N87.9 — Dysplasia of cervix uteri, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Not all plans provide coverage of preventive services. Please check benefit plan descriptions for details.
- CPT Codes / HCPCS Codes: 'CPT codes covered if selection criteria are met' (implies coverage is subject to meeting the policy's selection/medical necessity criteria).
- If vaccination providers do not know or do not have available the HPV vaccine product previously administered, or are in settings transitioning to Gardasil 9, then Gardasil 9 HPV vaccine product is considered medically necessary to continue or complete the three-dose series. (Implied documentation: prior vaccination history or lack thereof may be relevant to coverage determination.)
- Avian influenza A virus (H5N1): documentation of symptoms consistent with Avian influenza A virus and history of travel to or contact with persons or birds from a country with documented H5N1 avian influenza infections within 10 days of symptom onset.
Key Coverage Criteria
- Aetna considers human papillomavirus (HPV) 9-valent vaccine (Gardasil 9) a medically necessary preventive service for persons age 9 to 45 years.
- Gardasil nine‑valent is indicated in boys 9 through 15 years of age for the prevention of the following precancerous or dysplastic lesions caused by HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58: Anal intraepithelial neoplasia (AIN) grades 1, 2, and 3.
- FDA approved age expansion for Gardasil 9 to include women and men 27 through 45 years of age (per FDA 2018); Aetna's medical necessity statement covers persons age 9 to 45 years.
- Gardasil nine‐valent is indicated in girls and women 9 through 26 years of age for the prevention of the following diseases: Cervical, vulvar, vaginal, and anal cancer caused by Human Papillomavirus (HPV) types 16, 18, 31, 33, 45, 52 and 58; Genital warts (condyloma acuminata) caused by HPV types 6 and 11; and the following precancerous or dysplastic lesions caused by HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58: Cervical intraepithelial neoplasia (CIN) grade 2/3 and cervical adenocarcinoma i [...]
- Gardasil nine‐valent is indicated in boys 9 through 15 years of age for the prevention of the following diseases: Anal cancer caused by HPV types 16, 18, 31, 33, 45, 52, and 58; Genital warts (condyloma acuminata) caused by HPV types 6 and 11; and anal intraepithelial neoplasia (AIN) grades 1, 2, and 3 caused by HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58.
- Gardasil 9 is administered as three separate injections, with the initial dose followed by additional injections given two and six months later. (Note: ACIP recommends a 2-dose schedule for youth starting HPV vaccination between ages 9 and 14 years, given 6 to 12 months apart; patients aged 15 to 26 still need three doses.)
3 Active Policies
AETNA-CPB-0510 — Progestins
AETNA-CPB-0650 — Polymerase Chain Reaction Testing: Selected Indications
AETNA-CPB-0726 — Human Papillomavirus (HPV) Vaccine
Related Codes
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