CurrentArizona Complete HealthPolicy CG.CP.MP.05

Concert Infectious Disease: Primary Care & Preventative Screening (PDF)

Outpatient clinical coverage criteria for HPV genotyping (high- and low-risk), hepatitis C antibody and nucleic acid/PCR testing, and group B streptococcus (GBS) vaginal-rectal screening in pregnancy, including medically necessary indications and investigational exclusions.

Policy Summary

PayerArizona Complete Health

PolicyConcert Infectious Disease: Primary Care & Preventative Screening (PDF)

Policy CodePolicy CG.CP.MP.05

Change TypeMaterial revisions and coding additions

Effective Date

Next Review Date

Key ActionDocument that member was born with a cervix and age (30-65 for routine 5-year genotyping) and prior surgical history or relevant HCV/GBS eligibility per policy criteria.

SourceLink

POLICY UPDATE CHANGES

Changed policy statement verbiage from 'may be considered medically necessary' to 'are considered medically necessary' for Group B Streptococcus screening, High Risk HPV genotyping, and Hepatitis C Nucleic Acid/PCR tests.

Added CPT code 87626 to CPT Coding table and HCPCS code G0476 to new HCPCS table.

For Hepatitis C Nucleic Acid/PCR Tests, added the criteria option: 'The member was exposed to HCV perinatally and is between 2 months and 17 months of age'.

Removed CPT codes 0500T, 87081, 87149 and 87150 from the policy reference table.

Corrected CPT code descriptions and policy number updated.

3Covered screening categories (HPV, HCV, GBS)

3Investigational categories

14CPT/HCPCS codes listed

Coverage Summary

This outpatient coverage policy addresses screening for three infectious disease areas aligned with national guidance: high-risk HPV genotyping for cervical cancer screening, hepatitis C virus (HCV) antibody and nucleic acid (PCR) testing (including reflex RNA testing), and antepartum Group B Streptococcus (GBS) vaginal-rectal screening. The policy scope is limited to outpatient screening indications and documents medically necessary criteria and investigational exclusions for each test category.

Guideline alignment: HPV screening recommendations follow USPSTF and CDC guidance for cervical cancer screening (including hrHPV testing and cotesting strategies); HCV recommendations reflect USPSTF, CDC, and IDSA/AASLD guidance supporting universal or risk-based antibody screening with reflex HCV-RNA testing and specific recommendations for perinatally exposed infants; and GBS antepartum screening timing and methods reference ACOG Committee Opinion (screening at 36 weeks 0 days to 37 weeks 6 days). The policy incorporates these national recommendations into coverage criteria for outpatient testing.

Surface thresholds[]

HPV genotyping frequencyOnce every 5 years (in absence of increased risk factors)

GBS gestational window36 weeks 0 days to 37 weeks 6 days gestation

HCV exposure PCR windowWithin the past 6 months (for suspected exposure)

Perinatal HCV PCR age window2 months to 17 months of age for perinatally exposed infants

Policy metadata

policy_numberCG.CP.MP.05

subjectInfectious disease screening: HPV, Hepatitis C, Group B Streptococcus

statusCURRENT

last_review2024-11-01

has_material_changetrue

scope_summaryOutpatient clinical coverage criteria for HPV genotyping, hepatitis C antibody and nucleic acid/PCR testing, and GBS vaginal-rectal screening in pregnancy

HPV Genotyping — High- and Low-Risk

Genotyping of High Risk Human Papillomavirus (HPV) Types for Cervical Cancer Screening

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Genotyping of High Risk Human Papillomavirus (HPV) Types for Cervical Cancer Screening - Medical Necessity

ALL of the following

ALL of the following
- Has NOT had a hysterectomy with removal of the cervix
- Or has a history of high-grade precancerous lesion (eg, cervical intraepithelial neoplasia [CIN] grade 2 or 3)

Hepatitis C Screening and NAAT/PCR Testing

Hepatitis C Antibody Screening Tests

Hepatitis C antibody screening tests are considered medically necessary when ALL of the criteria below are met:

ALL of the following

Pre-test exclusions
- The member/enrollee does NOT have a known past positive HCV Antibody test result
- The member/enrollee does not have a known history of chronic HCV infection
At least one of
- The member/enrollee is pregnant

Group B Streptococcus (GBS) Screening in Pregnancy

Group B Streptococcus Screening Tests of Vaginal-Rectal Specimens

Group B Streptococcus screening tests of vaginal-rectal specimens are considered medically necessary when ALL of the following are met:

Gestational timing

The member/enrollee is pregnant
The pregnancy is between 36 weeks 0 days and 37 weeks and 6 days gestation36 weeks 0 days to 37 weeks 6 days

Investigational / Not covered: GBS screening is considered investigational for pregnant members/enrollees who have GBS bacteriuria during the current pregnancy; GBS screening is considered investigational for pregnant members/enrollees who have a history of a previous GBS-infected newborn; GBS screening is considered investigational for all other indications

Coding

CPT codes referenced (informational)mixed

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
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
87624	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types, 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 and high-risk pooled result(s)
87653	Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique

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Provider Actions & Billing Impact

Billing Rule

HCV reflex PCR billing guidance

Billing rule / Reflex testing: PCR/NAAT reflex testing from HCV antibody screening is appropriate as an automatic reflex; use appropriate HCV NAAT CPT codes for reflex and quantification when required.

Reflex HCV NAAT/PCR CPT codes: 87521, 87522
Guidance: use appropriate NAAT/quantitative HCV CPT codes for reflex and confirmatory testing

Background & Evidence

Background: This policy summarizes and adopts key elements from USPSTF, CDC, ACOG, and IDSA/AASLD guidance for outpatient infectious disease screening. HPV is described as the most common STI with specific high-risk types linked to cervical cancer; USPSTF recommends screening strategies for individuals with a cervix aged 30 to 65 years using cytology every 3 years, hrHPV alone every 5 years, or cotesting every 5 years. CDC guidance outlines appropriate uses and limitations of HPV testing.

HCV guidance: USPSTF and CDC recommend routine HCV antibody screening for adults (with reflex to nucleic acid testing for confirmation), universal screening in pregnancy per CDC, and IDSA/AASLD endorse antibody testing with reflex HCV-RNA PCR for initial testing and quantitative RNA testing for monitoring and treatment decisions. The policy reflects recommendations for reflex NAAT and for testing of perinatally exposed infants at appropriate ages.

GBS guidance: ACOG recommends antepartum screening for GBS in pregnant individuals at 36 0/7 to 37 6/7 weeks gestation; NAAT-based testing is an acceptable alternative to culture under specified laboratory protocols. The policy is intended for outpatient prenatal screening and incorporates these timing and methodological recommendations.

Source	Summary
USPSTF cervical screening recommendation (age/frequency)
Screen individuals with a female reproductive system aged 30–65: cytology every 3 years, high-risk HPV testing alone every 5 years, or cotesting every 5 years (USPSTF 2018). Do not screen those post-hysterectomy without prior high-grade lesion or cancer; individualize for high-risk persons.
CDC HCV screening
CDC recommends universal hepatitis C screening for adults and screening of all pregnant individuals during each pregnancy (with exceptions based on very low prevalence); reflex NAT/HCV RNA testing is recommended for initial testing and perinatal exposed infants guidance supports NAT at specified ages.
ACOG GBS guidance
ACOG recommends antepartum GBS screening for all pregnant individuals at 36 0/7 to 37 6/7 weeks; NAAT-based testing is an acceptable alternative to culture when enrichment protocols are used.

Definitions:

• Increased risk for cervical cancer: includes immunocompromised status or HIV infection, in-utero exposure to diethylstilbestrol, and a history of cervical lesion (e.g., CIN2/3) or cervical cancer.

• Perinatal HCV exposure: an infant born to an HCV-infected mother (perinatally exposed infants should receive NAT for HCV RNA at age 2–6 months or at ages 7–17 months if not previously tested, per CDC/IDSA-AASLD recommendations).

Revision History

11/24wording_changeLatest

11/24code_addedLatest

Added CPT code 87626 to CPT coding table (HPV genotyping separately reported high‑risk types) (material).

11/24code_added

Policy Summary

PayerArizona Complete Health

PolicyConcert Infectious Disease: Primary Care & Preventative Screening (PDF)

Policy CodePolicy CG.CP.MP.05

Change TypeMaterial revisions and coding additions

Effective Date

Next Review Date

Key ActionDocument that member was born with a cervix and age (30-65 for routine 5-year genotyping) and prior surgical history or relevant HCV/GBS eligibility per policy criteria.

SourceLink

On This Page

Or has a history of cervical cancer

The member/enrollee is an individual born with a cervix, who is younger than 30 or older than 65 years of age, AND is at increased risk for cervical cancer (eg, immunocompromised, HIV infection, in-utero exposure to diethylstilbestrol, history of cervical lesion or cervical cancer)

Genotyping of High Risk Human Papillomavirus (HPV) Types - Frequency

Human papillomavirus (HPV) genotyping of high risk types is considered medically necessary once every 5 years in the absence of increased risk factors for cervical cancer (eg, immunocompromised, HIV infection, in-utero exposure to diethylstilbestrol, history of cervical lesion or cervical cancer).

Genotyping of High Risk Human Papillomavirus (HPV) Types - Not Medically Necessary / Investigational

Human papillomavirus (HPV) genotyping of high risk types is considered investigational for all other indications, including evaluation of genital warts or general sexually transmitted infection screening.

Genotyping of Low Risk Human Papillomavirus (HPV) Types

ALL of the following

Human papillomavirus (HPV) genotyping of low risk types is considered investigational.

Documentation Required

Documentation Requirements

Documentation required: Indicate cervix status, member age, and relevant history (eg, prior CIN2/3, cervical cancer, hysterectomy, immunocompromised state) in the medical record.

Document whether member was born with a cervix and whether cervix remains present (eg, prior hysterectomy with cervix removal).
Record member age at time of testing and any history of high-grade precancerous lesion or cervical cancer.
Document immunocompromising conditions (eg, HIV) or in-utero diethylstilbestrol exposure if present.

Prior Authorization

Frequency Limitation and Affected Codes

Prior authorization / frequency limit: HPV genotyping for high-risk types is limited to once every 5 years for routine screening in individuals without increased risk. Affected CPT codes include 87624 and 87626.

Frequency limit: once every 5 years for routine screening absent increased risk.
Affected CPT codes: 87624, 87626.
Tests outside criteria or more frequent testing may be denied without documentation of increased risk or medical necessity.

Prior Authorization

HCV Antibody Screening — Provider Action

HCV antibody screening eligibility (provider action): Before ordering HCV antibody screening, confirm member does NOT have a known past positive HCV antibody result and does not have a known history of chronic HCV infection. HCV antibody screening is medically necessary when the member meets at least one: pregnant; asymptomatic adult age 18–79; child ≥18 months with perinatal exposure not previously tested; age <18 or >79 with increased risk; or member requests screening.

Do not order HCV antibody screening if there is a documented past positive HCV antibody or known chronic HCV history—consider quantitative HCV-RNA testing instead.
Medically necessary indications include: pregnancy; asymptomatic adults 18–79; perinatally exposed children ≥18 months not previously tested; individuals outside 18–79 with risk factors; or patient request.
If HCV antibody is positive or high suspicion exists, follow with confirmatory HCV nucleic acid/PCR testing per policy.

The member/enrollee is an asymptomatic adult between the ages of 18 and 79 years

Child >=18 months perinatal exposure

The member/enrollee is a child 18 months or older
The member/enrollee was perinatally exposed to HCV
The member/enrollee has not been previously tested

Younger than 18 or older than 79 with increased risk

The member/enrollee is younger than 18 or older than 79 years of age
The member/enrollee is at increased risk of HCV infection (e.g., past or current injection drug use, liver disease, chronic hemodialysis, HIV infection, HIV PrEP use, individuals with male reproductive systems who have sexual intercourse with individuals with male reproductive systems, partners of HCV infected individuals, organ transplant donor/recipient)

The member/enrollee requests screening (regardless of age or disclosure of potentially stigmatizing risks)

Not medically necessary / investigational: Hepatitis C antibody screening tests are considered investigational for all other indications

This criteria does not apply to members/enrollees with liver disease and/or other signs and symptoms of active hepatitis C virus infection

Notes: A quantitative HCV-RNA test rather than an HCV-antibody test is recommended to assess for HCV recurrence; This criteria does not apply to members/enrollees with liver disease and/or other signs and symptoms of active hepatitis C virus infection

Hepatitis C Nucleic Acid/PCR Tests

Hepatitis C nucleic acid/PCR tests for routine screening or confirmatory testing following a positive HCV antibody screening test are considered medically necessary when ANY of the following are met:

ANY of the following

The member/enrollee is immunocompromised (e.g., receives chronic hemodialysis)
The member/enrollee has a suspected HCV exposure within the past six months (regardless of antibody status)within the past 6 months
The member/enrollee has an initial HCV antibody positive test
The member/enrollee is undergoing monitoring for chronic HCV infection (i.e., prior to starting direct-acting antiviral (DAA) treatment, while receiving treatment, or having completed therapy)
The member/enrollee was exposed to HCV perinatally and is between two months and 17 months of age2 months to 17 months
Post-SVR ongoing risk
- The member/enrollee has a history of HCV infection followed by eradication/sustained virologic response (SVR)
- The member/enrollee has ongoing risk factors for HCV reinfection

Not medically necessary / investigational: Hepatitis C nucleic acid/PCR tests for routine screening or confirmatory testing following a positive HCV antibody screening test are considered investigational for all other indications

This criteria does not apply to members/enrollees with liver disease and/or other signs and symptoms of active hepatitis C virus infection

Notes: PCR testing as an automatic reflex from initial antibody tests is considered appropriate for initial HCV screening; A quantitative HCV-RNA test rather than an HCV-antibody test is recommended to assess for HCV recurrence; This criteria does not apply to members/enrollees with liver disease and/or other signs and symptoms of active hepatitis C virus infection

Billing Rule

Reflex PCR testing

PCR (NAAT) testing as an automatic reflex from an initial positive HCV antibody test is considered appropriate for initial HCV screening. Use appropriate NAAT/quantitative HCV CPT codes when performing reflex testing and document reflex testing on the claim.

Reflex PCR/NAAT CPT codes: 87521, 87522
Guidance: use appropriate NAAT/quantitative HCV CPT codes for reflex testing (e.g., amplified probe and quantification codes)

Documentation Required

GBS gestational timing

For antepartum GBS screening, document gestational age to confirm testing falls within the policy window and record exclusions per policy (current GBS bacteriuria or prior GBS‑infected newborn).

Document: gestational age confirming 36 weeks 0 days to 37 weeks 6 days
Document: exclude testing for current GBS bacteriuria in pregnancy
Document: exclude testing for history of prior GBS‑infected newborn
Affected CPT code (informational): 87653

Added HCPCS code G0476 to new HCPCS table (HPV high‑risk types for cervical cancer screening, must be performed in addition to pap test) (material).

11/24criteria_expansionLatest

Expanded Hepatitis C Nucleic Acid/PCR criteria to include perinatal exposure: 'The member was exposed to HCV perinatally and is between 2 months and 17 months of age' (material).

03/24coding_cleanup

Administrative coding cleanup: removed CPT codes 0500T, 87081, 87149 and 87150 from the policy reference table (non‑material/administrative).

02/24coding_correction

Corrected CPT code descriptions and policy number updated (administrative/technical corrections).