CAM 20409

Cervical Cancer Screening Technologies with Pap and HPV

Category:Laboratory   Last Reviewed:October 2020
Department(s):Medical Affairs   Next Review:October 2021
Original Date:July 1998    

Description
Cervical cancer screening detects cervical precancerous lesions and cancer through cytology, human papillomavirus (HPV) testing, and if needed, colposcopy (Feldman, Goodman, & Peipert, 2020). The principal screening test to detect cancer in asymptomatic women is the Papanicolaou (Pap) smear. It involves cells being scraped from the cervix during a pelvic examination and spread onto a slide. The slide is then sent to an accredited laboratory to be stained, observed, and interpreted (Feldman & Crum, 2020).

Human papilloma virus (HPV) has been associated with development of cervical intraepithelial neoplasia, and FDA approved HPV tests detecting the presence of viral DNA from high risk strains have been developed and validated as an adjunct primary cancer screening method (Feldman & Crum, 2019).

Regulatory Status
Several liquid-based preparations have received premarket approval from the U.S. Food and Drug Administration (FDA). For example, in May 1996, "ThinPrep® Pap Test" was approved by the FDA through the premarket approval process for use in collecting and preparing cervical cytology specimens for Pap stain-based screening for cervical cancer.

Several automated screening systems have received premarket approval through FDA. For example, in September 1995, "AutoPap® Automatic Pap Screener, now FocalPointTM, was approved by the FDA through the premarket approval process for use in initial screening of cervical cytology slides. The device is intended to be used on both conventionally prepared and prepstain system cervical cytology studies.

In March 2003, test kit "digene® HPV test" was approved by the FDA through premarket approval process for use in diagnostic testing for the qualitative detection of DNA from 13 high-risk papillomavirus types (16, 18,, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68) in cervical specimens.

In March 2009, test kit "Cervista® HPV HR" was approved by the FDA through the premarket approval process for use in diagnostic testing for the qualitative detection of DNA from 14 high-risk papillomavirus (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68) in cervical specimens.

Several organizations and professional societies have developed guidelines or recommendations for cervical cancer screening, to optimize early detection and to reduce false positives.  The focus has been on test selection and frequency of testing, as well as follow-up testing for abnormal results. 

In 2012, the American Cancer Society (ACS), American Society for Colposcopy and Cervical Pathology (ASCCP) and American Society for Clinical Pathology (ASCP) issued joint guidelines regarding cervical cancer screening.(1)  The focus areas of their recommendations were listed as: 

  1. Optimal cytology screening intervals
  2. Screening strategies for women 30 years and older
  3. Management of discordant combinations of cytology and HPV results (e.g., HPV positive, cytology negative and HPV negative, atypical squamous cells of undetermined significance (ASCUS) results)
  4. Exiting women from screening
  5. Impact of HPV vaccination on future screening practices
  6. Potential utility of molecular screening (specifically, HPV testing for primary screening was assessed as a potential future strategy)."  

The recommendations are segregated primarily by age group: 

  1. Women under 21 years of age (regardless of sexual activity or other high risk behavior), or over 65 years of age, or who have had surgical removal of the cervix, should not receive cervical cancer screening tests, unless there is a compelling medical reason to do so.
  2. Women 21 - 29 years of age should have screening with cervical cytology only, at a frequency of every 3 years. Cytology results of ASCUS in this group should be followed up by high risk HPV testing for determination of the appropriate follow-up.
  3. Women 30 - 65 years of age should preferably have co-testing with cervical cytology plus high risk HPV testing every five years, or testing with cervical cytology alone every 3 years (deemed acceptable).
  4. Individuals who have been vaccinated against high risk HPV types should follow the testing recommendations for their age group.
  5. HPV testing alone (without cytology) is not recommended as a first tier cervical cancer screening test in any age group. 

Also in 2014, the U.S. Preventive Services Task Force issued an update to its 2012 recommendation statement on cervical cancer screening.2 The criteria in the USPSTF recommendations are consistent with those listed above for the ACS, ASCCP, ASCP recommendation, except that the USPSTF does not indicate a preference for co-testing with Pap and HPV every 5 years over testing with Pap alone every 3 years, for women ages 30 - 65. 

The USPSTF report notes that women have historically used the annual Pap test visit to discuss other health concerns with their health care provider. They urge that, "Individuals, clinicians and health systems should seek effective ways to facilitate the receipt of recommended preventive services at intervals that are beneficial to the patient. Efforts should also be made to ensure that individuals are able to seek care for additional health concerns as they present." 

Similarly, the American College of Obstetricians and Gynecologists issued a Practice Bulletin in 2012, which aligns with the recommendations above.(4) Members of ACOG participated in the development of both sets of guidelines. 

Referral for cancer genetic consultation is recommended by the American College of Medical Genetics and Genomics and the National Society of Genetic Counselors for individuals with a personal or family history indicative of a hereditary form of cancer.   

Policy
Application of coverage criteria is dependent upon an individual’s benefit coverage at the time of the request

The criteria below are based on recommendations by the U.S. Preventive Services Task Force, The National Cancer Institute, NCCN, The American Society for Colposcopy and Cervical Pathology, The American Cancer Society, The American Society for Clinical Pathology, and the American College of Obstetricians and Gynecologists. 

  1. Women under 21 years of age is considered NOT MEDICALLY NECESSARY for cervical cancer screening unless one of the following criteria are met:
    • History of HIV and/or other Non-HIV immunocompromised conditions
    • Previous diagnosis of cervical cancer
    • Previous diagnosis of cervical dysplasia
    • History of an organ transplant
  2. Cervical cancer screening is considered MEDICALLY NECESSARY in immunosuppressed women without an HIV infection in the following situations:.
    • Annual cytology testing for individuals 30 years or younger
    • Every 3 years co-testing (cytology and HPV) for individuals 30 years or older
  3. For women 21 - 29 years of age, cervical cancer screening using conventional or liquid based Papanicolaou (Pap) smears is considered MEDICALLY NECESSARY at a frequency of every 3 years
  4. For women 30 - 65 years of age, cervical cancer screening using conventional or liquid based Pap smear at a frequency of every 3 years, or cervical cancer screening using the high-risk HPV test alone at a frequency of every 5 years, or co-testing (cytology with concurrent high-risk HPV testing) at a frequency of every 5 years, is considered MEDICALLY NECESSARY.
  5. Testing for high-risk strains HPV-16 and HPV-18 is considered MEDICALLY NECESSARY if BOTH of the following co-testing criteria are present:
    • Cytology negative AND
    • HPV positive
  6. Cervical cancer screening is considered MEDICALLY NECESSARY for women >65 years of age who are considered high-risk (women with a high-grade precancerous lesion or cervical cancer, women with in utero exposure to diethylstilbestrol, or women who are immunocompromised).
  7. Routine cervical cancer screening is considered NOT MEDICALLY NECESSARY in women >65 years of age who are not considered high-risk and have an adequate screening history:
    • Three consecutive negative Pap smears, or
    • Two consecutive negative HPV tests within 10 years before cessation of screening, with the most recent test occurring within 5 years
  8. Repeat cervical cancer screening by Pap smear or HPV testing in one year is considered MEDICALLY NECESSARY if a previous cervical cancer screen had an abnormal cytology result and/or was positive for HPV, or if the woman is at high risk for cervical cancer (organ transplant, exposure to the drug DES, immunocompromised women).
  9. Cervical cancer screening (at any age) is considered NOT MEDICALLY NECESSARY for women who have undergone surgical removal of uterus and cervix and have no history of cervical cancer or pre-cancer.

The following does not meet coverage criteria due to a lack of available published scientific literature confirming that the test(s) is/are required and beneficial for the diagnosis and treatment of a patient’s illness

  1. The following is considered NOT MEDICALLY NECESSARY:
    • Inclusion of low-risk strains of HPV in co-testing, as the clinical utility has not been established.
    • Other technologies for cervical cancer screening because of insufficient evidence of clinical utility.

Policy Guidelines:
CPT codes 88142-88143 and 88174-88175 refer to the use of monolayer preparation (i.e., collected in preservative fluid) with various different screening options. CPT codes 88147 and 88148 refer to conventionally prepared slides with various different screening options, while 88152, 88166 and 88167 refer to conventionally prepared slides with computer-assisted rescreening with or without cell selection.

CPT codes 87620-87622 refer to the DNA probe technique for detecting HPV.   

Benefit Application
BlueCard®/National Account Issues
State or federal mandates (e.g., FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and, thus, may only be assessed on the basis of their medical necessity.

Rationale
The American Cancer Society estimates that 13,800 new cases of cervical cancer will be diagnosed in 2020 and approximately 4,290 women will die from the disease (ACS, 2020). To screen for cervical cancer, a Papanicolaou (Pap) test or human papillomavirus (HPV) test is performed. Co-testing with both is also a common clinical practice. To obtain the cell sample for cytology, cells are scraped from both the ectocervix (external surface) and endocervix (cervical canal) during a speculum exam to evaluate the squamocolumnar junction where most neoplasia occur. Cytological examination can be performed as either a traditional Pap smear where the swab is rolled directly on the slide for observation or as a liquid-based thin layer cytology examination where the swab is swirled in a liquid solution so that the free cells can be trapped and plated as a monolayer on the glass slide. One advantage of the liquid cytology assay is that the same sample can be used for HPV testing whereas a traditional Pap smear requires a second sample to be taken. HPV testing is typically a nucleic acid-based assay that checks for the presence of high-risk types of HPV, especially types 16 and 18. HPV testing can be performed on samples obtained during a cervical exam; furthermore, testing on samples obtained from vaginal swabs, tampons, and urine samples have been reported (Feldman & Crum, 2019). 

Analytical Validity
A study by Marchand, Mundt, Klein, and Agarwal (2005) explored the optimal collection technique for Pap testing. Their study consisted of two different cytology labs and 128 clinicians over the course of one year. They discovered that in conventional Pap testing the sequence of collection—the cytobrush for the endocervix and the spatula for the ectocervix—had no effect on the quality of the assay. Further, 47% of the clinicians who had high levels of absent endocervical cells on their samples used the cytobrush method alone. The authors conclude, “The combination of the Cytobrush (endocervix) and spatula (ectocervix) is superior for a quality Pap smear. The sequence of collection was not important in conventional Pap smears. The broom alone performs poorly (Marchand et al., 2005).”

Urine-based HPV DNA testing as a screening tool would be a less invasive method than cervical examinations and swabs.  A study by Mendez et al. (2014) using both urine samples and cervical swabs from 52 female patients, however, showed that there was only 76% agreement between the two methodologies. The urine testing correctly identified 100% of the uninfected individuals but only 65% of the infected as compared to the cervical swab controls (Mendez et al., 2014). An extensive meta-analysis of 14 different studies using urinary testing, on the other hand, reported an 87% sensitivity and 94% specificity of the urine-based methodology for all strains of HPV, but the sensitivity for high-risk strains alone was only 77%. The specificity for the high-risk strains alone was reported to be higher at 98%. “The major limitations of this review are the lack of a strictly uniform method for the detection of HPV in urine and the variation in accuracy between individual studies. Testing urine for HPV seems to have good accuracy for the detection of cervical HPV, and testing first void urine samples is more accurate than random or midstream sampling. When cervical HPV detection is considered difficult in particular subgroups, urine testing should be regarded as an acceptable alternative (Pathak, Dodds, Zamora, & Khan, 2014).”

Clinical Validity and Utility
The National Cancer Institute (NCI) reports that “Regular Pap screening decreases cervix cancer incidence and mortality by at least 80%” (NCI, 2020). They also note that Pap testing can result in the possibility of additional diagnostic testing, especially in younger women, when unwarranted, especially in cases of possible low-grade squamous intraepithelial lesions (LSILs); however, even though 50% of women undergoing Pap testing required additional, follow-up diagnostic procedures, only 5% were treated for LSILs. The NCI also reports that “HPV-based screening provides 60% to 70% greater protection against invasive cervical carcinoma, compared with cytology” (NCI, 2019).

A study by Sabeena et al. (2019) measured the utility of urine-based sampling for cervical cancer screening in low-resource settings. The researchers compared 114 samples to determine the accuracy of HPV detection (by polymerase chain reaction (PCR)) in paired cervical and urine samples. Samples were taken from patients previously diagnosed with cervical cancer through histological methods. Of the 114 samples, “HPV DNA was tested positive in cervical samples of 89 (78.1%) and urine samples of 55 (48.2%) patients. The agreement between the two sampling methods was 66.7%” (Sabeena et al., 2019). HPV detection in urine samples had a sensitivity of 59.6% and a specificity of 92%. The authors concluded, “Even though not acceptable as an HPV DNA screening tool due to low sensitivity, the urine sampling method is inexpensive and more socially acceptable for large epidemiological surveys in developing countries to estimate the burden” (Sabeena et al., 2019).

Cervical cancer guidelines published by the National Comprehensive Cancer Network (NCCN) (NCCN, 2020) state that, although the rates of both incidence and mortality of squamous cell carcinoma of the cervix has been declining over the last thirty years, “adenocarcinoma of the cervix has increased over the past 3 decades, probably because cervical cytologic screening methods are less effective for adenocarcinoma.” A study in the United Kingdom supports this because the risk-reduction associated with 3-yearly screening was reduced by 75% for squamous carcinoma and 83% for adenosquamous carcinoma, but adenocarcinoma was reduced only by 43% (Sasieni, Castanon, & Cuzick, 2009).  Another extensive study of more than 900,000 women in Sweden showed that PCR-based HPV testing for the high-risk types 16 and 18 is better at predicting the risk of both in situ and invasive adenocarcinoma. The authors conclude, “infections with HPV 16 and 18 are detectable up to at least 14 years before diagnosis of cervical adenocarcinoma. Our data provide prospective evidence that the association of HPV 16/18 with cervical adenocarcinoma is strong and causal (Dahlstrom et al., 2010).”

A report by Chen et al. (2011) reviewed HPV testing and the risk of the development of cervical cancer.  Of the 11,923 women participating in the study, 86% of the women who tested positive for HPV did not develop cervical cancer with ten years. The authors concluded, “HPV negativity was associated with a very low long-term risk of cervical cancer. Persistent detection of HPV among cytologically normal women greatly increased risk. Thus, it is useful to perform repeated HPV testing following an initial positive test (Chen et al., 2011).”

In 2018, the results of the multi-year HPV for cervical cancer screening trial (FOCAL) randomized clinical trial testing of the use of HPV testing alone for detection of cervical intraepithelial neoplasia (CIN) grade 3 or worse (CIN3+) were published. More than 19,000 women participated in the study split between the intervention group (HPV testing alone) and the control group (liquid-based cytology). “Baseline HPV-negative women had a significantly lower cumulative incidence of CIN3+ at 48 months than cytology-negative women (CIN3+ incidence rate, 1.4/1000 [95% CI, 0.8-2.4]; CIN3+ risk ratio, 0.25 [95% CI, 0.13-0.48]). Among women undergoing cervical cancer screening, the use of primary HPV testing compared with cytology testing resulted in a significantly lower likelihood of CIN3+ at 48 months. Further research is needed to understand long-term clinical outcomes as well as cost-effectiveness (Ogilvie et al., 2018).” In a commentary concerning the findings of this trial, the author notes that “multiple randomized trials have shown that primary HPV screening linked to subsequent identification and treatment of cervical precancer is more effective than Pap testing in reducing the incidence of cervical cancer and precancer, at the cost of lower specificity and more false-negative subsequent colposcopic assessments (Massad, 2018).” The author does address the limitations of the FOCAL study, including that the study concluded prior to seeing what effects, if any, women vaccinated against HPV 16 and HPV 18 would have since the adolescents vaccinated upon FDA approval of the vaccine would not have necessarily been included within the study. They also state that a limitation of the FOCAL trial is “the use of a pooled HPV test for screening, incorporating all carcinogenic HPV types in a single positive or negative result” (Massad, 2018).

Melnikow et al. (2018) performed a review for the USPSTF regarding cervical cancer screening through high-risk (hr) HPV testing. The authors reviewed the following studies: “8 randomized clinical trials (n = 410556), 5 cohort studies (n = 402615), and 1 individual participant data (IPD) meta-analysis (n = 176464).” Primary hr-HPV testing was found to detect cervical intraepithelial neoplasia (CIN) 3+ at an increased rate (relative risk rate ranging from 1.61 to 7.46) in round 1 screening. False positive rates for primary hr-HPV testing ranged from 6.6% to 7.4%, compared with 2.6% to 6.5% for cytology, whereas in cotesting, false-positives ranged from 5.8% to 19.9% in the first round of screening, compared with 2.6% to 10.9% for cytology. Overall, the authors concluded that “primary hrHPV screening detected higher rates of CIN 3+ at first-round screening compared with cytology. Cotesting trials did not show initial increased CIN 3+ detection (Melnikow et al., 2018).”

U.S. Preventive Services Task Force (USPSTF) (Bibbins-Domingo et al., 2017; USPSTF, 2018a)
The USPSTF updated their recommendations in 2018.  The recommendations are outlined in the table below. The USPSTF did change the recommendation concerning women aged 30-65 to now include the possibility of high-risk HPV testing alone once every 5 years as a screening. They still allow the possibility of co-testing every 5 years or for Pap testing alone every 3 years.

The USPSTF notes certain risk factors that may increase the risk of cervical cancer, such as “HIV infection, a compromised immune system, in utero exposure to diethylstilbestrol, and previous treatment of a high-grade precancerous lesion or cervical cancer.” Cytology, primary testing for high-risk HPV alone, or both methods simultaneously may detect the high-risk lesions that are precursors to cervical cancer (USPSTF, 2018b).

ACOG endorses these recommendations from the USPSTF (ACOG, 2018a).

USPSTF Summary of Recommendations and Evidence (USPSTF, 2018b)  

Population

Recommendation

Grade

Women 21 to 29

Screen for cervical cancer every 3 years with cytology alone. For women 30-65 years, screen for cervical cancer every 3 years with cytology alone, every 5 years with high-risk (hr) HPV testing alone, or every 5 years with co-testing.

The USPSTF recommends the service. There is high certainty that the net benefit is substantial.  Offer or provide this service. Grade A

Women younger than 21, older than 65, who have had adequate prior screening, or who have had had a hysterectomy

Do not screen for cervical cancer.

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. Discourage the use of this service. Grade D

In 2017, “The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of performing screening pelvic examinations in asymptomatic, nonpregnant adult women. (I statement) This statement does not apply to specific disorders for which the USPSTF already recommends screening (ie, screening for cervical cancer with a Papanicolaou smear, screening for gonorrhea and chlamydia).”

National Comprehensive Cancer Network (NCCN) (NCCN, 2020)
Concerning cervical cancer, the NCCN states, “Persistent human papillomavirus (HPV) infection is the most important factor in the development of cervical cancer.  The incidence of cervical cancer appears to be related to the prevalence of HPV in the population…. Screening methods using HPV testing may increase detection of adenocarcinoma” (NCCN, 2020). The NCCN lists chronic, persistent HPV infection along with persistently abnormal Pap tests as criteria to be considered for women contemplating hysterectomy. Further, the NCCN also states that “In developed countries, the substantial decline in incidence and mortality of squamous cell carcinoma of the cervix is presumed to be the result of effective screening, although racial, ethnic, and geographic disparities exist” (NCCN, 2020).

National Cancer Institute (NCI) (NCI, 2020)
Concerning the use of Pap testing in screening, the NCI recommends: “Based on solid evidence, regular screening of appropriate women for cervical cancer with the Pap test reduces mortality from cervical cancer. The benefits of screening women younger than 21 years are small because of the low prevalence of lesions that will progress to invasive cancer. Screening is not beneficial in women older than 65 years if they have had a recent history of negative test results…  Based on solid evidence, regular screening with the Pap test leads to additional diagnostic procedures (e.g., colposcopy) and treatment for low-grade squamous intraepithelial lesions (LSILs), with long-term consequences for fertility and pregnancy. These harms are greatest for younger women, who have a higher prevalence of LSILs, lesions that often regress without treatment. Harms are also increased in younger women because they have a higher rate of false-positive results (NCI, 2020).”

Concerning the use of HPV DNA testing, the NCI states: “Based on solid evidence, screening with the HPV DNA or HPV RNA test detects high-grade cervical dysplasia, a precursor lesion for cervical cancer. Additional clinical trials show that HPV testing is superior to other cervical cancer screening strategies. In April 2014, the U.S. Food and Drug Administration approved an HPV DNA test that can be used alone for the primary screening of cervical cancer risk in women aged 25 years and older… Based on solid evidence, HPV testing identifies numerous infections that will not lead to cervical dysplasia or cervical cancer. This is especially true in women younger than 30 years, in whom rates of HPV infection may be higher (NCI, 2020).”

Concerning co-testing, they recommend: “Based on solid evidence, screening every 5 years with the Pap test and the HPV DNA test (cotesting) in women aged 30 years and older is more sensitive in detecting cervical abnormalities, compared with the Pap test alone. Screening with the Pap test and HPV DNA test reduces the incidence of cervical cancer… Based on solid evidence, HPV and Pap cotesting is associated with more false-positives than is the Pap test alone. Abnormal test results can lead to more frequent testing and invasive diagnostic procedures (NCI, 2020).”

Choosing Wisely and the American Society for Colposcopy and Cervical Pathology (ASCCP) (ASCCP, 2017a, 2017b)
The ASCCP recommends: “Don’t perform cervical cytology (Pap tests) or HPV screening in immunocompetent women under age 21. Cervical cancer is rare in adolescents and screening does not appear to lower that risk. Screening adolescents for cervical cancer exposes them to the potential harms of tests, biopsies, and procedures, without proven benefit.”

The ASCCP also recommends against screening for low-risk HPV types (ASCCP, 2017a).

In 2019, the ASCCP also published guidelines for cervical cancer screening in immunosuppressed women without an HIV infection. The following table was provided by Moscicki et al. (2019):

Table 3. Summary of Cervical Cancer Screening Recommendations for Non-HIV Immunocompromised Women  

Risk group category

Recommendation

Solid organ transplant

  • Cytology is recommended if younger than 30 y
  • Co-testing is preferred, but cytology is acceptable if 30 y or older
  • If using cytology alone, perform annual cervical cytology. If results of 3 consecutive cytology results are normal, perform cytology every 3 y
  • If using co-testing, perform baseline co-test with cytology and HPV. If result of cytology is normal and HPV is negative, co-testing can be performed every 3 y
  • If transplant before the age of 21 y, begin screening within 1 y of sexual debut
  • Continue screening throughout lifetime (older than 65 y). Discontinue screening based on shared discussion regarding quality and duration of life rather than age

Allogeneic hematopoietic stem cell transplant

  • Cytology is recommended if younger than 30 y
  • Co-testing is preferred, but cytology is acceptable if 30 y or older
  • If using cytology alone, perform annual cervical cytology. If results of 3 consecutive cytology results are normal, perform cytology every 3 y
  • If using co-testing, perform baseline co-test with cytology and HPV. If result of cytology is normal and HPV is negative, co-testing can be performed every 3 y
  • If transplant before the age of 21 y, begin screening within 1 y of sexual debut
  • Continue screening throughout lifetime (older than 65 y). Discontinue screening based on shared discussion regarding quality and duration of life rather than age
  • For HSCT patients who develop a new diagnosis of genital GVHD or chronic GVHD, resume annual cervical cytology until 3 consecutive normal results at which time perform cytology every 3 y, or perform an initial baseline co-test and, if cytology is normal and HPV is negative, perform co-testing every 3 y

Inflammatory bowel disease on immunosuppressant treatments

  • Cytology is recommended if younger than 30 y
  • Co-testing is preferred, but cytology is acceptable if 30 y or older
  • If using cytology alone, perform annual cervical cytology. If results of 3 consecutive cytology results are normal, perform cytology every 3 y
  • If using co-testing, perform baseline co-test with cytology and HPV. If result of cytology is normal and HPV is negative, co-testing can be performed every 3 y
  • If on immunosuppressant therapy before the age of 21 y, begin screening within 1 y of sexual debut
  • Continue screening throughout lifetime (older than 65 y). Discontinue screening based on shared discussion regarding quality and duration of life rather than age

Inflammatory bowel disease not on immunosuppressant treatment

  • Follow general population screening guidelines

Systemic lupus erythematosus and rheumatoid arthritis on immunosuppressant treatments

  • Cytology is recommended if younger than 30 y
  • Co-testing is preferred, but cytology is acceptable if 30 y or older
  • If using cytology alone, perform annual cervical cytology. If results of 3 consecutive cytology results are normal, perform cytology every 3 y
  • If using co-testing, perform baseline co-test with cytology and HPV. If result of cytology is normal and HPV is negative, co-testing can be performed every 3 y
  • If on immunosuppressant therapy before the age of 21 y, begin screening within 1 y of sexual debut
  • Continue screening throughout lifetime (older than 65 y). Discontinue screening based on shared discussion regarding quality and duration of life rather than age

Rheumatoid arthritis not on immunosuppressive treatments

  • Follow general population screening guidelines

Type 1 diabetes mellitus

  • Follow general population screening guidelines

Society of Gynecologic Oncology, American Society for Colposcopy and Cervical Pathology, American College of Obstetricians and Gynecologists, American Cancer Society, American Society of Cytopathology, College of American Pathologists, and the American Society for Clinical Pathology (Huh et al., 2015)
Since the 2011 joint guidelines issued by the American Cancer Society, American Society for Colposcopy and Cervical Pathology , and American Society for Clinical Pathology Screening  concerning cervical cancer screening, additional reports concerning the use of primary hrHPV testing so that representatives from the Society of Gynecologic Oncology, American Society for Colposcopy and Cervical Pathology, American College of Obstetricians and Gynecologists, American Cancer Society, American Society of Cytopathology, College of American Pathologists, and the American Society for Clinical Pathology convened to issue interim clinical guidance in 2015. In the 2011 statement, primary hrHPV testing was not recommended.  The 2015 recommendations include:  

  • “Because of equivalent or superior effectiveness, primary hrHPV screening can be considered as an alternative to current US cytology-based cervical cancer screening methods. Cytology alone and cotesting remain the screening options specifically recommended in major guidelines.”
  • “A negative hrHPV test provides greater reassurance of low CIN3+ risk than a negative cytology result.”
  • “Rescreening after a negative primary hrHPV screen should occur no sooner than every 3 years.”
  • “Primary hrHPV screening should not be initiated prior to 25 years of age.”

They give the following algorithm concerning screening (Huh et al., 2015):

American College of Obstetricians and Gynecologists (ACOG) (Chelmow & ACOG, 2016)
In Practice Bulletin #168, ACOG updated their recommendations concerning cervical cancer screening based on new studies. The table below outlines their recommendation concerning screening:

ACOG does state that women who immunocompromised, including those who are HIV-positive, should start screening younger than age 21. Even though in their table, they do not recommend screening by HPV testing alone, they include the following noted caveat: “After the Joint Recommendations were published, a test for screening with HPV testing alone was approved by the U.S. Food and Drug Administration. Gynecologic care providers using this test should follow the interim guidance developed by the American Society for Colposcopy and Cervical Pathology and the Society for Gynecologic Oncology (Huh et al., 2015) (Chelmow & ACOG, 2016).”

The following table outlines the ACOG recommendation concerning the management of cervical cancer screening (Chelmow & ACOG, 2016):

This guideline was reaffirmed in 2018 (ACOG, 2018b).

References:

  1. ACOG. (2018a). Practice Advisory: Cervical Cancer Screening (Update)
  2. Retrieved from https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Advisories/Practice-Advisory-Cervical-Cancer-Screening-Update?IsMobileSet=false
  3. ACOG. (2018b). Practice Bulletins. Retrieved from https://www.acog.org/Clinical-Guidance-and-Publications/Practice-Bulletins-List
  4. ACS. (2020, 01/04/2018). Key Statistics for Cervical Cancer. Retrieved from https://www.cancer.org/cancer/cervical-cancer/about/key-statistics.html
  5. ASCCP. (2017a, 02/14/2017). Don’t order screening tests for low-risk HPV types.
  6. . Five Things Physicians and Patients Should Question. Retrieved from http://www.choosingwisely.org/clinician-lists/asccp-screening-tests-for-low-risk-hpv-types/
  7. ASCCP. (2017b, 02/14/2017). Don’t perform cervical cytology (Pap tests) or HPV screening in immunocompetent women under age 21. Five Things Physicians and Patients Should Question. Retrieved from http://www.choosingwisely.org/clinician-lists/asccp-pap-tests-or-hpv-screening-in-women-under-21/
  8. Bibbins-Domingo, K., Grossman, D. C., Curry, S. J., Barry, M. J., Davidson, K. W., Doubeni, C. A., . . . Tseng, C. W. (2017). Screening for Gynecologic Conditions With Pelvic Examination: US Preventive Services Task Force Recommendation Statement. Jama, 317(9), 947-953. doi:10.1001/jama.2017.0807
  9. Chelmow, D., & ACOG. (2016). Practice Bulletin No. 168: Cervical Cancer Screening and Prevention. Obstet Gynecol, 128(4), e111-130. doi:10.1097/aog.0000000000001708
  10. Chen, H. C., Schiffman, M., Lin, C. Y., Pan, M. H., You, S. L., Chuang, L. C., . . . Chen, C. J. (2011). Persistence of type-specific human papillomavirus infection and increased long-term risk of cervical cancer. J Natl Cancer Inst, 103(18), 1387-1396. doi:10.1093/jnci/djr283
  11. Dahlstrom, L. A., Ylitalo, N., Sundstrom, K., Palmgren, J., Ploner, A., Eloranta, S., . . . Sparen, P. (2010). Prospective study of human papillomavirus and risk of cervical adenocarcinoma. Int J Cancer, 127(8), 1923-1930. doi:10.1002/ijc.25408
  12. FDA. (2018a). BD ONCLARITY HPV ASSAY. Retrieved from https://www.accessdata.fda.gov/scripts/cdrh/devicesatfda/index.cfm?db=pma&id=391601
  13. FDA. (2018b, 07/09/2018). BD ONCLARITY HPV ASSAY. Devices@FDA. Retrieved from https://www.accessdata.fda.gov/scripts/cdrh/devicesatfda/index.cfm?db=pma&id=391601
  14. FDA. (2018c, 08/06/2018). PMA Monthly approvals from 7/1/2018 to 7/31/2018. Retrieved from https://www.fda.gov/downloads/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/PMAApprovals/UCM615947.pdf
  15. FDA. (2019). Devices@FDA. Devices@FDA. Retrieved from https://www.accessdata.fda.gov/scripts/cdrh/devicesatfda/index.cfm
  16. FDA. (2020). Cobas HPV For Use On The Cobas 6800/8800 Systems. Retrieved from https://www.accessdata.fda.gov/scripts/cdrh/devicesatfda/index.cfm?db=pma&id=448383
  17. Feldman, S., & Crum, C. (2019). Cervical cancer screening tests: Techniques for cervical cytology and human papillomavirus testing. In S. Falk & B. Goff (Eds.), UpToDate. Retrieved from https://www.uptodate.com/contents/cervical-cancer-screening-tests-techniques-for-cervical-cytology-and-human-papillomavirus-testing
  18. Feldman, S., & Crum, C. (2020). Cervical cancer screening tests: Techniques for cervical cytology and human papillomavirus testing. In S. Falk & B. Goff (Eds.), UpToDate. Retrieved from https://www.uptodate.com/contents/cervical-cancer-screening-tests-techniques-for-cervical-cytology-and-human-papillomavirus-testing
  19. Feldman, S., Goodman, A., & Peipert, J. (2020). Screening for cervical cancer. In B. Goff, J. G. Elmore, & J. Melin (Eds.), UpToDate. Retrieved from https://www.uptodate.com/contents/screening-for-cervical-cancer
  20. Huh, W. K., Ault, K. A., Chelmow, D., Davey, D. D., Goulart, R. A., Garcia, F. A., . . . Einstein, M. H. (2015). Use of primary high-risk human papillomavirus testing for cervical cancer screening: interim clinical guidance. J Low Genit Tract Dis, 19(2), 91-96. doi:10.1097/lgt.0000000000000103
  21. Marchand, L., Mundt, M., Klein, G., & Agarwal, S. C. (2005). Optimal collection technique and devices for a quality pap smear. Wmj, 104(6), 51-55.
  22. Massad, L. S. (2018). Replacing the Pap Test With Screening Based on Human Papillomavirus Assays. Jama, 320(1), 35-37. doi:10.1001/jama.2018.7911
  23. Melnikow, J., Henderson, J. T., Burda, B. U., Senger, C. A., Durbin, S., & Weyrich, M. S. (2018). Screening for Cervical Cancer With High-Risk Human Papillomavirus Testing: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. Jama, 320(7), 687-705. doi:10.1001/jama.2018.10400
  24. Mendez, K., Romaguera, J., Ortiz, A. P., Lopez, M., Steinau, M., & Unger, E. R. (2014). Urine-based human papillomavirus DNA testing as a screening tool for cervical cancer in high-risk women. Int J Gynaecol Obstet, 124(2), 151-155. doi:10.1016/j.ijgo.2013.07.036
  25. Moscicki, A. B., Flowers, L., Huchko, M. J., Long, M. E., MacLaughlin, K. L., Murphy, J., . . . Gold, M. A. (2019). Guidelines for Cervical Cancer Screening in Immunosuppressed Women Without HIV Infection. J Low Genit Tract Dis, 23(2), 87-101. doi:10.1097/lgt.0000000000000468
  26. NCCN. (2020). NCCN Clinical Practice Guidelines in Oncology Cervical Cancer. NCCN Guidelines, 1.2020 - January 14, 2020. Retrieved from https://www.nccn.org/professionals/physician_gls/pdf/cervical.pdf
  27. NCI. (2019, 06/14/20108). Cervical Cancer Screening (PDQ®)–Health Professional Version. Retrieved from https://www.cancer.gov/types/cervical/hp/cervical-screening-pdq
  28. NCI. (2020, 06/14/20108). Cervical Cancer Screening (PDQ®)–Health Professional Version. Retrieved from https://www.cancer.gov/types/cervical/hp/cervical-screening-pdq
  29. Ogilvie, G. S., van Niekerk, D., Krajden, M., Smith, L. W., Cook, D., Gondara, L., . . . Coldman, A. J. (2018). Effect of Screening With Primary Cervical HPV Testing vs Cytology Testing on High-grade Cervical Intraepithelial Neoplasia at 48 Months: The HPV FOCAL Randomized Clinical Trial. Jama, 320(1), 43-52. doi:10.1001/jama.2018.7464
  30. Pathak, N., Dodds, J., Zamora, J., & Khan, K. (2014). Accuracy of urinary human papillomavirus testing for presence of cervical HPV: systematic review and meta-analysis. Bmj, 349, g5264. doi:10.1136/bmj.g5264
  31. Rice, S. L., Editor. (2018, August 2018). Cobas HPV test approved for first-line screening using SurePath preservative fluid. CAP Today.
  32. Sabeena, S., Kuriakose, S., Binesh, D., Abdulmajeed, J., Dsouza, G., Ramachandran, A., . . . Arunkumar, G. (2019). The Utility of Urine-Based Sampling for Cervical Cancer Screening in Low-Resource Settings. Asian Pac J Cancer Prev, 20(8), 2409-2413. doi:10.31557/apjcp.2019.20.8.2409
  33. Sasieni, P., Castanon, A., & Cuzick, J. (2009). Screening and adenocarcinoma of the cervix. Int J Cancer, 125(3), 525-529. doi:10.1002/ijc.24410
  34. USPSTF. (2018a). Screening for cervical cancer: US Preventive Services Task Force recommendation statement. Jama, 320(7), 674-686. doi:10.1001/jama.2018.10897
  35. USPSTF. (2018b). Screening for Cervical Cancer: US Preventive Services Task Force Recommendation StatementUSPSTF Recommendation: Screening for Cervical CancerUSPSTF Recommendation: Screening for Cervical Cancer. Jama, 320(7), 674-686. doi:10.1001/jama.2018.10897

Coding Section  

Code Number

Code Description

87623

Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44)

87624

Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) 

87625

Infectious agent detection by nucleic acid (DNA or RNA); 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) 

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

G0476

Infectious agent detection by nucleic acid (DNA or RNA); human papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) for cervical cancer screening, must be performed in addition to pap test

P3000

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

P3001

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

Q0091

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

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.  

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward      

10/01/2020 

Annual review, adding policy verbiage related to immunocompromised members. Updating coding, description, rationale and references. 

10/09/2019 

Annual review, no change to policy intent. Updating coding. 

11/27/2018 

Annual review, updating medical necessity criteria related to HPV testing. No other changes. 

12/7/2017 

Removed cpt code 88154 per 2018 coding and add 0500T code. No other changes 

10/19/2017 

Annual review, no change to policy intent. 

06/19/2017 

Updated coding section. No other changes made. 

05/24/2017 

Corrected Typo in Policy Guideline section. No change to policy intent. 

04/26/2017 

Updated category to Laboratory. No other changes. 

07/18/2016 

Annual review, review month moved to July from June. Updating policy verbiage for specificity. Updating background and coding. 

03/09/2016 

Interim review, adding the following verbiage: Primary HPV testing (testing for HPV without cytology) is considered investigational as a method of screening for cervical cancer. 

06/25/2015 

Annual review, no change to policy intent. Updated guidelines and added coding. 

07/07/2014

Annual review. Policy criteria updated for both Pap smear and HPV testing. 2012 ACOG guidelines added to update previous guidelines.


Go Back