No prior authorization specified in excerpt

The policy excerpt does not specify any prior authorization requirements for hepatitis testing or related laboratory assays.

Prior authorization not provided here

No prior authorization requirements are described in these excerpts; the document concentrates on recommended testing algorithms, indications, and available assays rather than payer authorization rules.

Document quantitative HCV RNA and baseline labs before DAA

Quantitative HCV RNA testing and recommended pretreatment laboratory tests should be obtained prior to initiating direct-acting antiviral (DAA) therapy; document a baseline quantitative HCV viral load.

• Quantitative HCV RNA prior to initiation of DAA therapy MEETS COVERAGE CRITERIA (AASLD recommendation).
• Obtain baseline labs within six months prior to DAA: CBC, INR, hepatic function panel, and eGFR.

Order HBV DNA testing after a positive HBsAg

Laboratory-based HBV DNA nucleic acid testing (quantitative or qualitative) is recommended following a positive HBsAg to assess viral load for treatment eligibility; reflex HBV DNA testing from the same sample is an acceptable strategy where available.

• Use laboratory-based HBV DNA assays directly after a positive HBsAg to assess viral load for treatment decisions.
• When available, reflex HBV DNA testing from an existing sample or immediate collection after a positive rapid HBsAg may be used to promote linkage to care.

Refer to policy CPT/HCPCS code list for hepatitis tests

The policy lists applicable CPT and HCPCS procedure codes for hepatitis serology and nucleic acid testing; providers should consult the coding table when submitting claims.

• Serology and antibody CPT codes (e.g., 86692, 86704–86706, 86708–86709, 86803–86804) are listed in the policy.
• Nucleic acid detection CPT codes (e.g., 87516–87523, 87799) and HCPCS codes (G0472, G0567) are included in the coding section.

Use current policy-listed CPT/HCPCS codes when billing

Multiple HCPCS and CPT codes were added or updated in recent revisions; ensure claims use the currently listed codes from the policy's coding table.

• Revision history documents addition of HCPCS G0567 and several CPT codes (e.g., 86692, 86708, 86709, 87380, 87516, 87523, 87799).
• Confirm the current policy code list prior to billing to avoid use of outdated codes.

Perform genotype and viral-load testing to guide DAA therapy

Although not a payer step-therapy requirement in this excerpt, the policy recommends obtaining HCV genotype and quantitative viral load testing prior to DAA therapy to guide regimen selection and monitoring.

• One-time HCV genotype testing prior to DAA when it may alter treatment selection.
• Quantitative HCV viral load testing at pre-specified on-therapy and post-therapy timepoints for monitoring.

Use recommended HCV testing algorithm (antibody→NAT or RNA-first)

Follow the recommended sequencing: either two-step testing (anti-HCV antibody screening followed by NAT confirmation) or a viral-first (RNA-first) approach; choose the algorithm based on test availability and population to avoid diagnostic delays.

• Two-step: antibody screening with reflex NAT for HCV RNA when antibody is reactive.
• Viral-first: direct HCV RNA detection may be used where appropriate (e.g., point-of-care RNA tests).

Document SVR: undetectable HCV RNA 12 weeks post-DAA

Confirm sustained virologic response (SVR) by documenting undetectable HCV RNA at 12 weeks after completion of DAA therapy and record the result in the medical record.

• Routine confirmation at 48 weeks post-treatment is recommended; consider 24-week testing individually.
• Periodic HCV RNA testing beyond 48 weeks is reserved for patients with ongoing reinfection risk.

Document history, exam, and baseline labs for HBV evaluation

Document a focused history and physical for chronic HBV evaluation and include recommended laboratory testing (CBC with platelets; liver chemistry tests including AST, ALT, total bilirubin, alkaline phosphatase, albumin; INR) and HBV replication tests (HBeAg, anti-HBe, HBV DNA).

• Assess risk factors for coinfection (HCV, HDV, HIV), alcohol use, family history of HBV/HCC, and signs of cirrhosis.
• Consider HAV IgG testing in those not immune and additional evaluation for liver disease severity per guidelines.

Collect samples in one visit and reflex HCV RNA when antibody is reactive

Collect all samples needed to diagnose hepatitis C during a single visit when possible and order HCV RNA testing automatically (reflex) when the HCV antibody is reactive to reduce delays.

• For perinatally exposed infants, perform HCV RNA NAT at 2–6 months of age.
• Ensure labs and reflex testing are ordered per CDC operational guidance to streamline diagnosis and treatment initiation.

Document quantitative HCV viral load before starting therapy

Obtain quantitative HCV RNA prior to initiating antiviral therapy to document baseline viremia; document the quantitative viral load in the medical record to support treatment decisions.

• Quantitative HCV RNA is specifically recommended prior to DAA initiation (AASLD).
• Record baseline viral load and relevant hepatic function tests before starting therapy.

Document serologic interpretation and follow-up per AASLD table

Interpretation of combined HBsAg, anti-HBc, and anti-HBs results should be documented per the referenced AASLD interpretation table, including indicated follow-up steps such as additional testing, HBV DNA assessment, or vaccination recommendations.

• Use the policy's referenced interpretation table to classify current infection, past/resolved infection, immunity, or susceptibility and document the plan.
• Document any recommended follow-up testing (e.g., IgM anti-HBc, HBV DNA) when indicated by results.

Document HCV RNA results, hepatic function, and liver disease assessment

Document HCV RNA results to confirm SVR (undetectable HCV RNA at 12 weeks post-treatment) and record hepatic function panel and liver disease severity assessment prior to HCV therapy.

• Record hepatic panel (albumin, bilirubin, ALT, AST, alkaline phosphatase) and liver disease assessment before initiating treatment.
• Include documentation of follow-up HCV RNA testing at recommended post-treatment intervals.

Document the high‑risk indication when ordering HBV triple panel

When ordering the HBV triple panel (HBsAg, anti-HBs, anti-HBc) for screening, document the high-risk indication or clinical rationale that meets the policy criteria (e.g., geographic birth/ancestry, injection-drug use, planned immunosuppression).

• Policy specifies triple panel once per lifetime for adults ≥18 and for numerous high-risk scenarios—document which criterion applies.
• Support panel orders with patient history (travel, birth country, exposures, comorbidities) as appropriate.

Do not request quantitative HAV or HDV viral load testing (non‑covered)

Quantitative nucleic acid testing for HAV or HDV viral load does not meet coverage criteria and requests for quantitative HAV/HDV viral load testing may be denied.

• For acute HAV, use IgM anti-HAV or qualitative HAV RNA testing (quantitative HAV RNA not covered).
• For HDV, anti-HDV serology or qualitative HDV RNA is allowed; quantitative HDV RNA testing does not meet coverage.

Order automatic reflex HCV RNA when antibody is reactive

Order reflex NAT testing (HCV RNA) automatically when an HCV antibody test is reactive; failure to perform reflex NAT may delay diagnosis and is contrary to CDC operational guidance.

• CDC recommends collecting all samples in a single visit and automatic NAT when antibody is reactive to reduce time to diagnosis and treatment.
• Ensure laboratory orders include reflex HCV RNA for reactive antibody results.

Use FDA‑approved HBsAg tests and perform confirmatory testing for reactive results

Screening must use FDA-approved HBsAg tests followed by a confirmatory test for initially reactive results; lack of confirmatory testing for reactive HBsAg may affect coverage or trigger denial.

• USPSTF states HBsAg tests should be FDA-approved and followed by confirmatory testing for initially reactive results.
• When performing HBsAg screening, include confirmatory testing workflow in orders and documentation.

Avoid repeat HCV antibody testing after prior positive result

Do not repeat HCV antibody testing in patients with a prior positive HCV antibody result; instead order HCV viral load testing to determine active versus resolved infection.

• AASLD recommends against repeat HCV antibody testing because it adds cost without clinical benefit.
• Order HCV RNA (viral load) to assess active infection when prior antibody positivity is known.

Government policies override this policy when conflicts exist

If this policy conflicts with an applicable government policy (e.g., LCDs or NCDs), the government policy governs coverage determinations and could lead to denial if provider documentation relies on conflicting policy language.

• Refer to current Medicare/Medicaid LCDs/NCDs or state Medicaid rules when applicable.
• When in doubt, follow the government policy that applies to the member's coverage.

Quantitative HAV/HDV viral-load testing does not meet coverage

Quantitative nucleic acid testing for HAV and HDV viral load is explicitly stated as not meeting coverage criteria; such testing requests are subject to denial.

• Policy statements in coverage and revision history explicitly note quantitative HAV and HDV viral load testing DOES NOT MEET COVERAGE CRITERIA.
• Use allowed qualitative tests (IgM anti-HAV, qualitative HAV RNA; anti-HDV, qualitative HDV RNA) instead when clinically indicated.

Background context (informational)

General background on hepatitis viruses is provided in the policy for clinical context; no provider action is required beyond following the coverage criteria and testing recommendations.