Does N87.0 require prior authorization?

No, N87.0 does not require prior authorization (high confidence). Covered without prior authorization.

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`N87.0`, Mild cervical dysplasia

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Not all plans provide coverage of preventive services. Please check benefit plan descriptions for details.
CPT Codes / HCPCS Codes: 'CPT codes covered if selection criteria are met' (implies coverage is subject to meeting the policy's selection/medical necessity criteria).
If vaccination providers do not know or do not have available the HPV vaccine product previously administered, or are in settings transitioning to Gardasil 9, then Gardasil 9 HPV vaccine product is considered medically necessary to continue or complete the three-dose series. (Implied documentation: prior vaccination history or lack thereof may be relevant to coverage determination.)
Avian influenza A virus (H5N1): documentation of symptoms consistent with Avian influenza A virus and history of travel to or contact with persons or birds from a country with documented H5N1 avian influenza infections within 10 days of symptom onset.

Key Coverage Criteria

Aetna considers human papillomavirus (HPV) 9-valent vaccine (Gardasil 9) a medically necessary preventive service for persons age 9 to 45 years.
Gardasil nine‑valent is indicated in boys 9 through 15 years of age for the prevention of the following precancerous or dysplastic lesions caused by HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58: Anal intraepithelial neoplasia (AIN) grades 1, 2, and 3.
FDA approved age expansion for Gardasil 9 to include women and men 27 through 45 years of age (per FDA 2018); Aetna's medical necessity statement covers persons age 9 to 45 years.
Gardasil nine‐valent is indicated in girls and women 9 through 26 years of age for the prevention of the following diseases: Cervical, vulvar, vaginal, and anal cancer caused by Human Papillomavirus (HPV) types 16, 18, 31, 33, 45, 52 and 58; Genital warts (condyloma acuminata) caused by HPV types 6 and 11; and the following precancerous or dysplastic lesions caused by HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58: Cervical intraepithelial neoplasia (CIN) grade 2/3 and cervical adenocarcinoma i [...]
Gardasil nine‐valent is indicated in boys 9 through 15 years of age for the prevention of the following diseases: Anal cancer caused by HPV types 16, 18, 31, 33, 45, 52, and 58; Genital warts (condyloma acuminata) caused by HPV types 6 and 11; and anal intraepithelial neoplasia (AIN) grades 1, 2, and 3 caused by HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58.
Gardasil 9 is administered as three separate injections, with the initial dose followed by additional injections given two and six months later. (Note: ACIP recommends a 2-dose schedule for youth starting HPV vaccination between ages 9 and 14 years, given 6 to 12 months apart; patients aged 15 to 26 still need three doses.)

4 Active Policies

AETNA-CPB-0510, Progestins

AETNA-CPB-0650, Polymerase Chain Reaction Testing: Selected Indications

AETNA-CPB-0726, Human Papillomavirus (HPV) Vaccine

REGENCE-SUR218, Hysterectomy

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N87.0, Mild cervical dysplasia