Concert Infectious Disease: Primary Care & Preventative Screening (PDF)
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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.
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.
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.
HPV Genotyping — High- and Low-Risk
Genotyping of High Risk Human Papillomavirus (HPV) Types for Cervical Cancer Screening
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)
- 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
Genotyping of High Risk Human Papillomavirus (HPV) Types - Not Medically Necessary / Investigational
Genotyping of Low Risk Human Papillomavirus (HPV) Types
ALL of the following
- Human papillomavirus (HPV) genotyping of low risk types is considered investigational.
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.
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.
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
- 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)
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
This criteria does not apply to members/enrollees with liver disease and/or other signs and symptoms of active hepatitis C virus infection
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.
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
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
Coding
| 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 |
Provider Actions & Billing Impact
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.
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
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 (material).
Added CPT code 87626 to CPT coding table (HPV genotyping separately reported high‑risk types) (material).
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).
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).
Administrative coding cleanup: removed CPT codes 0500T, 87081, 87149 and 87150 from the policy reference table (non‑material/administrative).
Corrected CPT code descriptions and policy number updated (administrative/technical corrections).
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