57465
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.79
Facility
$36.74
Non-Facility
$55.11
Documentation Required
- Laboratory validation/assay information when novel tests (FISH, methylation assays, mRNA assays, p16/Ki-67 dual stain) are used: method, probes/markers used, thresholds and interpretation criteria, and correlation with histology.
- The document does not state explicit documentation requirements for coverage or billing.
- Study-specific documentation referenced in the literature included cytology, hrHPV DNA status, mRNA test results, colposcopy findings, and histopathologic follow-up (e.g., CIN2+ endpoints) — but no payer-required documentation instructions are provided in the text.
- Diagnostic Pap smears are considered medically necessary when Pap smear is accompanied by a diagnosis of a malignancy of the female genital tract (i.e., cervix, ovary, uterus, or vagina) — thus documentation must include the malignancy diagnosis.
Key Coverage Criteria
- HPV DNA testing medically necessary: "Follow-up of women with low-grade squamous intra-epithelial lesions (LSIL) who have had negative colposcopy results within the past 2 years."
- Li et al (2021): "This large routine-clinical-practice study confirmed the previously reported high sensitivity of hrHPV mRNA testing for the detection of high-grade cervical dysplasia and cervical cancers." (Aptima hrHPV mRNA testing co-testing data in HSIL cytology cases)
- Zhang et al (2022): "The authors concluded that the AHPV assay is both specific and sensitive for detecting HSIL+ and may be suitable for use in primary cervical cancer screening in China. AHPV genotyping with reflex LBC triage may be a feasible triage strategy."
- UpToDate (quoted in document): "RNA-based methods are not approved for primary HPV testing. However, they may be as effective as DNA-based methods in detecting cervical disease... Further studies evaluating RNA-based methods for primary HPV testing are needed."
- Consistent with guidelines from the U.S. Preventive Services Task Force (USPSTF) and the American College of Obstetricians and Gynecologists (ACOG), Aetna considers annual cervical cancer screening with conventional or liquid-based Papanicolaou (Pap) smears a medically necessary preventive service for nonhysterectomized women age 21 years and older.
- Pap screening is considered medically necessary beginning in adolescence in HIV-infected women. The ACOG guidelines on cervical cancer in adolescents (2010) recommend that adolescents with HIV have cervical cytology screening twice in the first year after diagnosis and annually thereafter.
1 Active Policy
AETNA-CPB-0443 — Cervical Cancer Screening and Diagnosis
Related Codes
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