Gynecology Payment Policy Updates

Harvard Pilgrim is making updates concerning cervical or vaginal screening and HPV testing to our commercial Gynecology Payment Policy, effective for dates of service beginning Sept. 1, 2021. The updates are consistent with guidance from the American College of Obstetricians and Gynecologists (ACOG) and the U.S. Preventive Services Task Force (USPSTF).

Cervical or vaginal screening

Cervical or vaginal screening is not recommended for female patients younger than 21 years of age (regardless of sexual history), as cervical cancer is rare in young women and screening leads to unnecessary treatment, which increases the risk of reproductive problems. It is also not recommended to be performed annually for women age 21 years of age or older, because conducting annual screening presents no advantage over performing screening at three-year intervals for average-risk women.

As a result, Harvard Pilgrim will deny cervical or vaginal screening services for patients younger than 21 years of age when the only diagnosis on the claim is a screening diagnosis code. In addition, Harvard Pilgrim will deny cervical or vaginal screening services for patients 21 years of age or older when the only diagnosis on the claim is a screening diagnosis code and any other cervical or vaginal screening services have been reported in the previous three years.

HPV testing

ACOG and USPSTF guidance indicates that screening for cervical cancer with high-risk HPV testing done alone or in combination with cytology for women younger than 30 years of age is not recommended as the potential harmful effects outweigh the potential benefits, and that screening for HPV combined with cytology more frequently than every 5 years in women between 30 and 65 offers little additional benefit and the potential for significant harms associated with additional procedures for transient lesions.

With the policy update, Harvard Pilgrim will also deny HPV testing (codes 87624-87625 and G0476) for patients younger than 30 years of age when the only diagnosis is a screening diagnosis code. These codes will also be denied when they are billed more than once in a five-year period by any provider for a patient between 30 and 65 years of age when the only diagnosis is a screening diagnosis code.

For more information, please refer to the updated Gynecology Payment Policy.


Publication Information

Helen Connaughton,
Director, Network Operations

Annmarie Dadoly,
Editor

Joseph O’Riordan,
Writer

Kristin Edmonston,
Production Coordinator