CONCERT INFECTIOUS DISEASE: PRIMARY CARE & PREVENTATIVE SCREENING
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This outpatient policy governs medical-necessity criteria for preventive HPV, hepatitis C, and group B streptococcus screening laboratory services for members and enrollees receiving care through health plans affiliated with Centene Corporation.
Policy Summary
PayerAmbetter Nevada
PolicyCONCERT INFECTIOUS DISEASE: PRIMARY CARE & PREVENTATIVE SCREENING
Policy CodePolicy CG.CP.MP.05
Change TypeModified
Effective DateN/A
Last ReviewNov 1, 2024
Next Review DateN/A
Key ActionApply the listed criteria before ordering HPV, HCV, or GBS screening; testing outside the covered criteria is investigational.
The November 2024 annual review changed policy language from services that “may be considered medically necessary” to services that “are considered medically necessary” for Group B Streptococcus screening, high-risk HPV genotyping, and hepatitis C nucleic acid/PCR testing.
The policy added a hepatitis C PCR testing criterion for members exposed to HCV perinatally who are 2 through 17 months of age.
CPT code 87626 and HCPCS code G0476 were added to the coding tables.
CPT codes 0500T, 87081, 87149, and 87150 were removed from the coding table in the prior revision history.
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3Infectious disease screening areas addressed
18–79Adult HCV antibody screening age range
36–37 weeksCovered GBS screening window
2–17 monthsPerinatally exposed age range added for HCV PCR testing
InvestigationalLow-risk HPV genotyping
Medical Necessity Criteria
High-risk HPV genotyping for cervical cancer screening
Covered when the applicable cervical cancer screening criteria are met.
High-risk HPV medical-necessity pathways
Standard-age pathway
Cervical history conditions: The member has not had a hysterectomy with removal of the cervix, or has a history of a high-grade precancerous lesion such as cervical intraepithelial neoplasia (CIN) grade 2 or 3, or has a history of cervical cancer.
Increased-risk pathway: The member/enrollee is an individual born with a cervix, is younger than 30 or older than 65 years of age, and is at increased risk for cervical cancer.Younger than 30 or older than 65 years
Examples of increased risk include immunocompromise, HIV infection, in-utero exposure to diethylstilbestrol, or a history of cervical lesion or cervical cancer.
Routine interval: High-risk HPV genotyping is medically necessary once every 5 years when increased risk factors for cervical cancer are absent.Every 5 years
Examples of increased risk factors include immunocompromise, HIV infection, in-utero exposure to diethylstilbestrol, history of cervical lesion, or history of cervical cancer.
HCV antibody screening
Covered when all applicable HCV antibody screening conditions are met and at least one qualifying indication is present.
HCV antibody prerequisites: The member/enrollee does not have a known past positive HCV antibody test result and does not have a known history of chronic HCV infection.
A quantitative HCV-RNA test rather than an HCV-antibody test is recommended to assess HCV recurrence.
HCV antibody qualifying indications
Pregnancy: The member/enrollee is pregnant.
Asymptomatic adult screening: The member/enrollee is an asymptomatic adult between 18 and 79 years of age.18-79 years
HCV nucleic acid/PCR testing
Covered when HCV nucleic acid/PCR testing is used for routine screening or confirmation after a positive HCV antibody test and at least one listed condition is met.
HCV PCR qualifying indications
Immunocompromise: The member/enrollee is immunocompromised, such as receiving chronic hemodialysis.
Recent suspected exposure: The member/enrollee has a suspected HCV exposure within the past six months, regardless of antibody status.Within the past 6 months
Positive antibody test: The member/enrollee has an initial HCV antibody positive test.
This includes PCR testing as an automatic reflex from an initial antibody test; the policy identifies reflex testing as the most appropriate option for initial HCV screening.
GBS vaginal-rectal specimen screening
Covered when all criteria are met.
GBS pregnancy screening: The member/enrollee is pregnant and the pregnancy is between 36 weeks 0 days and 37 weeks 6 days gestation.36 weeks 0 days to 37 weeks 6 days
Hepatitis C Screening and Testing
Hepatitis C screening and nucleic acid/PCR testing are considered medically necessary when one or more applicable screening, exposure, perinatal, treatment, or follow-up indications are met.
Hepatitis C testing indications
Universal pregnancy screening: The individual is pregnant and is being screened during each pregnancy.Each pregnancy
This does not apply in settings where HCV RNA positivity prevalence is less than 0.1%.
Recognized condition or exposure: The person has HIV; has ever injected drugs and shared needles, syringes, or other drug-preparation equipment; ever received maintenance hemodialysis; has persistently abnormal ALT levels; received clotting-factor concentrates before 1987; received a blood or blood-component transfusion before July 1992; received an organ transplant before July 1992; or was notified of blood exposure from a donor later testing positive for HCV.One-time testing
These are listed one-time testing indications.
Hepatitis C Testing Methodology
Initial HCV testing and follow-up should use the testing method appropriate to the patient's antibody status, exposure history, and reinfection risk.
HCV testing methodology
Initial testing: Initial HCV testing is being performed.HCV-antibody testing with reflex HCV RNA PCR
Reflex RNA testing is recommended after initial antibody testing.
Recent exposure with negative antibody: The person has a negative HCV-antibody test and was exposed within the prior six months.Within six months of exposure
Use HCV RNA or repeat antibody testing six months or longer after exposure; RNA may also be considered for immunocompromised persons.
Risk of reinfection:
Group B Streptococcus Screening
Antepartum group B Streptococcus screening is considered medically necessary when the standard pregnancy-timing criterion is met, unless an identified exception applies.
Routine antepartum GBS screening: The patient is pregnant and reaches the recommended antepartum screening window.36 0/7-37 6/7 weeks of gestation
Screening is not required under this routine pathway when intrapartum antibiotic prophylaxis is already indicated because of GBS bacteriuria during the pregnancy or a previous GBS-infected newborn.
High-risk HPV genotyping is investigational when performed outside the specified cervical cancer screening criteria, including evaluation of genital warts, sexually transmitted infection screening, or any other indication not covered under the cervical cancer screening pathways. Coverage is limited to applicable screening of individuals born with a cervix, including the standard pathway for ages 30–65 years and an increased-risk pathway for those younger than 30 or older than 65.
Low-risk HPV genotyping is considered investigational for all indications.
HCV antibody screening is investigational for indications other than the listed pregnancy, age-based, exposure-risk, perinatal, or member-requested screening pathways. This limitation does not apply when the member has liver disease or other signs and symptoms of active HCV infection. A quantitative HCV-RNA test, rather than an antibody test, is recommended to assess HCV recurrence.
HCV nucleic acid/PCR testing for routine screening or confirmation after a positive HCV antibody test is investigational for indications outside the specified criteria, including immunocompromise, recent suspected exposure, a positive antibody result, chronic HCV monitoring, perinatal exposure at ages 2–17 months, or reinfection risk after viral eradication or sustained virologic response. The limitation does not apply when the member has liver disease or other signs and symptoms of active HCV infection.
GBS vaginal-rectal specimen screening is investigational for pregnant members with GBS bacteriuria during the current pregnancy, pregnant members with a history of a previous GBS-infected newborn, and all other indications outside the routine antepartum screening window of 36 weeks 0 days through 37 weeks 6 days.
Universal hepatitis C screening is recommended during each pregnancy, except in settings where the prevalence of HCV infection, measured by HCV RNA positivity, is less than 0.1%. The policy also identifies one-time testing for recognized conditions or exposures, periodic testing while ongoing risks persist, and testing for any person who requests it.
Infectious agent detection by nucleic acid (DNA or RNA); human papillomavirus (HPV), high-risk types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) for cervical cancer screening, must be performed in addition to pap test.
High-risk HPV screening age
Standard screening age30–65 years for individuals born with a cervix
Younger than 30Covered when the individual is at increased risk for cervical cancer
Older than 65Covered when the individual is at increased risk for cervical cancer
High-risk HPV screening interval
Screening intervalOnce every 5 years
Applies whenIncreased cervical cancer risk factors are absent
Examples of increased risk
Investigational and Denial-Risk Conditions
Denial Risk
High-Risk HPV Testing Outside Covered Criteria
Before ordering high-risk HPV genotyping, confirm the member meets the covered screening criteria. Testing for all other indications is investigational and may be denied.
Covered once every 5 years when there are no increased cervical-cancer risk factors.
For members younger than 30 or older than 65, coverage requires increased cervical-cancer risk, such as immunocompromise, HIV infection, in-utero diethylstilbestrol exposure, or a history of cervical lesion or cervical cancer.
High-risk history includes a prior high-grade precancerous lesion (CIN 2 or 3) or cervical cancer.
Investigational for evaluation of genital warts or sexually transmitted infection screening, and for all other indications.
Denial Risk
Low-Risk HPV Genotyping
Use low-risk HPV genotyping only with the understanding that it is investigational for every indication and is subject to denial.
Policy Background
This outpatient policy addresses preventive laboratory screening for human papillomavirus (HPV), hepatitis C virus (HCV), and group B streptococcus (GBS). High-risk HPV types are associated with cervical cancer risk; HCV is a blood-borne infection that may cause chronic liver disease; and maternal GBS colonization can contribute to newborn illness during vaginal delivery. Coverage distinctions use clinical factors such as risk status, age, pregnancy, gestational age, prior testing, exposure history, and infection history to distinguish medically necessary testing from investigational testing.
Key Definitions
High-risk HPV
DefinitionAn oncogenic HPV type associated with cervical cancer risk
Clinical relevanceUsed in cervical cancer screening criteria
The member/enrollee is a child 18 months or older, was perinatally exposed to HCV, and has not been previously tested.
18 months or older
Increased-risk screening outside routine age range: The member/enrollee is younger than 18 or older than 79 years and is at increased risk of HCV infection.Younger than 18 or older than 79 years
Examples include past or current injection drug use, liver disease, chronic hemodialysis, HIV infection, HIV PrEP use, sex between individuals with male reproductive systems, partners of HCV-infected individuals, or organ transplant donor/recipient status.
Member-requested screening: The member/enrollee requests screening, regardless of age or disclosure of potentially stigmatizing risks.
Chronic HCV monitoring: The member/enrollee is being monitored for chronic HCV infection before starting direct-acting antiviral treatment, while receiving treatment, or after completing therapy.
Perinatally exposed infant: The member/enrollee was exposed to HCV perinatally and is between 2 months and 17 months of age.2-17 months
Post-eradication reinfection risk: The member/enrollee has a history of HCV infection followed by eradication or sustained virologic response and has ongoing risk factors for HCV reinfection.
A quantitative HCV-RNA test rather than an HCV-antibody test is recommended to assess HCV recurrence.
Ongoing risk: The person currently injects drugs and shares needles, syringes, or other drug-preparation equipment, or has ever received maintenance hemodialysis.Periodic testing while risk persists
Patient-requested testing: Any person requests hepatitis C testing.Regardless of disclosed risk
Testing should be provided because individuals may not disclose stigmatizing risks.
Perinatal exposure: The child was perinatally exposed to HCV.Two through 17 months or age 18 months and older if previously untested
Testing method and timing vary by age.
Treatment or post-treatment monitoring: The patient is preparing to start antiviral therapy, is completing or has completed therapy, or achieved sustained virologic response with ongoing reinfection risk.Quantitative HCV RNA before therapy and at least 12 weeks after completion; annual RNA testing with ongoing risk after sustained virologic response
Quantitative HCV RNA is used to establish baseline viremia, document sustained virologic response, or assess recurrence when antibody testing is not appropriate.
The person is at risk of reinfection after spontaneous or treatment-related viral clearance.
HCV RNA testing
A positive antibody test is expected, so RNA testing is recommended.
Before antiviral therapy: The patient is initiating direct-acting antiviral therapy.Quantitative HCV RNA before treatment
Testing documents baseline viremia or viral load.
Immunocompromise, HIV infection, in-utero diethylstilbestrol exposure, cervical lesion history, or cervical cancer history
Routine adult HCV antibody screening
Eligible age range18–79 years
PopulationAsymptomatic adults
Testing conditionNo known past positive HCV antibody test or known chronic HCV infection
HCV antibody screening after perinatal exposure
Testing age18 months or older
Exposure statusPerinatally exposed to HCV
Prior testingChild has not been previously tested
HCV PCR testing after perinatal exposure
Testing age2 months through 17 months
Exposure statusInfant was exposed to HCV perinatally
Testing methodHCV nucleic acid/PCR testing
GBS screening gestational window
Covered gestational window36 weeks 0 days through 37 weeks 6 days
PopulationPregnant members/enrollees
SpecimenVaginal-rectal specimen
HCV pregnancy-screening prevalence exception
Routine approachUniversal hepatitis C screening during each pregnancy
Exception thresholdHCV RNA-positivity prevalence less than 0.1%
ExceptionUniversal pregnancy screening does not apply where prevalence is below the stated threshold
Follow-up after recent HCV exposure
Follow-up timingSix months or longer after exposure
Testing option 1HCV RNA testing
Testing option 2Follow-up HCV-antibody testing
Perinatal HCV NAT testing
Recommended age windowTwo through six months
PopulationPerinatally exposed infants
Testing methodNAT for HCV RNA
Testing previously untested children with perinatal HCV exposure
Age 7–17 monthsNAT for HCV RNA
Age 18 months or olderAnti-HCV test with reflex to NAT for HCV RNA
PopulationPerinatally exposed children who have not previously been tested
Post-treatment HCV viral-load monitoring
Testing timing12 or more weeks after completion of therapy
TestQuantitative HCV viral-load testing
PurposeDocument sustained virologic response (SVR), consistent with cure of chronic HCV infection
Antepartum GBS screening
Antepartum screening window36 0/7 through 37 6/7 weeks of gestation
PopulationAll pregnant individuals under the routine screening pathway
ExceptionsGBS bacteriuria during the pregnancy or history of a previous GBS-infected newborn
GBS NAAT methodology
Required preparation18–24-hour incubation in enrichment broth
SequenceIncubate the specimen before performing NAAT analysis
Testing contextAntepartum GBS screening
Low-risk HPV genotyping is investigational for all indications.
Do not represent low-risk HPV genotyping as covered screening based on the member’s age, symptoms, or risk factors.
Denial Risk
HCV Antibody Screening Outside Criteria
Verify the member’s eligibility before billing an HCV antibody screening test. Testing outside the listed criteria is investigational, except that this limitation does not apply when liver disease or other signs and symptoms of active hepatitis C are present.
Covered when the member has no known past positive HCV antibody result and no known chronic HCV infection, and meets at least one qualifying indication.
Qualifying indications include pregnancy; asymptomatic age 18–79; perinatal exposure in a child age 18 months or older who has not been previously tested; age younger than 18 or older than 79 with increased risk; or a screening request regardless of age or disclosure of potentially stigmatizing risks.
Increased-risk examples include past or current injection drug use, liver disease, chronic hemodialysis, HIV infection, HIV PrEP use, sex between individuals with male reproductive systems, partners of HCV-infected individuals, and organ transplant donor or recipient status.
Investigational for all other indications.
For suspected HCV recurrence, a quantitative HCV-RNA test rather than an HCV-antibody test is recommended.
Denial Risk
HCV PCR Testing Outside Criteria
For routine screening or confirmation after a positive HCV antibody result, order HCV nucleic acid/PCR testing only when a covered indication is documented. Testing for all other indications is investigational, except when liver disease or other signs and symptoms of active hepatitis C are present.
Covered for immunocompromised members; suspected HCV exposure within the past six months regardless of antibody status; an initial positive HCV antibody test; monitoring chronic HCV infection before, during, or after direct-acting antiviral treatment; perinatal exposure at age 2–17 months; or prior HCV infection followed by eradication/SVR with ongoing reinfection risk factors.
PCR testing may be used as an automatic reflex from an initial antibody test and is considered the most appropriate option for initial HCV screening.
Investigational for routine screening or confirmatory testing after a positive antibody result when none of the covered indications applies.
For suspected recurrence, quantitative HCV-RNA testing is recommended rather than an HCV-antibody test.
Denial Risk
GBS Screening Outside Covered Gestational Window
Schedule vaginal-rectal GBS screening within the covered gestational window and document the pregnancy and gestational age. Screening outside the covered criteria is investigational and may be denied.
Covered when the member is pregnant and the pregnancy is between 36 weeks 0 days and 37 weeks 6 days gestation.
Investigational for pregnant members with GBS bacteriuria during the current pregnancy.
Investigational for pregnant members with a history of a previous GBS-infected newborn.
Investigational for all other indications, including testing outside the covered gestational window.
HCV nucleic acid/PCR test
What it detectsHCV RNA
Testing terminologyHCV PCR or nucleic acid testing
Quantitative testingUsed to assess recurrence, document baseline viremia, and document SVR; it is preferred over HCV-antibody testing for recurrence assessment
GBS vaginal-rectal screening
SpecimenVaginal-rectal specimens
TimingDuring pregnancy, typically at 36 weeks 0 days through 37 weeks 6 days
PurposeDetect group B streptococcal colonization relevant to newborn infection risk during vaginal delivery