ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPLAB015

Hepatitis Testing

Defines BCBS New Mexico reimbursement criteria for laboratory testing for hepatitis A, B, C, and D (including indications, frequencies, and follow-up testing) and lists applicable procedure codes; applies to plan-covered services with plan documents and provider contracts governing conflicts.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyHepatitis Testing

Policy CodePolicy CPCPLAB015

Change TypeRevisions and additions to reimbursement criteria and procedure codes (2024–2025)

Effective DateNov 7, 2025

Next Review Date

Key ActionProviders must submit accurate documentation supporting the indication/risk factor for hepatitis testing per criteria and provide additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

Added 'individuals who are receiving immunosuppressant therapy' to Hepatitis B high-risk list.

Revised frequency for HCV antibody testing #8 to 'once every three months' for ongoing risk factors.

Added 'For individuals who are immunocompromised' to qualifying situations for qualitative nucleic acid HCV testing.

Added CPT/HCPCS code G0567 to procedure codes.

Changed perinatal infant HCV RNA screening window from 2-17 months to 2-6 months and specified 'qualitative' nucleic acid testing.

Added hepatitis A and D testing guidance including prohibiting quantitative viral load testing for HAV and HDV.

Added multiple procedure codes (86692, 86708, 86709, 87380, 87523, 87516, 87799) in 10/30/2024 update.

4Hepatitis types covered (A,B,C,D)

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3 monthsHCV repeat testing interval for ongoing risk

>=1HCV lifetime antibody screen (adults 18+)

CPCPLAB015Policy Number

Coverage Summary

Policy CPCPLAB015 (Hepatitis Testing) defines BCBS New Mexico reimbursement criteria for laboratory testing for Hepatitis A, B, C, and D. Effective date: 2025-11-07; Last review / policy update: 2025-07-25. The policy scope covers indications, frequencies, and follow-up testing and lists applicable procedure codes; coverage decisions are applied per plan-covered services and may vary by product. Coverage stance: mixed — tests may be reimbursable when specified clinical criteria are met and not covered in other situations.

Quick reference thresholds

Perinatal infant HCV screening age2-6 months

HCV repeat frequencyonce every three months while risk persists

Policy NumberCPCPLAB015

Hepatitis B — General and Screening

Hepatitis B - General and Screening

Covered when criteria below are met:

For all individuals 18 years of age and older, triple panel testing (HBsAg, anti-HBs, anti-HBc) for Hepatitis B infection once per lifetime may be reimbursable.

Annual HBV screening for asymptomatic, non-pregnant individuals

Individual born in or recently traveled to geographic regions with HBV prevalence >= 2% (See Note 1)
U.S.-born individuals not vaccinated as infants whose parents were born in geographic regions with HBV prevalence >= 8%
Individuals with a history of incarceration
Individuals infected with HIV
Individuals with a history of sexually transmitted infections or multiple sex partners

Hepatitis C — Screening, Risk-based and Monitoring

Hepatitis C - Screening, Risk-based and Monitoring

Covered when criteria below are met:

For all individuals 18 years of age and older, antibody testing for HCV infection once per lifetime may be reimbursable.

One-time, post-exposure antibody testing

Individuals who have used illicit intranasal or injectable drugs
Individuals who received clotting factor concentrates produced before 1987
Individuals with a history of hemodialysis

Hepatitis A — Testing Criteria

Hepatitis A

Covered when criteria below are met:

For individuals with signs and symptoms of acute viral hepatitis and who have tested negative for HBV and HCV, testing for IgM anti-hepatitis A (HAV) or qualitative testing for HAV RNA may be reimbursable.

Quantitative nucleic acid testing for HAV viral load is not reimbursable.

Hepatitis D — Testing Criteria

Hepatitis D

Covered when criteria below are met:

For individuals who have tested positive for HBV, testing for hepatitis D virus (HDV) antibody (anti-HDV) or qualitative testing for HDV RNA may be reimbursable.

Quantitative nucleic acid testing for HDV viral load is not reimbursable.

Procedure Codes

Listed Procedure Codes (may be reimbursable per criteria)mixed

86692
86704
86705
86706
86708
86709
86803
86804
87340
87341

1–10 of 22

1/3

Provider Actions & Billing Guidance

Documentation Required

Support medical necessity

Providers must submit accurate documentation supporting the indication/risk factor for hepatitis testing per the policy criteria and provide additional documentation upon request. Documentation should establish the clinical indication or risk factor cited (for example: patient age, known exposures, clinical signs/symptoms, vaccination status, immunocompromised or immunosuppressive therapy status, dialysis/hemodialysis, history of injection drug use, prior transfusion/transplant history, pregnancy/perinatal exposure, or abnormal liver tests). Upon request, providers should supply supporting medical records, lab results, treatment plans, and any relevant plan/benefit authorizations to justify medical necessity.

Document the specific risk factor or indication referenced in the policy (e.g., ongoing injection drug use, hemodialysis, known HBV/HCV exposure, immunosuppressant therapy).
Include relevant clinical data: symptoms, abnormal liver enzymes, prior positive antibody/antigen results, vaccination/seroconversion records, or transplant/transfusion history.
Attach pertinent lab reports, prior test dates/results, and any prior authorization or plan-level coverage determinations if available.
Be prepared to provide additional records upon request to support reimbursement.

Background & Evidence

Background: BCBSNM's lab management reimbursement policy outlines when hepatitis serologic and nucleic acid tests may be reimbursed and provides detailed criteria for hepatitis A, B, C, and D testing. The policy references CDC, AASLD-IDSA, WHO, and other clinical guidance as sources for recommendations and cites multiple peer-reviewed and public health documents to support testing and management recommendations. Providers must submit accurate documentation supporting the indication/risk factor for hepatitis testing and should review plan documents for product-specific coverage; plan and provider contract documents govern in case of conflict. Evidence: References cited include multiple CDC, AASLD-IDSA, WHO and peer-reviewed sources (policy reference list), with updates through 2025 noted in the policy history.

Definitions: Triple panel testing (HBV) is defined as Hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs), total antibody to hepatitis B core antigen (anti-HBc).

Revision History

07/25/2025addedLatest

Added 'individuals who are receiving immunosuppressant therapy' to Hepatitis B high-risk list.

07/25/2025revisedLatest

Revised frequency for HCV antibody testing #8 to 'once every three months' for ongoing risk factors.

07/25/2025

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyHepatitis Testing

Policy CodePolicy CPCPLAB015

Change TypeRevisions and additions to reimbursement criteria and procedure codes (2024–2025)

Effective DateNov 7, 2025

Next Review Date

Key ActionProviders must submit accurate documentation supporting the indication/risk factor for hepatitis testing per criteria and provide additional documentation upon request.

SourceLink

On This Page

Men who have sex with men

Household contacts, needle-sharing contacts, and sex partners of HBV-infected individuals

Injection-drug users

Individuals with an active hepatitis C virus infection or history of hepatitis C infection

Individuals with elevated liver enzymes

Individuals on long-term hemodialysis treatment

Individuals with diabetes

Healthcare and public safety workers exposed to blood or body fluids

Individuals receiving immunosuppressant therapy

Follow-up / additional HBV testing: For individuals who test positive for anti-HBc, follow-up IgM anti-HBc testing to distinguish between acute or chronic infection may be reimbursable. For confirmation of seroconversion after hepatitis B vaccination, anti-HBs testing may be reimbursable. For individuals who test positive for HBV by initial antibody screening and who will undergo immunosuppressive drug therapy, HBV DNA testing may be reimbursable.

Individuals with evidence of liver disease (clinical presentation, persistently abnormal ALT, or abnormal liver function studies)

Individuals infected with HIV

Individuals who received an organ transplant before July 1992

Individuals who received a blood transfusion or blood component before July 1992

Individuals notified that they received blood from a donor who later tested positive for HCV

Individuals with a history of incarceration

Individuals who received a tattoo in an unregulated setting

Healthcare, emergency medical, and public safety workers after needle sticks, sharps, or mucosal exposures to HCV-positive blood

Children born to HCV-positive individual

Current sexual partners of HCV-infected persons

Repeat antibody testing while ongoing risk persists

Individuals who currently inject drugs and share needles, syringes, or other drug preparation equipment
Individuals who are receiving ongoing hemodialysis
Individuals engaging in high-risk sexual behavior

Nucleic acid (qualitative) testing for HCV

As a follow-up for individuals who test positive for HCV by initial antibody screening (to differentiate between active infection and resolved infection)
One-time screening for perinatally exposed infants who are 2-6 months of age2-6 months
For individuals who are immunocompromised

HCV genotype and viral load testing related to treatment

Prior to initiation of DAA therapy
After 4 weeks of DAA therapy
At the end of treatment
Twelve, twenty-four and forty-eight (12, 24 and 48) weeks after completion of treatment12, 24, 48 weeks

HCV-specific numeric thresholds

HCV antibody repeat frequency for ongoing riskonce every three months while risk persists

Perinatal infant HCV screening age2-6 months

Billing Rule

Use valid code combinations

Claims should be submitted using valid HIPAA‑approved code sets and coded per industry coding guidelines. Use appropriate CPT/HCPCS, ICD-10, and other standard code sets and follow coding guidance (Uniform Billing, AMA CPT, HCPCS, CMS/CCI edits, etc.). The inclusion of a procedure code on the policy or claim does not guarantee that the service is a covered benefit or that it will be reimbursed; claims remain subject to benefit terms, provider contract language, code edits, and claim review.

Follow industry coding guidelines and CMS/CCI edits when selecting codes.
Inclusion of a code in the policy or code list is not a guarantee of coverage or payment.

Prior Authorization

Plan-specific applicability

Not all policy requirements apply to every product — providers should review the member's specific plan documents, benefit booklets, and provider contract for applicable coverage and eligibility. In the event of a conflict between this clinical payment and coding policy and a plan document or provider contract, the plan document or provider contract will govern. BCBSNM may exercise reasonable discretion in applying the policy to individual cases.

Review product-specific plan documents and the member's benefits to determine eligible coverage.
Plan documents and provider contracts take precedence over this policy when conflicts exist.

Added 'For individuals who are immunocompromised' to qualifying situations for qualitative nucleic acid HCV testing.

07/25/2025addedLatest

Added CPT/HCPCS code G0567 to procedure codes.

10/30/2024revised

Changed perinatal infant HCV RNA screening window from 2-17 months to 2-6 months and specified 'qualitative' nucleic acid testing.

10/30/2024added

Added hepatitis A and D testing guidance including prohibiting quantitative viral load testing for HAV and HDV.

10/30/2024added

Procedure code list expanded by adding multiple procedure codes (86692, 86708, 86709, 87380, 87523, 87516, 87799).