HIV Testing
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Clinical policy describing medical necessity, allowable tests, coding, and limitations for HIV screening and diagnostic testing; applies to Aetna-covered members and laboratories performing HIV tests.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Medical Necessity Criteria
Aetna considers HIV testing medically necessary when ANY of the following conditions are met or when testing follows the CDC/USPSTF algorithm:
Refer to USPSTF/CDC guidance for population-specific recommendations.
Use serum or plasma specimens for laboratory immunoassays.
Laboratories should follow manufacturer and regulatory repeat-testing recommendations as applicable.
Follow the CDC-recommended algorithm for sequencing immunoassays and NAT.
Specimens submitted to laboratories after a reactive rapid test should be tested beginning with an antigen/antibody combination immunoassay.
Aetna does not cover home HIV test kits that do not require a physician's prescription under any plans. Examples of non-covered kits include the Confide Home HIV Test (Johnson & Johnson) and the Home Access HIV Test System.
Studies of the OraQuick oral fluid rapid test (OFOQ) identified a substantial number of false-negative results in longitudinal cohorts. In these analyses there were 233 false-negative OFOQ results among seroconverting participants and delays in oral-fluid conversion with a median of 98.5 days. Because OFOQ failures were frequent and multifactorial, the policy recommends that negative oral fluid rapid test results in longitudinal trials be confirmed by blood testing (e.g., NAAT or enzyme immunoassay).
Billing and Code Sets
| 86689 | HTLV or HIV antibody, confirmatory test (e.g., Western Blot) |
| 86701 | Qualitative or semiquantitative immunoassay performed by multiple step methods for the detection of antibodies to infectious agents; HIV-1 |
| 86702 | Qualitative or semiquantitative immunoassay performed by multiple step methods for the detection of antibodies to infectious agents; HIV-2 |
| 86703 | Antibody; HIV-1 and HIV-2, single result |
| 87389 | Infectious agent antigen detection by immunoassay technique (eg, EIA, ELISA, IMCA) qualitative or semiquantitative, multiple-step method; HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies, single result |
| 87390 | HIV-1 |
| 87391 | HIV-2 |
| 87534 | Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, direct probe technique |
| 87535 | HIV-1, amplified probe technique, includes reverse transcription when performed |
| 87536 | HIV-1, quantification, includes reverse transcription when performed |
| G0432 | Infectious agent antigen detection by enzyme immunoassay (EIA) technique, qualitative or semi-quantitative, multiple-step method, HIV-1 or HIV-2, screening |
| G0433 | Infectious agent antigen detection by enzyme-linked immunosorbent assay (ELISA) technique, antibody, HIV-1 or HIV-2, screening |
| G0435 | Infectious agent antigen detection by rapid antibody test of oral mucosa transudate, HIV-1 or HIV-2, screening |
| G0475 | HIV antigen/antibody, combination assay, screening |
| S3645 | HIV-1 antibody testing of oral mucosal transudate |
| B20 | Human immunodeficiency virus [HIV] disease |
| Z11.4 | Encounter for screening for human immunodeficiency virus [HIV] |
| Z20.6 | Contact with and (suspected) exposure to human immunodeficiency virus [HIV] |
| Z20.828 | Contact with and (suspected) exposure to other viral communicable diseases |
| Z21 | Asymptomatic human immunodeficiency virus [HIV] infection status |
Provider Actions, Billing Guidance, and Laboratory Algorithm
Billing codes listed — bill with listed codes when criteria met
CPT, HCPCS, and ICD-10 codes listed in this policy are covered when the clinical and testing-algorithm criteria in the policy are met. Providers should bill using the codes shown in the policy for the corresponding tests.
Prior authorization
No prior authorization requirements are specified in the policy excerpts for these HIV testing services.
Testing algorithm and laboratory actions
Laboratories and providers must follow the CDC-recommended testing algorithm beginning with an FDA-approved antigen/antibody (Ag/Ab) combination immunoassay for initial screening. Specimens nonreactive on the initial Ag/Ab test require no further testing. Reactive (preliminary positive) initial Ag/Ab results should be followed by an FDA-approved HIV-1/HIV-2 antibody differentiation immunoassay. If the differentiation immunoassay is nonreactive or indeterminate after a reactive initial Ag/Ab result, an FDA-approved HIV-1 nucleic acid test (NAT) should be performed to resolve acute infection versus false positive.
- Initial test: FDA-approved Ag/Ab combination immunoassay (HIV-1/HIV-2 antibodies and HIV-1 p24 antigen).
- If initial Ag/Ab is nonreactive: no further testing required.
- If initial Ag/Ab is reactive: perform FDA-approved HIV-1/HIV-2 antibody differentiation immunoassay.
- If differentiation immunoassay is nonreactive or indeterminate after reactive initial Ag/Ab: perform an FDA-approved HIV-1 NAT to distinguish acute infection from false-positive results.
Algorithm sequencing
Algorithm sequencing must be followed as specified: start with the Ag/Ab combination immunoassay; follow reactive results with the HIV-1/HIV-2 antibody differentiation immunoassay; if differentiation is nonreactive or indeterminate, perform an HIV-1 NAT. This sequencing determines interpretation (established infection, acute infection, or false-positive initial result).
Step therapy
No step therapy requirements are described in the provided policy excerpts for HIV testing.
Provider and documentation requirements
No additional provider-specific requirements or explicit documentation requirements are specified in these chunks beyond following the testing algorithm and using the listed billing codes when criteria are met.
Non-covered home HIV test kits
Aetna does not cover over-the-counter home HIV test kits that do not require a physician prescription (examples listed in the policy include the Confide Home HIV Test and the Home Access HIV Test System).
- Non-covered examples: Confide Home HIV Test; Home Access HIV Test System.
Background and Scope
HIV testing is indicated for persons with risk factors and for routine screening consistent with USPSTF and CDC recommendations. CDC guidance supports routine, opt-out screening in healthcare settings for most adolescents and adults, and the USPSTF has issued Grade A recommendations for screening in specified age ranges.
Screening in pregnancy is included in these recommendations; all pregnant women should be screened for HIV as part of routine prenatal care.
Laboratories and clinicians are advised to follow the CDC-recommended testing algorithm, beginning with an FDA-approved antigen/antibody combination (fourth-generation) immunoassay to improve detection of acute infection, with reflex differentiation immunoassays and nucleic acid testing (NAT) as indicated.
Definitions and Key Terms
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