requiring interpretation by physician

Q0091

Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory

 

 

ICD-10 Diagnosis

 

 

All diagnoses

Discussion/General Information

According to the American Cancer Society (ACS), about 12,900 new cases of invasive cervical cancer will be diagnosed in 2015, with approximately 4100 women dying from the disease.

Cervical cancer screening is a highly effective method of identifying squamous cell cervical cancer, which is responsible for up to 90% of all cervical cancers. When identified early, cervical cancer can be treated and results in high 5 year survival rates of approximately 92%.

Currently cervical cancer screening comprises cervical cytology with Papanicolaou testing (also known as a 'Pap smear' or "Pap test"), and testing for human papillomavirus (HPV) DNA. Pap tests are used to identify pre-cancerous or cancerous cells present on the cervix. When such cells are found, excision treatments can be used to completely remove the cancer. The detection of HPV DNA is used as an indication of the cancerous potential of a lesion and the potential risk of the woman developing cervical cancer in the future. According to the American Cancer Society (ACS) nearly all cases of cervical cancer test positive for HPV DNA. However, not all HPV types result in the development of cervical cancer. Two types of HPV, type 16 and type 18 have been found to be associated with 65% to 75% of all cervical cancers. Another 10 HPV types are associated with the remaining cases.

The current recommendations from the Centers of Disease Control and Prevention (CDC), the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents state that for women with HIV infection, a Pap test should be obtained twice during the first year after diagnosis of HIV infection, even if younger than 21 years, and if the results are normal, annually thereafter (Kaplan, 2009).

The combined guideline from the ACS, the American Society for Colposcopy and Cervical Pathology (ASCCP), and the American Society for Clinical Pathology (ASCP) (Saslow, 2012) regarding cervical cancer screening recommends against the use of cervical cancer screening in women under the age of 21. The ACS states the following:

Cervical cancer is rare in adolescents and young women and may not be prevented by cytology screening. The incidence of cervical cancer screening in this age group has not changed with increasing screening coverage over the last 4 decades. Screening adolescents leads to unnecessary evaluation and potentially to the treatment of preinvasive cervical lesions that have a high probability of regressing spontaneously and that are on average many years from having significant potential for becoming invasive cancer. This overtreatment, and subsequent increased risk of reproductive problems, represents a net harm.

The American College of Obstetricians and Gynecologists (ACOG) practice bulletin number 168, Screening for Cervical Cancer (2016), states that cervical cancer screening should begin at 21 years of age, with the exception of women who are infected with HIV or who are otherwise immunocompromised.

Guidelines from the United States Preventive Services Task Force (USPSTF, 2012) currently recommend against cervical cancer screening for women <21, giving it a "D" rating, meaning,

The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

There is data to indicates that women receiving immunosuppression following organ transplantation are at higher risk for invasive cancers. The U.S. Transplant Center Match (TCM) Study was a large population based cohort study using data from the U.S. Scientific Registry of Transplant Recipients (USSRTR) from 1987 to 2008 (Engels, 2011). A total of 175,732 subjects of any age with invasive cancers were included in the analysis. The authors reported that solid organ transplant recipients have an approximately 2-fold greater increase in risk of any type of cancer compared to the general public. While this study did not identify an increased risk of cervical cancer, the authors noted that this finding may be the result of a high rate of cervical cancer screening and rapid treatment of precancerous lesions. A follow-up investigation by Madeleine and others (2013) using USSRTR data reported on the incidence of HPV-related cancers in a cohort of 187,679 subjects with both invasive and in situ cancers and aged 18 years and older. In this study, risk data was presented in standardized incidence ratios (SIRs), which is a ratio of the observed incidence of a disease to the expected incidence of a disease in the general population. The reported SIR was 3.3 for in situ cervical cancer, and 1.0 for invasive cervical cancer. This indicated a greater than 3-fold increased risk of in situ cervical cancers and no increased risk for invasive cancers. Additionally, compared to subjects 50 years of age and older, subjects 18 to 34 years of age had a significantly greater risk of in situ cervical cancer (incidence rate ratio [IRR]=4.7). As was commented on by Engels, the high rate of cervical cancer screening, rigorous surveillance of suspicious lesions, and rapid treatment of precancerous lesions may have had a significant impact on the rate of both in situ and invasive cervical cancers seen in the general population, as well as the study population. However, it is clear that younger women who have received solid organ transplantation are at higher risk of cervical cancer, and that screening women in this population who are under the age of 21 should be considered.

It is important to note that there are significant differences between general cancer screening and post-cancer diagnosis or treatment surveillance. The former is used to seek out new unidentified cancer cases in large portions of the general population with average risk of a disease. The latter is used to monitor the status of known disease (for example, someone with a greater than average risk for a disease) and minimize harms. These two uses are different clinically, and only screening is addressed in this document.

The use of HPV testing has become widely used as a tool for the screening of individuals as risk of cervical cancer. However, the USPSTF (2012) has recommended "against screening for cervical cancer with HPV testing, alone or in combination with cytology, in women younger than age 30 years." 

This position is supported by the ACS, ASCCP, and the ASCP (Saslow, 2012) by their recommendation that states HPV testing should not be used to screen women ages 21-29 years of age, either as a stand-alone test or as a cotest with cytology. They state that due to the high prevalence of HPV in women under the age of 30, the transient nature of these infections, and the low risk that such infections will develop into CIN3 or cancer, HPV testing should not be used to screen women in this age group. Their rationale further includes mention that the potential harms, such as increased unnecessary anxiety, discomfort and bleeding, and increased risk of pregnancy complications due to treatment, do not justify such testing.

Finally, ACOG practice bulletin number 168 (2016) states, "Women aged 21–29 years should be tested with cervical cytology alone, and screening should be performed every 3 years. Cotesting should not be performed in women younger than 30 years." For women 30 years and older, while cervical cytology is "acceptable," ACOG states that HPV cotesting is "preferred" to cytology alone.   

Definitions

Screening: The testing of persons, in either the general population or those at high risk, for specific diseases or conditions.

Surveillance: The ongoing systematic active observation or testing of a medical condition with the purpose of detecting changes that warrant new or additional interventions to prevent and control its worsening or spreading.

References

Peer Reviewed Publications:

  1. Engels EA, Pfeiffer RM, Fraumeni JF Jr, et al. Spectrum of cancer risk among US solid organ transplant recipients. JAMA. 2011; 306(17):1891-1901.
  2. Madeleine MM, Finch JL, Lynch CF, et al. HPV-related cancers after solid organ transplantation in the United States. Am J Transplant. 2013; 13(12):3202-3209.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American College of Obstetricians and Gynecologists. Practice Bulletin Number 168: Screening for Cervical Cancer. October, 2016.
  2. Kaplan JE, Benson C, Holmes, KK, et al. Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents. Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. MMWR. 2009; 58(RR-4):1-207.
  3. Saslow D, Solomon D, Lawson HW, et al.; American Cancer Society; American Society for Colposcopy and Cervical Pathology; American Society for Clinical Pathology. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology Screening guidelines for the prevention and early detection of cervical cancer. Am J Clin Pathol. 2012; 137(4):516-542.
  4. United States Preventive Services Task Force. Cervical Cancer. March 2012. Available at: http://www.uspreventiveservicestaskforce.org/page/document/updatesummaryfinal/cervical-cancer-screening. Accessed on May 31, 2017.
Index

Cervical cancer

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History

Status

Date

Action

  12/27/2017

The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Coding section with 01/01/2018 CPT changes; added 0500T, removed 88154 deleted 12/31/2017.

Revised 08/03/2017 Medical Policy & Technology Assessment Committee (MPTAC) review.
Revised 07/10/2017 Hematology/Oncology Subcommittee review. Revised title. Added reference to ADMIN.00006 Preventive Health Guidelines to description section. Added MN and NMN statements regarding HPV testing. Changed the term 'women' to 'individual' in clinical indications section. Updated Coding, Rationale and References section.
Reviewed 11/03/2016 MPTAC review.
Reviewed 11/02/2016 Hematology/Oncology Subcommittee review. Updated References section.
New 11/05/2015 MPTAC review.
New 11/04/2015 Hematology/Oncology Subcommittee review. Initial document development.