Acute Hepatitis Panel (coverage criteria)
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This policy governs medical necessity and coverage for acute hepatitis panel testing (CPT 80074) for BCBSRI Medicare Advantage and Commercial products, including indications, limitations, and coding requirements for providers ordering the test.
No material clinical or coverage changes in this revision.
Coverage Criteria — When the Acute Hepatitis Panel is Covered
inv-01: Medically Necessary Indications
Acute hepatitis panel testing is medically necessary for Medicare Advantage Plans and Commercial Products when filed with a covered diagnosis code for the following indications:
Must be filed with a covered diagnosis code (see Coding section).
inv-02: Not Medically Necessary / Limitations
Coverage exclusions and non-covered uses for specified products:
Use of a laboratory representative or third party to obtain authorization or support the authorization process is a violation and may result in severe action up to termination from the BCBSRI provider network.
The acute hepatitis panel is not indicated as a screening test for Hepatitis B or Hepatitis C, and it is not indicated to assess prior vaccination status for Hepatitis A or Hepatitis B. After a hepatitis diagnosis has been established, ordering the entire panel is unnecessary; only the appropriate individual tests should be performed.
Coverage is limited to the indications listed in this policy. All other indications beyond the two specified (evaluation for viral hepatitis when there are abnormal liver function tests, and testing prior to or after liver transplantation) are not covered for Medicare Advantage and are not medically necessary for Commercial Products. Laboratories are not permitted to obtain authorization on behalf of the ordering physician, and unauthorized laboratory services may be denied as the financial liability of the laboratory.
Coding — CPT and Component Codes
Provider Actions — Authorization, Billing, and Laboratory Responsibilities
Prior authorization — not applicable; labs cannot obtain authorization
Prior authorization does not apply for this policy; laboratories are prohibited from obtaining authorization on behalf of the ordering physician and unauthorized laboratory services may be denied.
- Prior authorization: Not applicable.
- Laboratories may not obtain clinical authorization or participate in the authorization process on behalf of the ordering physician.
Step therapy — none specified
There are no step therapy requirements specified in this policy.
Ordering physician responsible for authorization and appeals
Only the ordering physician may be involved in prior authorization, appeal, or other administrative processes; laboratories or third parties must not obtain authorization or facilitate appeals on the physician's behalf.
- Only the ordering physician shall be involved in authorization, appeal, or other administrative processes related to prior authorization/medical necessity.
- Use of a laboratory representative or third party to obtain authorization, facilitate the process, or prepare documentation is prohibited and may result in severe action including termination from the BCBSRI provider network.
Unauthenticated lab services denied — laboratory financial liability
If a laboratory provides a service that has not been authorized, the service will be denied and the financial liability will fall on the participating laboratory; such services may not be billed to the member.
- Unauthenticated laboratory services will be denied as the financial liability of the participating laboratory.
- Denied unauthorized services may not be billed to the member.
Definitions — Panel Components and Diagnostic Criteria
Background
The acute hepatitis panel evaluates common viral causes of acute liver inflammation. The panel typically includes tests for Hepatitis A IgM, Hepatitis B core IgM, Hepatitis B surface antigen, and Hepatitis C antibody. Timing of antigen and antibody appearance and persistence differs by virus, which affects result interpretation; the panel is intended to help with differential diagnosis when patients have abnormal liver function tests or symptoms of hepatitis and may be repeated if the timing of exposure is uncertain.
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