Pap Smears with Medical Conditions

Section: Laboratory
Effective Date: November 01, 2019
Revised Date: September 26, 2019

Description

The pap smear is used as the primary screening test to detect cervical cancer in asymptomatic women. It can also detect premalignant and malignant changes of the cervix or vagina and some changes due to noncancerous conditions such as inflammation from infections.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

Criteria

Diagnostic pap smears may be considered medically necessary for ANY of the following indications (this is not an all-inclusive list):

  • Abnormal vaginal bleeding or discharge; or
  • Cervical ulcerations; or
  • Chronic Cervicitis; or
  • Condyloma; or
  • Endometriosis; or
  • Fibroma of cervix; or
  • Follow-up to previous or suspicious pap smear; or
  • Menopausal syndrome; or
  • Neoplastic disease; or
  • Pelvic malignancy; or
  • Polyps or cysts, cervical or uterine; or
  • Post-menopausal bleeding; or
  • Pregnancy; or
  • Vaginal or vulvar lesions, any type; or
  • Vaginitis, any type; or
  • Vulvitis and vulvovaginitis; or
  • Women exposed to DES (Diethylstilbestrol) prior to birth.

Cyto-hormonal study is used primarily to determine the need for, or possible response to, estrogen therapy and to evaluate the hormonal status in individuals who have certain types of endocrine problems (e.g., failure to ovulate, possible abnormal sexual development, infertility, etc.)

Claims for pap smears with diagnoses/conditions other than those listed above will be denied as not medically necessary.

Procedure Codes

88141

88142

88143

88147

88148

88150

88152

88153

88155

88164

88165

88166

88167

88174

88175

Speculoscopy

Speculoscopy is considered experimental/investigational and, therefore, non-covered. There is insufficient scientific evidence to support the use of speculoscopy in the triage of low-grade atypical pap smears or for routine screening for cervical cancer. The clinical role of speculoscopy as a screening device remains undefined.

Procedure Codes

58999

Diagnosis Codes

A51.31

A51.39

A54.00

A54.02

A54.09

A54.1

A56.02

A59.00

A59.01

A60.04

A63.0

 

B07.9

B37.3

 

C45.1

C48.1

C48.8

C51.0

C51.1

C51.2

C51.8

C51.9

C52

C53.0

C53.1

C53.8

C53.9

C54.0

C54.1

C54.2

C54.3

C54.8

C54.9

C55.55

C56.1

C56.2

C56.9

C57.00

C57.01

C57.02

C57.10

C57.11

C57.12

C57.20

C57.21

C57.22

C57.3

C57.4

C57.7

C57.8

C57.9

C58

C76.3

C78.6

C79.60

C79.61

C79.62

C79.82

 

D06.0

D06.1

D06.7

D06.9

D07.0

D07.1

D07.2

D07.30

D07.39

D25.0

D25.1

D25.2

D25.9

D26.0

D26.1

D26.7

D26.9

D27.0

D27.1

D27.9

D28.0

D28.1

D28.2

D28.7

D28.9

D39.0

D39.10

D39.11

D39.12

D39.2

D39.8

D39.9

 

N72

N73.9

N75.0

N75.1

N75.8

N75.9

N76.0

N76.1

N76.2

N76.3

N76.4

N76.5

N76.6

N76.81

N76.89

N77.0

N77.1

N80.0

N80.1

N80.2

N80.3

N80.4

N80.5

N80.6

N80.8

N80.9

N83.00

N83.01

N83.02

N83.10

N83.11

N83.12

N83.201

N83.202

N83.209

N83.291

N83.292

N83.299

N83.311

N83.312

N83.319

N83.321

N83.322

N83.329

N83.331

N83.332

N83.339

N83.6

N83.8

N84.0

N84.1

N84.2

N84.3

N84.8

N84.9

N85.8

N86

N87.0

N87.1

N87.9

N88.8

N89.0

N89.1

N89.3

N89.7

N89.8

N90.3

90.60

N90.69

N90.7

N90.89

N92.0

N92.1

N92.4

N92.5

N92.6

N93.0

N93.1

N93.8

N93.9

N94.10

N94.11

N94.12

N94.19

N95.0

N95.1

N95.2

N95.8

N95.9

N99.83

 

O00.00

O00.01

O00.101

O00.102

O00.111

O00.112

O00.201

O00.202

O00.211

O00.212

O00.80

O00.81

O00.90

O00.91

O01.0

O01.1

O01.9

O02.0

O02.1

O02.81

O02.89

O02.9

O03.0

O03.1

O03.2

O03.30

O03.31

O03.32

O03.33

O03.34

O03.35

O03.36

O03.37

O03.38

O03.39

O03.4

O03.5

O03.6

O03.7

O03.80

O03.81

O03.82

O03.83

O03.84

O03.85

O03.86

O03.87

O03.88

O03.89

O03.9

O04.5

O04.6

O04.7

O04.80

O04.81

O04.82

O04.83

O04.84

O04.85

O04.86

O04.87

O04.88

O04.89

O07.0

O07.1

O07.2

O07.30

O07.31

O07.32

O07.33

O07.34

O07.35

O07.36

O07.37

O07.38

O07.39

O07.4

O09.A0

O09.A1

O09.A2

O09.A3

O09.00

O09.01

O09.02

O09.03

O09.10

O09.11

O09.12

O09.13

O09.211

O09.212

O09.213

O09.219

09.291

O09.292

O09.293

O09.299

O09.40

O09.41

O09.42

O09.43

O09.511

O09.512

O09.513

O09.519

O09.521

O09.522

O09.523

O09.529

O09.611

O09.612

O09.613

O09.619

O09.621

O09.622

O09.623

O09.629

O09.70

O09.71

O09.72

O09.73

O09.811

O09.812

O09.813

O09.819

O09.821

O09.822

O09.823

O09.829

O09.891

O09.892

O09.893

O09.899

O09.90

O09.91

O09.92

O09.93

O10.011

O10.012

O10.013

O10.019

O10.02

O10.03

O10.111

O10.112

O10.113

O10.119

O10.12

O10.13

O10.211

O10.212

O10.213

O10.219

O10.22

O10.23

O10.311

O10.312

O10.313

O10.319

O10.32

O10.33

O10.411

O10.412

O10.413

O10.419

O10.42

O10.43

O10.911

O10.912

O10.913

O10.919

O10.92

O10.93

O11.1

O11.2

O11.3

O11.4

O11.5

O11.9

O12.00

O12.01

O12.02

O12.03

O12.04

O12.05

O12.10

O12.11

O12.12

O12.13

O12.14

O12.15

O12.20

O12.21

O12.22

O12.23

O12.24

O12.25

O13.1

O13.2

O13.3

O13.4

O13.5

O13.9

O14.00

O14.02

O14.03

O14.04

O14.05

O14.10

O14.12

O14.13

O14.14

O14.15

O14.20

O14.22

O14.23

O14.24

O14.25

O14.90

O14.92

O14.93

O14.94

O14.95

O15.00

O15.02

O15.03

O15.1

O15.2

O15.9

O16.1

O16.2

O16.3

O16.4

O16.5

O16.9

O20.0

O20.8

O20.9

O21.0

O21.1

O21.2

O21.8

O21.9

O22.00

O22.01

O22.02

O22.03

O22.10

O22.11

O22.12

O22.13

O22.20

O22.21

O22.22

O22.23

O22.30

O22.31

O22.32

O22.33

O22.40

O22.41

O22.42

O22.43

O22.50

O22.51

O22.52

O22.53

O22.8X1

O22.8X2

O22.8X3

O22.8X9

O22.90

O22.91

O22.92

O22.93

O23.00

O23.01

O23.02

O23.03

O23.10

O23.11

O23.12

O23.13

O23.20

O23.21

O23.22

O23.23

O23.30

O23.31

O23.32

O23.33

O23.40

O23.41

O23.42

O23.43

O23.511

O23.512

O23.513

O23.519

O23.521

O23.522

O23.523

O23.529

O23.591

O23.592

O23.593

O23.599

O23.90

O23.91

O23.92

O23.93

O24.011

O24.012

O24.013

O24.019

O24.02

O24.03

O24.111

O24.112

O24.113

O24.119

O24.12

O24.13

O24.311

O24.312

O24.313

O24.319

O24.32

O24.33

O24.410

O24.414

O24.419

O24.420

O24.424

O24.429

O24.430

O24.434

O24.439

O24.811

O24.812

O24.813

O24.819

O24.82

O24.83

O24.911

O24.912

O24.913

O24.919

O24.92

O24.93

O25.10

O25.11

O25.12

O25.13

O25.2

O25.3

O26.00

O26.01

O26.02

O26.03

O26.10

O26.11

O26.12

O26.13

O26.20

O26.21

O26.22

O26.23

O26.30

O26.31

O26.32

O26.33

O26.40

O26.41

O26.42

O26.43

O26.50

O26.51

O26.52

O26.53

O26.611

O26.612

O26.613

O26.619

O26.62

O26.63

O26.711

O26.712

O26.713

O26.719

O26.72

O26.73

O26.811

O26.812

O26.813

O26.819

O26.821

O26.822

O26.823

O26.829

O26.831

O26.832

O26.833

O26.839

O26.841

O26.842

O26.843

O26.849

O26.851

O26.852

O26.853

O26.859

O26.86

O26.891

O26.892

O26.893

O26.899

O26.90

O26.91

O26.92

O26.93

O29.011

O29.012

O29.013

O29.019

O29.021

O29.022

O29.023

O29.029

O29.091

O29.092

O29.093

O29.099

O29.111

O29.112

O29.113

O29.119

O29.121

O29.122

O29.123

O29.129

O29.191

O29.192

O29.193

O29.199

O29.211

O29.212

O29.213

O29.219

O29.291

O29.292

O29.293

O29.299

O29.3X1

O29.3X2

O29.3X3

O29.3X9

O29.40

O29.41

O29.42

O29.43

O29.5X1

O29.5X2

O29.5X3

O29.5X9

O29.60

O29.61

O29.62

O29.63

O29.8X1

O29.8X2

O29.8X3

O29.8X9

O29.90

O29.91

O29.92

O29.93

 

O30.001

O30.002

O30.003

O30.009

O30.011

O30.012

O30.013

O30.019

O30.031

O30.032

O30.033

O30.039

O30.041

O30.042

O30.043

O30.049

O30.091

O30.092

O30.093

O30.099

O30.101

O30.102

O30.103

O30.109

O30.111

O30.112

O30.113

O30.119

O30.121

O30.122

O30.123

O30.129

O30.131

O30.132

O30.133

O30.139

O30.191

O30.192

O30.193

O30.199

O30.201

O30.202

O30.203

O30.209

O30.211

O30.212

O30.213

O30.219

O30.221

O30.222

O30.223

O30.229

O30.231

O30.232

O30.233

O30.239

O30.291

O30.292

O30.293

O30.299

O30.801

O30.802

O30.803

O30.809

O30.811

O30.812

O30.813

O30.819

O30.821

O30.822

O30.823

O30.829

O30.831

O30.832

O30.833

O30.839

O30.891

O30.892

O30.893

O30.899

O30.90

O30.91

O30.92

O30.93

O31.00X0

O31.00X1

O31.00X2

O31.00X3

O31.00X4

O31.00X5

O31.00X9

O31.01X0

O31.01X1

O31.01X2

O31.01X3

O31.01X4

O31.01X5

O31.01X9

O31.02X0

O31.02X1

O31.02X2

O31.02X3

O31.02X4

O31.02X5

O31.02X9

O31.03X0

O31.03X1

O31.03X2

O31.03X3

O31.03X4

O31.03X5

O31.03X9

O31.10X0

O31.10X1

O31.10X2

O31.10X3

O31.10X4

O31.10X5

O31.10X9

O31.11X0

O31.11X1

O31.11X2

O31.11X3

O31.11X4

O31.11X5

O31.11X9

O31.12X0

O31.12X1

O31.12X2

O31.12X3

O31.12X4

O31.12X5

O31.12X9

O31.13X0

O31.13X1

O31.13X2

O31.13X3

O31.13X4

O31.13X5

O31.13X9

O31.20X0

O31.20X1

O31.20X2

O31.20X3

O31.20X4

O31.20X5

O31.20X9

O31.21X0

O31.21X1

O31.21X2

O31.21X3

O31.21X4

O31.21X5

O31.21X9

O31.22X0

O31.22X1

O31.22X2

O31.22X3

O31.22X4

O31.22X5

O31.22X9

O31.23X0

O31.23X1

O31.23X2

O31.23X3

O31.23X4

O31.23X5

O31.23X9

O31.30X0

O31.30X1

O31.30X2

O31.30X3

O31.30X4

O31.30X5

O31.30X9

O31.31X0

O31.31X1

O31.31X2

O31.31X3

O31.31X4

O31.31X5

O31.31X9

O31.32X0

O31.32X1

O31.32X2

O31.32X3

O31.32X4

O31.32X5

O31.32X9

O31.33X0

O31.33X1

O31.33X2

O31.33X3

O31.33X4

O31.33X5

O31.33X9

O31.8X10

O31.8X11

O31.8X12

O31.8X13

O31.8X14

O31.8X15

O31.8X19

O31.8X20

O31.8X21

O31.8X22

O31.8X23

O31.8X24

O31.8X25

O31.8X29

O31.8X30

O31.8X31

O31.8X32

O31.8X33

O31.8X34

O31.8X35

O31.8X39

O31.8X90

O31.8X91

O31.8X92

O31.8X93

O31.8X94

O31.8X95

O31.8X99

O32.0XX0

O32.0XX1

O32.0XX2

O32.0XX3

O32.0XX4

O32.0XX5

O32.0XX9

O32.1XX0

O32.1XX1

O32.1XX2

O32.1XX3

O32.1XX4

O32.1XX5

O32.1XX9

O32.2XX0

O32.2XX1

O32.2XX2

O32.2XX3

O32.2XX4

O32.2XX5

O32.2XX9

O32.3XX0

O32.3XX1

O32.3XX2

O32.3XX3

O32.3XX4

O32.3XX5

O32.3XX9

O32.4XX0

O32.4XX1

O32.4XX2

O32.4XX3

O32.4XX4

O32.4XX5

O32.4XX9

O32.6XX0

O32.6XX1

O32.6XX2

O32.6XX3

O32.6XX4

O32.6XX5

O32.6XX9

O32.8XX0

O32.8XX1

O32.8XX2

O32.8XX3

O32.8XX4

O32.8XX5

O32.8XX9

O32.9XX0

O32.9XX1

O32.9XX2

O32.9XX3

O32.9XX4

O32.9XX5

O32.9XX9

O33.0

O33.1

O33.2

O33.3XX0

O33.3XX1

O33.3XX2

O33.3XX3

O33.3XX4

O33.3XX5

O33.3XX9

O33.4XX0

O33.4XX1

O33.4XX2

O33.4XX3

O33.4XX4

O33.4XX5

O33.4XX9

O33.5XX0

O33.5XX1

O33.5XX2

O33.5XX3

O33.5XX4

O33.5XX5

O33.5XX9

O33.6XX0

O33.6XX1

O33.6XX2

O33.6XX3

O33.6XX4

O33.6XX5

O33.6XX9

O33.7XX1

O33.7XX2

O33.7XX3

O33.7XX4

O33.7XX5

O33.7XX9

O33.8

O33.9

O34.00

O34.01

O34.02

O34.03

O34.10

O34.11

O34.12

O34.13

O34.211

O34.212

O34.29

O34.30

O34.31

O34.32

O34.33

O34.40

O34.41

O34.42

O34.43

O34.511

O34.512

O34.513

O34.519

O34.521

O34.522

O34.523

O34.529

O34.531

O34.532

O34.533

O34.539

O34.591

O34.592

O34.593

O34.599

O34.60

O34.61

O34.62

O34.63

O34.70

O34.71

O34.72

O34.73

O34.80

O34.81

O34.82

O34.83

O34.90

O34.91

O34.92

O34.93

O35.0XX0

O35.0XX1

O35.0XX2

O35.0XX3

O35.0XX4

O35.0XX5

O35.0XX9

O35.1XX0

O35.1XX1

O35.1XX2

O35.1XX3

O35.1XX4

O35.1XX5

O35.1XX9

O35.2XX0

O35.2XX1

O35.2XX2

O35.2XX3

O35.2XX4

35.2XX5

O35.2XX9

O35.3XX0

O35.3XX1

O35.3XX2

O35.3XX3

O35.3XX4

O35.3XX5

O35.3XX9

O35.4XX0

O35.4XX1

O35.4XX2

O35.4XX3

O35.4XX4

O35.4XX5

O35.4XX9

O35.5XX0

O35.5XX1

O35.5XX2

O35.5XX3

O35.5XX4

O35.5XX5

O35.5XX9

O35.6XX0

O35.6XX1

O35.6XX2

O35.6XX3

O35.6XX4

O35.6XX5

O35.6XX9

O35.8XX0

O35.8XX1

O35.8XX2

O35.8XX3

O35.8XX4

O35.8XX5

O35.8XX9

O35.9XX0

O35.9XX1

O35.9XX2

O35.9XX3

O35.9XX4

O35.9XX5

O35.9XX9

 

O36.0110

O36.0111

O36.0112

O36.0113

O36.0114

O36.0115

O36.0119

O36.0120

O36.0121

O36.0122

O36.0123

O36.0124

O36.0125

O36.0129

O36.0130

O36.0131

O36.0132

O36.0133

O36.0134

O36.0135

O36.0139

O36.0190

O36.0191

O36.0192

O36.0193

O36.0194

O36.0195

O36.0199

O36.0910

O36.0911

O36.0912

O36.0913

O36.0914

O36.0915

O36.0919

O36.0920

O36.0921

O36.0922

O36.0923

O36.0924

O36.0925

O36.0929

O36.0930

O36.0931

O36.0932

O36.0933

O36.0934

O36.0935

O36.0939

O36.0990

O36.0991

O36.0992

O36.0993

O36.0994

O36.0995

O36.0999

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O36.93X9

 

O40.1XX0

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O47.1

O47.9

O48.0

O48.1

 

O60.00

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O68

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O76

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O80

O82

O85

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O89.5

O89.6

O89.8

O89.9

 

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O99.719

O99.72

O99.73

O99.810

O99.814

O99.815

O99.820

O99.824

O99.825

O99.830

O99.834

O99.835

O99.840

O99.841

O99.842

O99.843

O99.844

O99.845

O99.89

 

Q50.4

Q50.5

Q51.6

Q52.120

Q52.121

Q52.122

Q52.123

Q52.124

Q52.129

Q52.4

 

R19.00

R19.01

R19.02

R19.03

R19.04

R19.05

R19.06

R19.07

R19.09

R87.610

R87.611

R87.612

R87.613

R87.614

R87.615

R87.616

R87.619

R87.620

R87.621

R87.622

R87.623

R87.624

R87.625

R87.628

R87.810

R87.811

R87.820

R87.821

 

Z20.2

Z29.8

Z29.9

Z30.015

Z30.016

Z30.017

Z30.44

Z30.45

Z30.46

Z31.7

Z33.1

Z33.2

Z33.3

Z34.00

Z34.01

Z34.02

Z34.03

Z34.80

Z34.81

Z34.82

Z34.83

Z34.90

Z34.91

Z34.92

Z34.93

Z85.40

Z85.41

Z85.42

Z85.43

Z85.44

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