DHCS California Medi-Cal has been erroneously denying claims for HPV testing for patients under the age of 30. This applied to women who’ve had pap smears previously diagnosed with ASCUS. Currently, the CA Medi-Cal manual regarding HPV coverage does not specifically address coverage for diagnostic purposes. Therefore, each HPV ordered requires a Treatment Authorization Request (TAR) for HPV testing (CPT 87624) for women under 30. However, Family PACT continues to recognize and pay for this type of service with specific diagnosis.
According to Bob Achermann of the California Society of Pathologists (CSP), the policy makes the pathologist/laboratory look bad when the policy clearly does not reflect medical practice/standards. The CSP has taken the necessary steps to appeal to the Division Chief of CA Medi-Cal Benefits Division. After lengthy research, the Division Chief of Medi-Cal Benefits Division has concluded that they will remove the HPV TAR Requirement for women under the age of 30. Additionally, providers will then be able to perform Reflex High-Risk HPV testing for ASCUS on cytology without pre-authorization requirements as this is consistent with the Family Pact policy. Please note that these changes may take 60-90 days for implementation because it will require a system change on their end.
APS will continue to monitor and provide updates as they become available.
Verdugo Hills, CA