ModifiedAmbetter NevadaPolicy 2025.1

CONCERT INFECTIOUS DISEASE: PRIMARY CARE & PREVENTATIVE SCREENING

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Outpatient policy governing medical necessity criteria for HPV (high- and low-risk genotyping), hepatitis C antibody and nucleic acid/PCR testing, and group B streptococcus (GBS) vaginal-rectal screening, affecting primary care and prenatal providers and members of Ambetter Nevada.

Policy Summary

PayerAmbetter Nevada

PolicyCONCERT INFECTIOUS DISEASE: PRIMARY CARE & PREVENTATIVE SCREENING

Policy CodePolicy 2025.1

Change TypeAffirmed medical necessity languageadded perinatal HCV PCR criterioncoding table revisions

Effective Date

Last ReviewNov 1, 2024

Next Review Date

Key ActionDocument clinical indication, patient age/risk factors, pregnancy gestational age (for GBS), prior test results (for HCV antibody) and support use of listed codes with documentation meeting policy criteria.

SourceLink

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ModifiedAmbetter NevadaPolicy 2025.1

CONCERT INFECTIOUS DISEASE: PRIMARY CARE & PREVENTATIVE SCREENING

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Sign up for Ambetter Nevada Policy 2025.1 alerts

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Policy Summary

PayerAmbetter Nevada

PolicyCONCERT INFECTIOUS DISEASE: PRIMARY CARE & PREVENTATIVE SCREENING

Policy CodePolicy 2025.1

Change TypeAffirmed medical necessity languageadded perinatal HCV PCR criterioncoding table revisions

Effective Date

Last ReviewNov 1, 2024

Next Review Date

SourceLink

POLICY UPDATE CHANGES

Changed policy statement verbiage from "may be considered medically necessary" to "are considered medically necessary" for Group B Streptococcus screening of vaginal-rectal specimens, genotyping of high-risk HPV types for cervical cancer screening, and Hepatitis C nucleic acid/PCR tests.

For Hepatitis C nucleic acid/PCR tests, added criterion option that the member was exposed to HCV perinatally and is between 2 months and 17 months of age.

Added CPT code 87626 and HCPCS code G0476 to coding tables.

q5yHPV genotyping interval (no increased risk)

18–79HCV screening ages

36–37 wkGBS screening window

Quant PCRQuantitative HCV-RNA

≥3 changesCoding revisions noted

11+References cited

Coverage Criteria — When Tests Are Medically Necessary

Genotyping of High Risk HPV — Medically Necessary

Covered when ALL of the following are met

Population and age

Age 30-65 branch: Age between 30 and 65 AND has NOT had a hysterectomy with removal of the cervix OR has a history of high-grade precancerous lesion (CIN 2 or 3) OR has a history of cervical cancerage 30-65
See USPSTF-based criteria (chunk 5)
Other age with increased risk: Age younger than 30 or older than 65 AND is at increased risk for cervical cancer (e.g., immunocompromised, HIV infection, in‑utero DES exposure, history of cervical lesion or cervical cancer)
See chunk 5

Frequency: Testing is considered medically necessary once every 5 years in the absence of increased risk factors for cervical cancerq5y

Chunk 5

Genotyping of Low-Risk HPV — Investigational

Stance: Human papillomavirus (HPV) genotyping of low‑risk types is considered investigational

Chunk 6

Hepatitis C Antibody Screening — Medically Necessary

Covered when ALL of the following are met

Preconditions: Member does NOT have a known past positive HCV antibody test result AND does not have a known history of chronic HCV infection

Chunk 7

Eligible populations: Member meets at least one of: is pregnant; is an asymptomatic adult aged 18–79 years; is a child ≥18 months with perinatal HCV exposure and not previously tested; is younger than 18 or older than 79 AND is at increased risk for HCV infection; or requests screening (regardless of age)

Chunk 7; aligns with USPSTF/CDC guidance (chunks 12,13)

Hepatitis C Nucleic Acid/PCR — Medically Necessary

Covered when ANY of the following are present

Indications: Member is immunocompromised (e.g., receives chronic hemodialysis) OR has suspected HCV exposure within the past 6 months OR has an initial HCV antibody positive test OR is undergoing monitoring for chronic HCV infection (pre‑treatment, on treatment, or post‑treatment) OR was exposed to HCV perinatally and is between 2 months and 17 months of age OR has history of HCV with SVR and ongoing risk factors for reinfection

Chunk 8; perinatal age window added in revision note (chunk 21)

Reflex testing: PCR (HCV‑RNA) testing performed automatically as a reflex from a positive HCV antibody test is considered appropriate for initial HCV screening

Chunk 8; see IDSA/AASLD recommendations (chunks 14,15)

Quantitative testing: Quantitative HCV‑RNA testing is indicated prior to initiating direct‑acting antiviral therapy and recommended 12 or more weeks after therapy to document sustained virologic response; also used for monitoring and assessment of recurrence

Chunks 14,15

Group B Streptococcus Vaginal-Rectal Screening — Medically Necessary

Covered when ALL of the following are met

Pregnancy and timing: Member is pregnant AND pregnancy is between 36 weeks 0 days and 37 weeks 6 days gestation36 0/7–37 6/7 wk

Chunks 9,17

Covered with criteria (summary)

Policy statements updated to indicate medical necessity where criteria are met for specific test groups

Group B Streptococcus Screening Tests: Group B Streptococcus screening of vaginal‑rectal specimens are considered medically necessary when the policy criteria are met

Verbiage changed to affirmative coverage in revision notes (chunk 21)

Genotyping of High‑Risk HPV Types: Genotyping of high‑risk HPV types for cervical cancer screening are considered medically necessary when the policy criteria are met

Affirmed in revision notes; coding updates noted (chunk 21)

Hepatitis C Nucleic Acid/PCR Tests: Hepatitis C nucleic acid/PCR tests are considered medically necessary when relevant clinical criteria are met, including when the member was perinatally exposed and is between 2 months and 17 months of ageage 2–17 months included as option

Added in recent revision (chunk 21)

Tests performed for indications that are not included in the specific medically necessary criteria in this policy are considered investigational (not covered). Examples in this policy include: low-risk HPV genotyping (investigational for all indications) and HPV genotyping of high-risk types when used for indications other than those listed for cervical cancer screening. Similarly, Hepatitis C antibody and nucleic acid/PCR tests, and Group B Streptococcus vaginal-rectal screening, are considered investigational when performed outside the enumerated medically necessary scenarios (for example, outside specified age ranges, risk conditions, pregnancy timing, or monitoring indications).

The CPT and HCPCS codes referenced in this clinical policy are provided for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers must reference current professional coding guidance and applicable plan requirements prior to claim submission and verify any prior authorization requirements in the payer system.

This policy explicitly designates low-risk HPV genotyping as investigational. It also states that high-risk HPV genotyping is investigational when used for indications outside the specified cervical cancer screening criteria (for example, evaluation of genital warts or general STI screening).

This clinical policy provides guidance to help determine medical necessity but does not constitute a contract or guarantee of payment. Coverage and payment remain subject to the terms, conditions, exclusions and limitations of the enrollee's coverage documents and to applicable state and federal laws. Providers should use this policy to support documentation but verify benefit coverage and any required administrative steps with the Health Plan prior to delivering or billing services.

Coding Tables and Key Coding Details

Hepatitis C antibody and relatedCPT

86803	Hepatitis C antibody.
86804	Hepatitis C antibody; confirmatory test (eg, immunoblot).
87520	Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, direct probe technique

Hepatitis C antibody and related (duplicate)CPT

86803	Hepatitis C antibody.
86804	Hepatitis C antibody; confirmatory test (eg, immunoblot).
87520	Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, direct probe technique

HPV and other NAAT codesCPT

87521	Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, amplified probe technique, includes reverse transcription when performed.
87522	Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performed.
87623	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44).
87624	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68), pooled result.
87625	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed.
87626	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), separately reported high-risk types (eg, 16, 18, 31, 45, 51, 52) and high-risk pooled result(s).
87653	Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique

Referenced CPT Codes (Hepatitis C antibody and NAAT)CPT

86803	Hepatitis C antibody.
86804	Hepatitis C antibody; confirmatory test (eg, immunoblot).
87520	Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, direct probe technique

Referenced CPT Codes (HPV, GBS, HCV NAAT)CPT

87521	Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, amplified probe technique, includes reverse transcription when performed.
87522	Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performed.
87623	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44).
87624	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68), pooled result.
87625	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed.
87626	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), separately reported high-risk types (eg, 16, 18, 31, 45, 51, 52) and high-risk pooled result(s).
87653	Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique

Referenced HCPCS CodesHCPCS

G0476

Infectious agent detection by nucleic acid (DNA or RNA); human papillomavirus (HPV), high-risk types ... for cervical cancer screening, must be performed in addition to pap test

inv-16: HPV genotyping interval

IntervalOnce every 5 years

ConditionWhen member is an individual born with a cervix aged 30–65 without hysterectomy or younger/older with increased risk

ExceptionMore frequent testing if increased risk factors present (eg, immunocompromised, HIV, in‑utero DES exposure, history of CIN2/3 or cervical cancer)

inv-17: GBS screening gestational window

Gestational window36 weeks 0 days to 37 weeks 6 days (36 0/7–37 6/7 weeks)

Population

Provider Requirements, Billing, and Documentation

Prior Authorization

Code list tied to medical necessity

Coverage for tests is determined by the policy’s medical necessity criteria; use of the CPT/HCPCS codes listed in the policy must be supported by documentation that demonstrates the patient meets those criteria.

Inclusion of a code in the policy is informational and does not by itself establish medical necessity.

Billing Rule

Confirm prior authorization and correct coding

Verify whether any of the CPT/HCPCS codes referenced (e.g., 86803, 86804, 87520–87522, 87623–87626, 87653, G0476) require prior authorization in the payer system and ensure the correct code is submitted for the billed service.

Background and Scope

Human papillomaviruses (HPV) include low-risk types that commonly cause anogenital warts and high-risk (oncogenic) types associated with cervical cancer. Screening for cervical cancer is performed using cytology (Pap test), high-risk HPV testing, or a combination of both; this policy addresses molecular genotyping of high-risk HPV types for cervical cancer screening and specifies age- and risk-based indications. Hepatitis C (HCV) is a blood-borne viral infection for which one-time antibody screening is recommended for most adults and for pregnant persons; nucleic acid (RNA/PCR) testing is used to confirm infection, detect early exposure, and monitor antiviral therapy. Group B Streptococcus (GBS) commonly colonizes the genital tract and is screened in pregnancy near term (between 36 weeks 0 days and 37 weeks 6 days gestation) to identify colonization and guide intrapartum prophylaxis decisions.

Definitions and Test Descriptions

inv-28: High-risk HPV genotyping definition

DefinitionMolecular testing to detect oncogenic (high‑risk) HPV types used for cervical cancer screening and risk stratification

Use caseUsed for individuals born with a cervix as part of screening (alone or cotesting) per age/risk criteria

ExamplesDetects high‑risk types such as 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68

inv-29: HCV nucleic acid/PCR definition

DefinitionQuantitative or qualitative HCV RNA testing (nucleic acid amplification/PCR) used for confirmatory diagnosis, early post‑exposure detection, and monitoring

IndicationsInitial antibody positive, suspected recent exposure, immunocompromised, monitoring before/during/after antiviral therapy

Policy Summary

PayerAmbetter Nevada

PolicyCONCERT INFECTIOUS DISEASE: PRIMARY CARE & PREVENTATIVE SCREENING

Policy CodePolicy 2025.1

Change TypeAffirmed medical necessity languageadded perinatal HCV PCR criterioncoding table revisions

Effective Date

Last ReviewNov 1, 2024

Next Review Date

SourceLink

On This Page

NotesScreening performed on vaginal–rectal specimens to identify colonization and guide intrapartum prophylaxis

inv-18: Perinatal HCV testing age window

Age window2 months to 17 months for perinatally exposed infants

IndicationUsed when member was exposed to HCV perinatally

PurposeDiagnostic confirmation of perinatal exposure (HCV RNA PCR) as specified in policy

Confirm PA requirements in Ambetter Nevada systems before ordering or submitting claims.

Step Therapy

Reflex HCV RNA PCR testing after positive antibody

When an HCV antibody is positive, PCR (HCV RNA) testing as an automatic reflex from the initial antibody test is considered an appropriate and recommended approach for initial screening confirmation.

Reflex HCV RNA PCR testing is explicitly noted as the most appropriate option for initial HCV screening following antibody testing.

Note

Order tests only when clinical criteria are met

Follow the policy’s medically necessary indications before ordering tests; do not rely on code lists alone—ensure clinical reasons meet the policy criteria to avoid denials.

Tests must meet the specific clinical criteria in the policy (e.g., age windows, pregnancy gestational timing, exposure or risk conditions).

Documentation Required

Required clinical documentation

Document the clinical indication and supporting details in the medical record, including patient age and relevant risk factors; for pregnant patients include gestational age, and for HCV testing include prior antibody results or exposure history and rationale for nucleic acid/PCR testing.

Clinical indication and patient age/risk factors
Pregnancy gestational age for GBS screening (36 0/7–37 6/7 weeks)
Prior HCV antibody results, exposure history, or monitoring rationale for PCR testing

Billing Rule

Use current CPT and professional coding guidance

Reference current CPT descriptions and professional coding guidance when assigning codes; the policy notes CPT codes and descriptions are informational and recommends checking up-to-date coding sources before claim submission.

Policy moved CPT codes into a CPT table and removed certain codes; verify current manuals and payer guidance.

Denial Risk

Denial risk for out‑of‑criteria testing

Tests ordered outside the policy’s specified medically necessary indications (for example outside age ranges, outside the GBS gestational window, or for investigational indications such as low‑risk HPV genotyping) may be considered investigational and are at risk for denial.

Low‑risk HPV genotyping is explicitly investigational.
GBS screening outside 36 0/7–37 6/7 weeks or for current GBS bacteriuria/history of GBS-infected newborn is investigational.
HCV NAAT/PCR outside listed indications is investigational.

Denial Risk

Code listing does not ensure coverage

Inclusion of CPT/HCPCS codes in the policy does not guarantee payment; confirm coverage and prior authorization requirements with the payer and support claims with documentation that meets the medical necessity criteria.

Codes listed are informational; providers must verify coverage with Ambetter Nevada prior to submission.

Reflex practicePCR testing as automatic reflex from positive HCV antibody is considered appropriate

inv-30: GBS vaginal-rectal screening definition

DefinitionCulture or NAAT-based testing of vaginal–rectal specimens to detect Group B Streptococcus colonization

TimingPerformed at 36 0/7 to 37 6/7 weeks gestation

PurposeIdentify colonization to guide intrapartum prophylaxis; NAAT methods may be equivalent or more sensitive if enrichment step used

inv-31: Hepatitis C nucleic acid/PCR testing

DefinitionMolecular testing to detect or quantify HCV RNA (CPT codes include 87520–87522) used for diagnostic confirmation and for perinatally exposed infants

CPT rangeIncludes CPT codes 87520–87522 for HCV RNA testing as referenced in policy coding sections

Clinical usesUsed for confirmation after positive antibody, early detection post‑exposure, baseline/monitoring prior to and after DAA therapy, and perinatal testing