Obtain genotyping/phenotyping for specified indications

HIV genotyping or phenotyping meets coverage criteria for specified situations; providers must obtain genotypic and phenotypic testing prior to initiating doravirine and when indicated for treatment-experienced or failing regimens (e.g., suboptimal viral load reduction, noncompliance, acute/recent infection, ARV‑naïve entering care, pregnant individuals prior to ART or with detectable RNA).

• Required prior to initiating doravirine therapy (genotyping and phenotyping is required).
• Phenotyping meets coverage for treatment‑experienced individuals on failing regimens thought to have multidrug resistance.

Order genotypic resistance testing for initial care and virologic failure

Order genotypic resistance testing at entry into care to guide initial ART and when virologic failure occurs (HIV‑RNA >200 copies/mL), and include integrase genotyping when INSTI resistance is suspected or prior CAB‑LA exposure occurred.

• Genotypic testing recommended at entry into care (to guide selection of initial ART).
• Perform resistance testing for virologic failure (>200 copies/mL; stronger evidence at >1,000 copies/mL).
• Include INSTI genotyping if INSTI resistance is suspected or prior CAB‑LA exposure occurred.

Include INSTI genotyping (and phenotyping when complex)

When ordering resistance testing for virologic failure or to guide regimen selection, ensure genotypic assays include INSTI sequencing when indicated; providers may need to order INSTI‑specific assays separately and consider adding phenotypic testing for complex resistance patterns.

• Reverse transcriptase and protease genotypic testing should be performed for everyone with virologic failure; order integrase testing for INSTI‑based regimen failures.
• Add phenotypic testing when complex mutation patterns are known or suspected.

Use referenced procedure codes and follow PA rules

Refer to the listed CPT/HCPCS and proprietary codes when submitting claims; follow payer prior authorization policies for advanced assays or phenotypic testing as applicable.

• Codes listed include: 86701–86703, 87389–87391, 87534–87539, 87901, 87903–87904, 87906, 0219U, G0432–G0435, G0475, S3645.
• Prior authorization may be required for certain resistance or phenotypic assays per payer rules.

Do not use removed CPT code 86689 on claims

The policy removed CPT code 86689; do not bill using this removed code — claims using 86689 may be denied or require recoding to current covered codes.

• 86689 was removed from the policy's listed codes and may trigger denial or need recoding.
• Use current covered CPT/HCPCS codes from the policy when submitting claims.

Perform genotyping/phenotyping before doravirine

Obtain genotyping and phenotyping prior to initiating doravirine; document genotypic testing and use phenotyping when treatment‑experienced patients are on failing regimens suspected to have multidrug resistance.

• Genotyping and phenotyping are required prior to doravirine initiation.
• Phenotyping meets coverage for treatment‑experienced individuals on failing regimens thought to have multidrug resistance.

Start ART immediately for PrEP patients with RNA ≥200 copies/mL

If HIV is suspected in a person on PrEP with HIV RNA ≥200 copies/mL, initiate an effective HIV treatment regimen immediately while awaiting confirmation of diagnosis.

• Immediate initiation of effective ART is recommended for persons on PrEP with RNA ≥200 copies/mL while confirming diagnosis (AIII).
• Very low‑positive RNA (<200 copies/mL) requires confirmatory testing before initiating ART.

Do not require proviral testing for routine switches without failure

Do not routinely require proviral (proviral DNA) resistance testing prior to switching suppressed patients to 2‑drug therapy unless there is documented or suspected treatment failure; switching from long‑acting CAB+rPV back to oral therapy does not require proviral testing if suppression maintained.

• Proviral resistance testing is not required prior to switching to 2‑drug therapy unless documented/suspected treatment failure.
• Switching from long‑acting cabotegravir plus rilpivirine back to daily oral therapy can be done without proviral DNA resistance testing in patients who have maintained suppression.

Initiate ART without waiting for resistance results

Do not delay ART initiation while awaiting resistance test results; start ART promptly and modify the regimen later if resistance results indicate a change is needed.

• ART initiation should not be delayed for resistance testing results; regimens can be modified once results are reported.
• EACS and DHHS guidance support starting ART promptly and using resistance results to adjust therapy.

Follow recent policy revisions and Change Log

(See policy notes and revision history) Recent revisions added and clarified provider actions and testing criteria — review policy Change Log and Notes for details when ordering tests or performing prior authorization.

• Revision history documents additions (CC3, CC4, CC9), frequency guidance moved into Note 1, and removal of CPT 86689.
• Ensure claims and orders adhere to updated test‑type criteria and new notes.

Adhere to testing frequency limits

Antibody and antigen/antibody testing should not be repeated more often than once every 90 days; nucleic acid testing (qualitative or quantitative) should not be repeated more often than once every month.

• Antibody/antigen retest interval: not more often than every 90 days (Note 1).
• Nucleic acid testing retest interval: not more often than once every month (Note 1).

Document viral load and CD4 timing/results in the record

Document timing and results of viral load and CD4 testing in the medical record at entry into care, at ART initiation, and at recommended monitoring intervals to support medical necessity and coverage.

• Document viral load and CD4 at entry into care and per DHHS monitoring schedule (e.g., 4–8 weeks after ART start, then every 3–4 months or up to 6 months if stable).
• Document genotypic resistance testing performed before ART initiation and when virologic failure occurs.

Review and document prior resistance results

Review and document all prior and current drug‑resistance test results when designing a new antiretroviral regimen; include evidence of reviewed prior tests in the medical record when changing therapy after virologic failure.

• All prior and current resistance results should be reviewed and considered when constructing a new regimen.
• Documentation of reviewed prior tests should be included in the medical record when changing therapy after virologic failure.

Document investigations for indeterminate serology and monitoring

For indeterminate serology or inconclusive diagnostic testing, document investigation including PCR for HIV‑2 proviral DNA when indicated; document timing of viral load measurements and any resistance testing performed.

• Investigate indeterminate HIV‑1 or HIV‑2 serology with PCR for HIV‑2 proviral DNA.
• Document viral load monitoring per schedule and document resistance testing when viral load thresholds are met.

Document risk factors and indication when ordering tests

When ordering tests such as PrEP initiation/maintenance screening or testing after suspected exposure, document the patient's risk factors and specific indication (see Note 2) to support medical necessity.

• Document elevated‑risk factors (e.g., MSM, multiple partners, injection drug use, transactional sex, prior/concurrent STI/hepatitis/TB) per Note 2.
• Include the indication (PrEP initiation/maintenance, suspected recent exposure, positive/indeterminate screen) on the order and in the medical record.

Avoid non‑rapid antibody‑only screening tests

Screening with an antibody test that is non‑rapid and lacks an antigen component DOES NOT MEET COVERAGE CRITERIA; ordering such tests risks denial of coverage.

• Explicit policy statement: antibody test that does not provide rapid results and does not incorporate antigen testing does not meet coverage criteria (CC9).
• Antigen testing alone is also noncovered per revision history; use antigen/antibody combination assays or rapid antibody tests where indicated.

Attempt and document resistance testing even if VL >500 copies/mL

Even if HIV‑RNA is >500 copies/mL (where genotyping may be unsuccessful), attempt drug‑resistance testing and document inability to obtain a genotype if unsuccessful; failure to attempt recommended testing may affect coverage of regimen changes.

• Drug‑resistance testing may be unsuccessful when HIV‑RNA levels are >500 copies/mL but should still be considered.
• If testing is unsuccessful, document attempts and rationale in the medical record to support subsequent treatment decisions.

Order resistance testing at virologic failure threshold (>200 copies/mL)

Order resistance testing for patients on combination ART with confirmed HIV‑RNA >200 copies/mL (AI); consider testing at 201–500 copies/mL and recognize evidence is stronger at >1,000 copies/mL.

• Recommended trigger: HIV‑RNA >200 copies/mL for virologic failure; AI strength for >1,000 copies/mL; consider testing at 201–500 copies/mL.
• Perform resistance testing while patient is on ART or within 4 weeks of stopping non‑long‑acting agents.

Perform resistance testing for HIV‑2 at ≥500 copies/mL

Perform resistance testing at diagnosis, prior to treatment initiation, and at virological failure for HIV‑2 when viral load meets or exceeds ≥500 copies/mL; omission when indicated may risk denial.

• HIV‑2 resistance testing threshold: ≥500 copies/mL for testing at diagnosis, prior to treatment initiation, and at virological failure.
• Document testing and results in the chart to support medical necessity.

Do not order antigen‑only tests for screening

Ordering HIV antigen testing alone (independent of antigen/antibody testing) does not meet coverage and will trigger noncoverage; use an antigen/antibody combination assay or rapid antibody test per policy.

• Antigen‑alone testing is explicitly stated as not meeting coverage criteria.
• Use approved antigen/antibody combination assays or rapid antibody tests for screening where indicated.

Claims using removed CPT 86689 may be denied

Claims submitted using removed CPT code 86689 may be denied or require recoding; update billing to current listed CPT/HCPCS codes in the policy.

• 86689 was removed from the policy's applicable procedure codes and may trigger claim denial.
• Ensure claims use current CPT/HCPCS codes listed in the policy (see code table).