Resistance testing authorization and testing sequence guidance

Genotypic resistance testing is recommended at entry into care and for persons with virologic failure; phenotypic testing is recommended when complex or multidrug resistance is suspected. Prefer genotypic testing before selecting initial ART in most patients; add phenotypic testing for complex mutation patterns or when genotyping alone is insufficient. If virologic failure is confirmed, perform genotypic resistance testing preferably while the patient is on the failing regimen; proviral DNA testing may be considered when plasma RNA is undetectable.

• Genotyping is preferred for ARV‑naïve patients; include integrase region when INSTI resistance is a concern or prior CAB‑LA/INSTI exposure (DHHS).
• Phenotyping is indicated for treatment‑experienced patients with suspected multidrug resistance.
• If ART is being initiated urgently (including in pregnancy), do not delay therapy while awaiting resistance results; modify regimen when results available.

Resistance testing trigger for HIV‑2

HIV‑2: perform resistance testing at diagnosis, prior to initiating treatment, and at virologic failure when HIV‑2 viral load is ≥500 copies/mL. Note that HIV‑2 plasma RNA is often low and RNA testing may be unreliable; use DNA testing to confirm infection when indicated.

• Trigger threshold for HIV‑2 resistance testing: ≥500 copies/mL.
• Use DNA testing for HIV‑2 confirmation as RNA assays may not detect HIV‑2 reliably.

Viral load and resistance testing documentation; pregnancy delivery planning

Providers must document viral load measurements at baseline (entry into care or prior to ART when possible) and during follow‑up (e.g., 4–8 weeks after ART initiation or modification) and record clinical reasons for ordering resistance or viral quantification tests. For pregnant patients, document viral load near delivery and the rationale for delivery planning decisions.

• Measure plasma viral load before ART initiation and within 4–8 weeks after starting or changing ART; repeat at intervals per guidelines until suppression.
• Document clinical justification for resistance testing, attempts/results, and any test failures (especially when RNA 500–1,000 copies/mL where assays may fail).
• For pregnancy: document near‑delivery viral load; if >1000 copies/mL schedule prelabor cesarean at 38 0/7 weeks and document rationale per ACOG/SMFM guidance.

Documentation for positive antibody tests

If an HIV antibody/antigen screening test is reactive or positive, follow-up nucleic acid testing (NAT) is required to confirm infection. Document the type of initial test, specimen collection timing, and the follow‑up NAT performed.

• Positive antibody/antigen tests require confirmatory NAT (qualitative or quantitative) and documentation of test type and timing relative to exposure and specimen collection.
• If initial antibody tests are positive but NAT is negative, document rationale for additional testing or interpretation given window periods.

Applicable CPT/HCPCS codes — check PA rules

Applicable CPT/HCPCS codes related to HIV antibody/antigen screening, NAT (qualitative and quantitative), genotyping, and phenotyping are listed below. Procedure codes in policy are reference only; check plan‑specific prior authorization and PA rules before billing.

• Common codes: 86689, 86701, 86702, 86703, 87389–87391, 87534–87539, 87806, 87900–87906, 0219U, G0432, G0433, G0435, G0475, S3645.
• Genotype/phenotype codes: 87901 (genotype RT/protease), 87903–87904 (phenotype), 87906 (other region), 0219U (targeted NGS genotyping).
• Check payer prior authorization rules for which codes require PA and for any coding/billing guidance.

Prior authorization status

Prior authorization requirements are not explicitly stated in this section. Providers must consult plan‑specific coverage rules and prior authorization (PA) procedures for Blue Cross Blue Shield of Louisiana to confirm whether testing or specific procedure codes require PA.

• Refer to member benefit documents and the plan's PA lookup tools for authorization requirements.
• When in doubt, submit preauthorization with clinical documentation (viral loads, prior treatments, pregnancy status, rationale for resistance testing).

Frequency limits

Frequency limits apply: antigen/antibody screening is covered no more than once every 90 days for repeat screening; nucleic acid testing (qualitative or quantitative) and plasma HIV RNA quantification are covered no more than once monthly unless clinically justified. Requests exceeding these limits may be denied.

• Repeat antigen/antibody screening: ≤1 test every 90 days for individuals 11–65 years.
• Nucleic acid testing/plasma quantification: ≤1 test per month unless clinical circumstances justify more frequent monitoring (document rationale).
• Excessive frequency requests should include clinical justification in documentation to avoid denial.

Conflict with government policy may trigger denial

Conflict with applicable government policies (e.g., Local Coverage Determinations or National Coverage Determinations for Medicare, or state Medicaid policies) takes precedence. If a government policy conflicts with this policy, the government policy will be used for coverage determinations and may result in denial.

• Check CMS LCD/NCD resources and applicable state Medicaid coverage when evaluating requests.
• When a denial is issued due to conflict with government policy, document the applicable government policy used to make the determination.