Page 270 - Medicare Benefit Policy Manual

There is evidence (on the basis of her medical history or other findings) that she is of
childbearing age and has had an examination that indicated the presence of cervical or
vaginal cancer or other abnormalities during any of the preceding 3 years; and at least 11
months have passed following the month that the last covered Pap smear was performed;
or

She is at high risk of developing cervical or vaginal cancer – ICD-9-CM code V15.89,
other specified personal history presenting hazards to health) or as applicable, ICD-10
code Z77.21, Z77.22, Z77.9, Z91.89, OR Z92.89 and at least 11 months have passed
following the month that the last covered screening Pap smear was performed. The high
risk factors for cervical and vaginal cancer are:

Cervical Cancer High Risk Factors

Early onset of sexual activity (under 16 years of age);

Multiple sexual partners (five or more in a lifetime);

History of a sexually transmitted disease (including HIV infection); and

Fewer than three negative or any Pap smears within the previous 7 years.

Vaginal Cancer High Risk Factors

The DES (diethylstilbestrol) - exposed daughters of women who took DES during
pregnancy.

The term “woman of childbearing age” means a woman who is premenopausal, and has
been determined by a physician, or qualified practitioner, to be of childbearing age, based
on her medical history or other findings. Payment is not made for a screening Pap smear
for women at high risk or who qualify for coverage under the childbearing provision
more frequently than once every 11 months after the month that the last screening Pap
smear covered by Medicare was performed.

B. For Claims with Dates of Service on or After July 1, 2001

When the beneficiary does not qualify for a more frequently performed screening Pap
smear as noted in items 1 and 2 above, contractors pay for the screening Pap smear only
after at least 23 months have passed following the month during which the beneficiary
received her last covered screening Pap smear. All other coverage and payment
requirements remain the same.

See the Medicare Claims Processing Manual, Chapter 18, “Preventive and Screening
Services,” for billing procedures.