Verify member benefits and regulatory requirements before requesting PA

Coverage application depends on the member’s benefit plan at the time of the request; verify the member’s coverage and any applicable Medicare/Medicaid requirements before requesting prior authorization. The policy notes that specifications pertaining to Medicare and Medicaid are in the 'Applicable State and Federal Regulations' section and that prior authorization may be required per the member’s benefit plan.

• Verify coverage and prior‑authorization requirements at time of request.
• Follow Applicable State and Federal Regulations for Medicare and Medicaid members.

Use CDC‑recommended testing approaches (antibody with reflex NAT)

Follow CDC testing guidance: start with an FDA‑approved HCV antibody test with automatic reflex to NAT for HCV RNA when antibody is reactive; no payer‑specific prior authorization language for testing modality is specified in these sections.

• Use FDA‑approved anti‑HCV assays and order NAT reflex automatically when antibody is reactive.
• CDC recommends HBV triple‑panel (HBsAg, anti‑HBs, anti‑HBc) screening for adults at least once—no PA language in the cited excerpts.

Obtain and document baseline quantitative HCV RNA before DAA

Document a baseline quantitative HCV RNA (viral load) prior to initiating direct‑acting antiviral (DAA) therapy to establish baseline viremia for treatment planning and monitoring; quantitative HCV RNA prior to DAA initiation MEETS COVERAGE CRITERIA.

• Obtain and document quantitative HCV RNA prior to DAA start (baseline viral load).
• Quantitative HCV RNA is listed as covered prior to initiation of DAA therapy.

Document indication and results for HBV DNA testing used in treatment assessment

When HBV DNA testing is used to assess treatment eligibility or monitor response after a positive HBsAg, document the indication and results; laboratory‑based HBV DNA assays are recommended following a positive HBsAg, and point‑of‑care HBV DNA assays may be used as an alternative.

• Document indication for HBV DNA testing (treatment eligibility, monitoring).
• Use laboratory‑based HBV DNA NAT per recommendations; POC HBV DNA assays acceptable as alternative.

Use listed CPT/HCPCS procedure codes on authorization requests and claims

Use the policy’s listed CPT/HCPCS codes when requesting authorization or submitting claims for hepatitis testing services; the document enumerates applicable procedure codes for antibody and nucleic acid tests.

• Include relevant codes (e.g., 86692, 86704–86709, 86803–86804, 87516–87523, 87902, G0472) on authorization requests and claims.
• Refer to the policy coding section for the full list of applicable procedure codes.

New and revised billing codes noted in revision history — verify PA separately

Revision history lists additional HCPCS/CPT codes added to the coding list (e.g., G0567, 87799, 86692, 86708, 86709, 87380, 87516, 87523); the revision notes do not specify separate prior‑authorization requirements for these added codes.

• Recognize newly added codes recorded in the revision history when billing (see revision section).
• Prior authorization requirements for these added codes are not specified in the cited chunks; verify benefits as needed.

Order one‑time HCV genotype test before initiating DAA therapy

Obtain one‑time HCV genotype testing prior to initiating DAA therapy when genotype information may alter regimen selection; the policy states genotype testing one time before DAA initiation MEETS COVERAGE CRITERIA.

• Order HCV genotype testing one time prior to DAA initiation if it will guide regimen selection.
• Document genotype result in the treatment plan when relevant to regimen choice.

Choose antibody‑first with reflex NAT or viral‑first RNA testing based on setting

Select testing approach based on availability and population: either antibody‑first with reflex NAT (CDC/WHO recommended) or a viral‑first (RNA) testing strategy where appropriate; no step‑therapy restrictions on testing approach are specified in these excerpts.

• Use two‑step (anti‑HCV then RNA) testing generally; consider viral‑first RNA testing when available or appropriate for the setting.
• Clinicians should test anyone requesting HCV testing regardless of stated risk.

Monitor viral load and liver parameters during and after HCV therapy; continue HCC surveillance when indicated

Follow recommended monitoring and posttreatment testing schedules: quantitative HCV RNA testing at baseline, after 4 weeks of therapy, at end of treatment, and at 12, 24, and 48 weeks post‑treatment as applicable; for patients with cirrhosis, continue HCC surveillance per AASLD guidance.

• Document quantitative HCV RNA at baseline, week 4, end of treatment, and 12/24/48 weeks post‑treatment when indicated.
• Perform hepatic panels and periodic labs per AASLD; continue HCC surveillance (ultrasound ± AFP) every 6 months for cirrhotic patients.

Perform anti‑HCV screening then confirm reactive results with HCV RNA NAT

When using the two‑step approach operationally: perform an initial anti‑HCV antibody test and follow a reactive result with HCV RNA NAT to confirm active infection before initiating treatment.

• Initial anti‑HCV antibody screening followed by confirmatory HCV RNA NAT when antibody is reactive.
• Ensure reflex NAT is performed automatically when available to reduce diagnostic delay.

Document genotype, baseline hepatic labs, and serial viral‑load monitoring around HCV therapy

Before and during HCV therapy, document HCV genotype (if needed), perform a hepatic function panel and baseline labs within six months prior to starting DAA, and monitor viral load according to recommended timepoints to guide treatment and confirm SVR.

• Obtain hepatic function panel, CBC, INR, and eGFR within 6 months prior to DAA start.
• Document quantitative HCV RNA prior to treatment and at recommended on‑therapy and post‑treatment intervals; confirm SVR by undetectable HCV RNA at 12 weeks post‑treatment.

No step‑therapy requirements specified in cited sections

No step therapy requirements for antiviral hepatitis treatment are specified in the provided sections of this policy.

• If you need confirmation about step therapy for a specific drug, verify benefit plan drug‑utilization management rules.

Verify member benefits and PA requirements at time of request

Verify coverage at the time of the request; the policy explicitly states application of coverage criteria depends on the individual’s benefit coverage and references Medicare/Medicaid specifications in the Applicable State and Federal Regulations section.

• Confirm member eligibility and any PA or coding requirements prior to ordering tests.
• Refer to the policy’s Applicable State and Federal Regulations for Medicare/Medicaid specifics.

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

Collect all samples needed to complete hepatitis C diagnosis in a single visit when possible and order reflex HCV RNA testing automatically when the HCV antibody is reactive to minimize delays in diagnosis and linkage to care.

• Collect specimens for both antibody and RNA testing during the same visit when feasible.
• Order automatic reflex HCV RNA testing for reactive antibody results, and for perinatally exposed infants, perform NAT at 2–6 months.

Document antibody + reflex RNA results and baseline quantitative HCV RNA before therapy

Document HCV‑antibody testing with reflex HCV RNA PCR for initial diagnosis and document baseline quantitative HCV RNA prior to initiating antiviral therapy; baseline labs (CBC, INR, hepatic panel, eGFR) are recommended within six months before starting DAA therapy.

• Include records of antibody test, reflex NAT result, and baseline quantitative viral load in the medical record.
• Document recommended baseline labs (CBC, INR, hepatic panel, eGFR) within six months of DAA initiation.

Document maternal infection status and reflex testing for exposed infants

For perinatally exposed infants and siblings, document the maternal HCV or HBV infection status and any reflex testing performed (e.g., reflex HBV DNA or anti‑HDV reflex) to support linkage to care for exposed children.

• Record maternal HBsAg/HCV status in the infant’s chart.
• Document reflex HBV DNA or anti‑HDV testing when performed to expedite diagnosis and care linkage.

Document risk status and clinical assessments that justify testing

Document clinical risk status and relevant assessments to support testing: examples include HBsAg, anti‑HBc, HBV DNA for patients undergoing immunosuppression; HCV RNA testing to confirm SVR or active infection; and liver disease severity assessment prior to HCV therapy.

• Record risk factors and clinical indications that justify testing and monitoring.
• For patients undergoing immunosuppression, document HBV serology and HBV DNA if positive.

Document clinical justification for qualitative HAV/HDV testing; quantitative viral loads not covered

Include documentation supporting qualitative HAV or HDV testing or antibody testing in covered scenarios (e.g., symptomatic acute HAV or HDV testing in HBV‑positive persons); quantitative HAV or HDV viral‑load testing does not meet coverage criteria.

• Support claims for qualitative HAV RNA or IgM anti‑HAV in symptomatic individuals with documentation of negative HBV/HCV testing.
• For HDV, document anti‑HDV or qualitative HDV RNA testing in HBV‑positive patients; avoid quantitative HDV viral‑load billing.

Denial risk: quantitative HAV and HDV viral‑load tests are not covered

Quantitative nucleic acid testing for HAV and for HDV viral load does not meet coverage criteria and may be denied if billed; avoid ordering or billing quantitative HAV or HDV viral‑load tests unless benefit confirmation indicates coverage.

• Do not bill quantitative HAV or HDV viral‑load tests (policy states these DO NOT MEET COVERAGE CRITERIA).
• If such testing is clinically requested, verify member benefits and coding guidance before ordering to avoid denial.

Denial risk/delay if confirmatory HCV RNA NAT is not performed after reactive antibody

Failure to perform confirmatory HCV RNA NAT after a reactive HCV antibody test (per CDC operational guidance) may delay diagnosis and care; ensure reflex NAT is done or ordered to confirm active infection.

• Order or ensure automatic reflex HCV RNA NAT when anti‑HCV is reactive.
• Document confirmatory NAT results in the record to support diagnosis and treatment decisions.

Confirm reactive HBsAg with FDA‑approved assays and confirmatory testing

Use FDA‑approved HBsAg assays for screening and perform confirmatory testing for initially reactive HBsAg results; failure to perform confirmatory HBsAg testing could lead to misclassification and inappropriate management.

• Perform confirmatory testing when HBsAg is initially reactive, as recommended by USPSTF and CDC.
• Use FDA‑approved HBsAg assays for screening per guideline recommendations.

Avoid repeat anti‑HCV antibody testing after previous positive—order HCV RNA

Do not repeat anti‑HCV antibody testing in patients with a prior positive antibody result; instead, order an HCV viral‑load (RNA) test to assess active versus resolved infection as repetition of antibody testing is not recommended and adds cost without benefit.

• If prior anti‑HCV is positive, order HCV RNA viral‑load testing rather than repeating antibody testing.
• Avoid billing redundant anti‑HCV tests for patients with prior positive results to reduce risk of denial.

Government policies (LCD/NCD/state Medicaid) take precedence—verify applicable rules

If this policy conflicts with an applicable government policy (LCD, NCD, or state Medicaid), the government policy takes precedence; noncompliant claims relative to applicable government policy risk denial.

• Check for applicable LCDs/NCDs or state Medicaid rules that may override this policy for the member.
• Use government policy resources (CMS website; state Medicaid site) to confirm coverage determinations.

Denial risk: quantitative HAV/HDV viral‑load testing reiterated as noncovered

Reiterates that quantitative nucleic acid testing for HAV and HDV viral loads DOES NOT MEET COVERAGE CRITERIA; such tests could be denied if billed.

• Avoid ordering or billing quantitative HAV/HDV viral‑load assays without explicit coverage confirmation.
• Document clinical rationale and verify benefits if such testing is considered despite policy exclusion.