CMS Pub. 100-04, ch. 18, § 30.1

B3-4603.1A.1, B3-4603.1A.2, B3-4603.1A.3, A3-3628.1A

The following requirements must be met.

1. The beneficiary has not had a screening Pap smear test during the preceding three years

(i.e., 35 months have passed following the month that the woman had the last covered Pap

smear. Use one of the following ICD-9-CM codes V76.2, V76.47, or V76.49; or

2. 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

3. She is at high risk of developing cervical or vaginal cancer (use ICD-9-CM code V15.89,

other specified personal history presenting hazards to health) 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:

a. Cervical Cancer High Risk Factors:

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

• Multiple sexual partners (5 or more in a lifetime)

• History of a sexually transmitted disease (including HIV infection)

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

b. Vaginal Cancer High Risk Factors:

• DES (diethylstilbestrol)-exposed daughters of women who took DES during

pregnancy.

NOTE: 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.

COUNTING: To determine the 11-, 23-, and 35-month periods, start counts beginning with the

month after the month in which a previous test/procedure was performed.

COUNTING EXAMPLE: A beneficiary identified as being at high risk for developing cervical

cancer received a screening Pap smear in January 2000. Start counts beginning with February

2000. The beneficiary is eligible to receive another screening Pap smear in January 2001 (the

month after 11 full months have passed).