Cervical Cancer Screening Technologies

Medical Policy: 02.04.06 
Original Effective Date: October 2003 
Reviewed: August 2011 
Revised: December 2008 

Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.

Description: 

Cervical cancer remains a leading cause of death among women. A majority of cervical cancer is associated with the sexually-transmitted human papillomavirus (HPV) infection. Because cervical cancer often presents no symptoms until it has spread beyond the cervix, screening is an important measure. There are several techniques available for cervical cancer screening; some are stand alone tests while others are used in combination.

Papanicolaou (Pap) Smear is a cytopathology examination of cervical cells and is intended for early detection of cervical cancer before it has advanced to the stage where overt symptoms are present.

Liquid-based cytology, or thin layer cytology, produces a monolayer slide by dispersing the cervical cell sample in a liquid medium, collecting the cells in a filter, and depositing them in a thin layer on the slide. This method of cell collection permits the entire cellular sample to be preserved for testing instead of the 20 percent of cells that are smeared onto a glass slide during the conventional Papanicolaou preparation. It is designed as an alternative to the Pap smear.

Human Papillomavirus Deoxyribonucleic Acid (HPV-DNA) Testing detects high-risk types of HPV in cell DNA prior to conclusive visible changes to the cervical cells. There are more than 100 distinct types of HPV, with approximately 30 known to infect the human genital tract; 5 types cause approximately 75 percent of squamous intraepithelial lesions and cervical malignancy.

Speculoscopy is an endoscopic visualization of the cervix using specialized blue-white chemiluminescence along with acetic acid and low power magnification. A disposable blue-white chemiluminescent light is attached to the inner aspect of the upper speculum blade. Epithelial cells with increased keratinization and nuclear cytoplasmic ratios have an increased light reflection and appear white. The presence of white lesions is considered a positive result.

Cervicography is a visual screening technique that uses a specially-designed 35-mm camera to photograph the cervix following the application of a 3-5 percent acetic acid wash. The photographs, known as “cervigrams”, are evaluated by a colposcopist and interpreted as negative, atypical, positive, or defective.

Spectroscopy emits light from a probe onto the cervix permitting the examiner to visually inspect and categorize tissues as normal or diseased. Abnormal tissue absorbs and emits light differently than normal tissue. An example of spectroscopy is the LUMA™ Cervical Imaging System by MediSpectra. This non-contact optical analysis system is intended for use as an adjunct to colposcopy for the identification of high-grade disease (CIN 2, 3+) in women referred to colposcopy with a Pap test result of atypical squamous cell (ASC), low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intraepithelial lesion or cancer (HSIL+).

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Prior Approval: 

Not applicable

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Policy: 

• Papanicolaou (pap) smear, for cancer screening of the cervix, may be considered medically necessary
• Thin-layer cytology (e.g., ThinPrep®), as a primary screening technique, may be considered medically necessary.
• Human Papillomavirus (HPV) DNA testing may be considered medically necessary for women with Atypical Squamous Cells of Undetermined Significance (ASCUS).
• The combination of cervical cytology and HPV DNA screening may be considered medically necessary for women aged 30 years and older. If this combination is used, women who receive negative results on both tests should be rescreened no more frequently than every 3 years. 
• Speculoscopy (e.g., Speculite® and PapSure®) as a primary screening technique for cervical cancer is considered investigational.
• Cervicography, as a primary screening technique or an adjunct for cancer screening of the cervix, is considered investigational.
• Spectroscopy as a primary screening technique for cervical cancer is considered investigational.

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Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, revenue codes, and/or ICD-9 diagnostic codes.
• 87620 for Papillomavirus, human, direct probe technique
• 87621 for Papillomavirus, human, amplified probe technique
• 87622 for papillomavirus, human, quantification
• 58999 when billing for Speculoscopy

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Selected References: 

• Parham GP. Comparison of cell collection and direct visualization cervical cancer screening adjuncts. Am J Obstet Gynecol. Vol 188 Number 3. Mar 2003.
• Wright PC. Chapter 10: Cervical Cancer Screening Using Visualization Techniques. Journal of the National Cancer Institute Monographs, No 31, 2003.
• Cronje HS, van Rensburg E, Cooreman BF, et al. Speculoscopy vs. the acetic acid test for cervical neoplasia. International Journal of Gynecology & Obstetrics 69(2000) 249-53.
• Smith JC, Greer NL, Technology Assessment Committee. HPV DNA Testing for Cervical Cancer. Institute for Clinical Systems Improvement (ICSI). Technology Assessment Report #56 June 2001.
• Soloman D, Schiffman M, Tarone R. Comparison of Three Management Strategies for Patients with Atypical Squamous Cells of Undetermined Significance: Baseline results from a Randomized Trial. Journal of the National Cancer Institute;93(4) (2001) 293-99.
• Smith RA, et al. American Cancer Society Guidelines for the Early Detection of Cancer, 2004. CA Cancer J Clin 2004 Jan/Feb; 54(1):41-52.
• Health Technology Assessment Information Service. Windows on Medical Technology^TM  (December 2004).  Pap Smear plus Speculoscopy for Cervical Cancer Screening.  Retrieved March 1, 2005 from ECRI HTAIS.
• Health Technology Assessment Information Service. Health Technology Trends. (May 2004). HPV DNA test and revised guidelines are gaining acceptance for cervical cancer screening. Retrieved March 1, 2005 from ECRI HTAIS.
• Health Technology Assessment Information Service. Hotline Response (April 2006). Multispectral Imaging Systems for Cervical Cancer Screening. Retrieved August 18, 2008 from ECRI Institute HTAIS.
• Chilakapati MK, Sockalingum GD, Vidyasagar MS et al. An overview on applications of optical spectroscopy in cervical cancers. J Can Res Ther 2008;4:26-36.
• Siddiqi AM, Li H, Faruque F et al. Use of hyperspectral imaging to distinguish normal, precancerous, and cancerous cells. Cancer. 2008 Feb 25; 114(1):13-21.
• American College of Obstetricians and Gynecologists (ACOG). Cervical cytology screening. Washington DC: American College of Obstetricians and Gynecologists (ACOG); 2003 Aug. 11 p. (ACOG practice bulletin; no. 45).
• Stout NK, Goldhaber-Fiebert JD, Ortendahl JD et al. Trade-offs in Cervical Cancer Prevention. Balancing Benefits and Risks. Arch Intern Med. 2008;168(17):1881-89.
• Goldhaber-Fiebert JD, Stout NK, Salomon JA et al. Cost-effectiveness of cervical cancer screening with human papillomavirus DNA testing and HPV-16, 18 vaccination. J Natl Cancer Inst. 2008 Mar 5; 100(5):308-20. Epub 2008 Feb 26.   

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Policy History: 

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Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.