CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Hepatitis Testing (A, B, C) — Coverage and Medical Necessity for Screening, Diagnostic, and Monitoring Tests

Coverage and medical necessity criteria for laboratory testing for hepatitis A, B, and C for Blue Cross Blue Shield - Tennessee members, including screening, diagnostic, and monitoring tests and indicated populations.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyHepatitis Testing (A, B, C) — Coverage and Medical Necessity for Screening, Diagnostic, and Monitoring Tests

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateN/A

Next Review DateN/A

Key ActionVerify member benefit and prior authorization requirements before ordering hepatitis screening or confirmatory testing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3lifetime/routine screening statements

12+HBV high-risk indications

13+HCV indications/monitoring

4HCV monitoring timepoints

~20Procedure codes listed

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Coverage and Medical Necessity Criteria

Hepatitis B - Screening, follow-up, and monitoring

Covered when the following conditions are met as specified:

HBV - Universal adult screening: For all individuals 18 years of age and older, triple panel testing (HBsAg, anti-HBs, total anti-HBc) once per lifetime MEETS COVERAGE CRITERIA.age >= 18

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HBV - Annual screening for specific situations: Annual HBV screening (HBsAg and anti-HBs for infants born to HBsAg-positive individuals; triple panel testing when high-risk situations are present) MEETS COVERAGE CRITERIA.annual while risk present

High-risk situations include residence or travel to regions with HBV prevalence >=2%; U.S.-born with parents from regions >=8%; incarceration; HIV infection; STI or multiple partners; men who have sex with men; household/needle-sharing/sex partners of HBV-infected individuals; injection drug use; active/history of HCV; elevated liver enzymes; long-term hemodialysis; diabetes; healthcare/public safety workers exposed to blood/body fluids.

HBV - Follow-up and confirmatory testing: If anti-HBc positive, IgM anti-HBc testing to distinguish acute vs chronic infection MEETS COVERAGE CRITERIA. Anti-HBs testing to confirm seroconversion after vaccination MEETS COVERAGE CRITERIA. For individuals who test positive by initial antibody screening and who will undergo immunosuppressive therapy, HBV DNA testing MEETS COVERAGE CRITERIA.

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Hepatitis C - Screening, confirmatory testing, and monitoring

Covered when the following conditions are met as specified:

HCV - Universal adult screening: For all individuals 18 years of age and older, antibody testing for HCV infection once per lifetime MEETS COVERAGE CRITERIA.age >= 18

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HCV - One-time post-exposure testing: One-time, post-exposure antibody testing MEETS COVERAGE CRITERIA for individuals with recognized exposures/conditions (illicit intranasal/injectable drug use; clotting factor concentrates before 1987; history of hemodialysis; evidence of liver disease; HIV infection; organ transplant before July 1992; blood transfusion before July 1992; notified of exposure via donor; incarceration; unregulated tattoo; healthcare/public safety workers after needle stick or mucosal exposures; children born to HCV-positive individuals; current sexual partners of HCV-infected persons).

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HCV - Routine periodic testing for ongoing risk: Routine periodic antibody testing MEETS COVERAGE CRITERIA while risk factors persist for individuals who currently inject drugs and share equipment, individuals receiving ongoing hemodialysis, and individuals engaging in high-risk sexual behavior.

Screening, Diagnostic Testing, and Monitoring Recommendations

Covered when criteria below are met per guideline groups (CDC, USPSTF, AASLD-IDSA):

HBV chronic infection testing: Perform HBsAg, anti-HBs, and total anti-HBc to evaluate chronic HBV infection.none

CDC serologic testing guidance

HBV acute infection testing: For suspected acute HBV include HBsAg and IgM anti-HBc.none

CDC

HBV screening indications: Screen persons born in countries with HBsAg prevalence >=2%, U.S.-born persons not vaccinated as infants whose parents were born in regions with high endemicity, pregnant women, persons needing immunosuppressive therapy, and other high-risk groups listed in Table 3.HBsAg prevalence >=2%

HBV Screening / Vaccination Candidate Groups

WHO/AASLD/other guidance identifies populations for HBV screening and vaccination. Covered when ANY of the following risk/population criteria apply:

HBV high-risk groups: Persons born in regions of high or intermediate HBV endemicity (HBsAg prevalence >2%); persons who have ever injected drugs; U.S.-born persons not vaccinated as infants whose parents were born in regions with high HBV endemicity (>8%); men who have sex with men; individuals with elevated ALT/AST of unknown etiology; persons needing immunosuppressive therapy; donors of blood/organs/tissues; all pregnant women; persons with chronic liver disease; infants born to HBsAg-positive mothers; persons with HIV; persons with multiple sex partners; household/needle-sharing/sexual contacts of HBsAg-positive persons; persons seeking STD evaluation; residents and staff of facilities for developmentally disabled persons; health care and public safety workers at risk of occupational exposure; travelers to countries with intermediate/high prevalence; inmates of correctional facilities; sources of exposures; unvaccinated persons with diabetes aged 19-59 (clinician discretion for >=60).

List adapted from Table 3 in the document; indicates those who should receive hepatitis B vaccine if seronegative.

HCV Screening and Diagnostic Testing

HCV screening/testing approach recommended by WHO and other societies:

HCV testing pathway: Offer anti-HCV serological testing to adults/adolescents in populations with high seroprevalence or with history of risk exposure/behavior; following a reactive anti-HCV test, perform NAT for HCV RNA (quantitative or qualitative) to diagnose viraemic infection; consider HCV core antigen assay as an alternative where appropriate; in settings with general population seroprevalence >=2-5% consider offering testing to all adults.

WHO recommendations summarized.

Post-treatment Confirmation and Monitoring

Monitoring and confirmation after HCV treatment and HBV evaluation requirements:

HCV SVR confirmation and monitoring: Confirm sustained virologic response (SVR) by undetectable HCV RNA at 12 weeks after completion of an all-oral DAA regimen (SVR12); routine confirmation at 48 weeks post end of treatment is recommended; testing at 24 weeks may be considered individually; periodic testing beyond 48 weeks is not routinely supported except for patients with ongoing reinfection risk.

AGA guidance.

HBV diagnostic and monitoring tests: For HBV diagnosis use HBsAg serological assay; following positive HBsAg, perform HBV DNA (NAT) to guide treatment decisions; monitor at least annually with ALT (and AST for APRI), HBsAg, HBeAg where appropriate, HBV DNA when available, and non-invasive fibrosis assessment; perform more frequent monitoring for persons on treatment or with advanced disease.

WHO/EASL recommendations.

Diagnostic and Screening Criteria

Covered when ALL of the following are met

Initial clinical assessment: Assessment of liver disease severity with physical exam, liver biochemistries (AST, ALT, GGT, alkaline phosphatase, bilirubin, albumin), full blood count and prothrombin time, and abdominal hepatic ultrasound is performed.

Abdominal hepatic ultrasound recommended for all patients; non-invasive testing or biopsy as clinically indicated.

HBV serology and molecular testing: HBeAg/anti-HBe detection and HBV DNA quantification are performed to determine phase of chronic HBV infection and to guide treatment decisions; HBsAg quantification may be useful particularly in HBeAg-negative patients and when considering interferon-alfa therapy.

HBV genotype not required routinely.

Exclude comorbidities and coinfections: Systematically exclude other liver diseases (alcoholic, autoimmune, metabolic) and coinfections including HDV, HCV, and HIV; test for anti-HAV and vaccinate if negative.

Document evaluation and vaccinations as appropriate.

This excerpt contains no explicit coverage exclusions beyond the scope statements presented. For specific exclusion language or payer-level limits, verify the full policy and the member's benefit plan.

Available rapid diagnostic tests (RDTs) for HCV showed reduced sensitivity in samples from people with HIV; none of the RDTs met the WHO sensitivity criterion in HIV-positive patients. Exercise caution when relying on point-of-care RDTs alone in HIV-positive individuals and consider confirmatory laboratory-based testing.

The CDC does not recommend routine testing for past hepatitis A infection. For suspected acute HAV infection, IgM anti-HAV is the serologic test of choice; testing for prior resolved HAV infection is generally not recommended.

Within the provided excerpt there are no explicit exclusions

HBV genotype testing is not required in the initial evaluation; genotype may be useful primarily when considering interferon-alfa (IFNα) therapy or for prognostic information but is not routine for initial workup.

The references section lists guideline and evidence sources (AASLD, WHO, USPSTF, UpToDate and multiple studies) and does not include explicit coverage exclusion statements; it serves as bibliographic support for the recommendations.

No statements in the excerpt are labeled as 'not medically necessary.' The guidance emphasizes appropriate testing algorithms and follow-up rather than explicit NMN designations.

AASLD advises not to repeat HCV viral load testing outside of antiviral therapy, noting that repeat virologic testing in the absence of treatment does not alter clinical management or outcomes.

The citation listings themselves contain bibliographic references and do not assert any not-medically-necessary (NMN) determinations within the excerpt.

Procedure Codes and Coding Notes

Referenced testing/actions (codes not specified in this excerpt)mixed

affected codes

document references to reflex HCV RNA PCR and pre-DAA labs (no explicit CPT/HCPCS codes listed in this segment)

Covered CPT Codes (serology)CPTCovered

86704	Hepatitis B core antibody (HBcAb); total
86705	Hepatitis B core antibody (HBcAb); IgM antibody
86706	Hepatitis B surface antibody (HBsAb)
86803	Hepatitis C antibody

Covered CPT/HCPCS Codes (confirmatory, molecular, genotype, screening)mixedCovered

87340	Infectious agent antigen detection by immunoassay; hepatitis B surface antigen (HBsAg)
87341	Infectious agent antigen detection by immunoassay; HBsAg neutralization
87517	Infectious agent detection by nucleic acid; hepatitis B virus, quantification
87520	Infectious agent detection by nucleic acid; hepatitis C, direct probe technique
87521	Infectious agent detection by nucleic acid; hepatitis C, amplified probe technique, includes reverse transcription when performed
87522	Infectious agent detection by nucleic acid; hepatitis C, quantification, includes reverse transcription when performed
87902	Infectious agent genotype analysis by nucleic acid; Hepatitis C virus
G0472	Hepatitis C antibody screening, for individual at high risk and other covered indication(s)
G0499	Hepatitis B screening in non-pregnant, high risk individual includes HBsAg, anti-HBs and anti-HBc, followed by neutralizing confirmatory when performed

HBsAg prevalence threshold for country-based screening

HBsAg country prevalence threshold>= 2%

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization
Prior authorization and benefit verification
Coverage for hepatitis B and C testing and related services depends on the member's individual benefit at the time of request; verify benefit and whether prior authorization (PA) is required. No explicit payer-level prior authorization rules are specified in this section of the policy excerpt.
Action: Verify member benefit and check for any PA requirements before ordering testing or treatment.
Note: Medicare (LCD/NCD) or state Medicaid policies may override this policy; consult applicable government coverage guidance.

Documentation Required
Testing and pre-treatment workup
Before initiating direct-acting antiviral (DAA) therapy or referring for treatment, perform recommended pre-treatment evaluation and testing to document baseline status and guide therapy selection.
Baseline labs within 6 months prior to DAA: CBC, INR, hepatic function panel (albumin, total and direct bilirubin, ALT, AST, alkaline phosphatase), and eGFR.
Obtain quantitative HCV RNA (viral load) any time prior to starting DAA; repeat per guideline timing (e.g., 4 weeks on treatment, end of treatment, and 12+ weeks after completion).
Perform HCV genotype testing at least once prior to treatment when a nonpangenotypic DAA is being considered.
For HBV evaluation: H&P, platelets, hepatic chemistry, HBeAg and anti-HBe, HBV DNA, and HAV IgG immunity testing in those not immune.

Note
Diagnostic testing recommended (informational)
Diagnostic testing recommendations for HCV and HBV screening and confirmation follow federal and specialty guidance; these are informational and not presented here as payer PA rules.
HCV: Initial testing with an FDA-approved anti-HCV assay; if positive or indeterminate, perform HCV nucleic acid testing (NAT/HCV RNA PCR) to confirm active infection.
HBV: Screen with HBsAg (FDA-approved tests); a reactive HBsAg should be confirmed and followed by HBV DNA testing to guide staging and treatment.
WHO/AASLD-IDSA guidance endorses antibody serology with reflex to RNA (or core antigen alternative) for HCV and HBsAg followed by HBV DNA for HBV.

Billing Rule
Procedure codes for testing
Use the listed CPT/HCPCS codes when ordering and billing for hepatitis B and C serologic and molecular testing; codes in the policy are for reference and may not be all-inclusive.
Examples: 86704 (HBcAb,total), 86705 (HBcAb IgM), 86706 (HBsAb), 86803 (HCV antibody), 87902 (HCV confirmatory/genotype), G0472/G0499 (screening/confirmatory HCPCS).
Procedure codes included are reference only; verify code applicability and modifier usage per billing rules.

Note
Prior authorization reference sources
Guideline and literature sources in this section may inform prior authorization and clinical documentation expectations although they do not specify payer PA rules.
References: AASLD-IDSA, CDC, USPSTF, WHO, AGA, and other cited evidence-based sources may be used to support medical necessity in PA submissions.
Clinical recommendations (e.g., reflex RNA after positive antibody) are drawn from these sources and can be attached to prior authorization or appeals as supporting documentation.

Denial Risk
Failure to perform confirmatory testing
Failure to perform confirmatory nucleic acid testing (NAT) after a reactive HCV antibody, or failure to confirm reactive HBsAg results, may lead to an incomplete diagnostic evaluation and could affect referral or treatment decisions.
Ensure HCV RNA PCR is performed following a reactive anti-HCV to document active infection prior to DAA referral.
Ensure confirmatory testing of reactive HBsAg per USPSTF/WHO guidance and follow with HBV DNA when indicated.

Step Therapy
No explicit payer denial criteria or step therapy specified
There are no explicit payer denial criteria or step-therapy requirements described within this policy excerpt. Providers should still verify member-specific coverage rules and any plan-level utilization management policies.
No step therapy requirements for DAAs are specified in the excerpt; if a plan implements step therapy, that requirement will be enforced based on the member's benefit and any applicable government policy.
Absence of explicit denial triggers in the citations: bibliographic references do not themselves define coverage denials.

Documentation Required
Evaluation and required test documentation
Document clinical evaluation and all relevant test results in the medical record when evaluating HBV or HCV. Proper documentation supports medical necessity for testing, treatment, and any PA requests.
Initial HBV evaluation should include history and physical examination, and labs: HBsAg, anti-HBs, total anti-HBc (and IgM anti-HBc if acute infection suspected), HBeAg/anti-HBe, HBV DNA, hepatic panel, platelets, and INR.
For HCV, document the FDA-approved anti-HCV assay result and follow-up NAT/HCV RNA PCR result when antibody is positive or indeterminate.
Record pre-treatment labs (CBC, INR, hepatic panel, eGFR), genotype results if performed, quantitative HCV RNA, and any linkage-to-care actions.

Documentation Required
Operational documentation guidance (no specific format required)
While the policy outlines recommended tests and documentation, it does not prescribe specific format requirements for medical record documentation; nonetheless, include test names, dates, quantitative/qualitative results, and follow-up actions in records and PA submissions.
Document assay type (e.g., FDA-approved anti-HCV assay), specimen type if relevant (e.g., DBS), quantitative viral loads with units and collection dates, and interpretation (active vs resolved infection).
Include evidence of counseling, referrals, and treatment plans (e.g., DAA initiation) when applicable.

Note
Before initiating direct-acting antivirals (DAAs)
Before initiating DAA therapy: ensure baseline viral load, hepatic panel, CBC, INR, eGFR, and genotype (if non-pangenotypic regimen considered) are available in the record to guide regimen selection and monitor safety and response.
Obtain quantitative HCV RNA and repeat per recommended monitoring schedule (on-treatment, end-of-treatment, and 12 weeks post-treatment to confirm SVR).
Confirm absence of co-infections or comorbidities that may alter management (HAV immunity, HIV, HBV status).

Key Terms and Test Definitions

Key test acronyms and serologies

HBsAgHepatitis B surface antigen (HBsAg)

anti-HBsHepatitis B surface antibody (anti-HBs)

anti-HBcTotal antibody to hepatitis B core antigen (anti-HBc)

IgM anti-HBcIgM antibody to hepatitis B core antigen (IgM anti-HBc) — used to distinguish acute from chronic HBV

NAT/NAATNucleic acid (amplification) test — molecular testing for viral nucleic acid

IgM anti-HAVImmunoglobulin M antibody to hepatitis A virus — used for acute HAV diagnosis

Sustained virologic response (SVR) definition

SVR12Undetectable HCV RNA level 12 weeks following completion of therapy (proxy for elimination of HCV RNA)

HCV nucleic acid test (NAT) definition

HCV NAT (NAT/NAAT)Molecular test to detect HCV RNA used to differentiate active (viraemic) from resolved infection; recommended after a reactive anti-HCV test

HBV seromarkers

HBsAgHepatitis B surface antigen (HBsAg)

anti-HBsHepatitis B surface antibody (anti-HBs)

Total anti-HBcTotal antibody to hepatitis B core antigen (anti-HBc)

HCV RNA PCR definition

HCV RNA PCRPolymerase chain reaction assay to detect and quantify HCV RNA; used as the laboratory-based confirmatory test after antibody screening

Screening vs confirmatory tests (HBV/HCV)

HBV screening testsHBsAg and anti-HBs are recommended for screening; anti-HBc may be used but positives require confirmatory HBsAg/anti-HBs testing

HCV screening testAnti-HCV serology (RDT or laboratory immunoassay) is the initial screening test

HCV confirmatory testHCV RNA NAT/PCR (qualitative or quantitative) is the confirmatory test for viraemic infection after reactive antibody

Key HBV serologic markers and their use

HBsAgHepatitis B surface antigen — indicates current infection

HBeAgHepatitis B e antigen — marker of viral replication and infectivity

anti-HBeAntibody to HBeAg — used to assess seroconversion

anti-HBcAntibody to hepatitis B core antigen — indicates prior exposure (total anti-HBc)

anti-HBsAntibody to hepatitis B surface antigen — indicates immunity from vaccination or prior infection

Confirmatory molecular test for active HCV infection

HCV RNA PCR (confirmatory)Laboratory-based HCV RNA PCR is used to confirm active HCV infection after a positive antibody screen and to guide referral for DAA therapy

Major guideline sources cited

AASLDAmerican Association for the Study of Liver Diseases — clinical guidance on HBV/HCV diagnosis and management

WHOWorld Health Organization — global testing and screening recommendations

USPSTFUnited States Preventive Services Task Force — HCV screening age-based recommendations

UpToDateClinical reference resource cited for epidemiology and prevention information

Clinical Background

Hepatitis A, B, and C cause liver inflammation but differ in transmission and clinical course: HAV is fecal-oral and typically causes acute, self-limited illness with IgM anti-HAV used for acute diagnosis; HBV transmits via blood, body fluids and perinatally and can become chronic; HCV is primarily bloodborne, often asymptomatic, and chronic infection can progress to cirrhosis and hepatocellular carcinoma.

Policy Revision History

policy_creationLatest

Initial policy published (effective date not specified in source).

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyHepatitis Testing (A, B, C) — Coverage and Medical Necessity for Screening, Diagnostic, and Monitoring Tests

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateN/A

Next Review DateN/A

Key ActionVerify member benefit and prior authorization requirements before ordering hepatitis screening or confirmatory testing.

SourceLink

On This Page

HCV - Confirmatory and monitoring testing: If antibody positive, follow-up nucleic acid testing for HCV (to differentiate active vs resolved infection) MEETS COVERAGE CRITERIA. Prior to DAA initiation, one-time HCV genotype testing MEETS COVERAGE CRITERIA. Quantitative HCV viral load testing MEETS COVERAGE CRITERIA prior to DAA therapy, after 4 weeks of therapy, at end of treatment, and at 12, 24, and 48 weeks after treatment completion.

[[chunk 6]]

HCV screening initial testing: Perform anti-HCV antibody testing followed by confirmatory HCV RNA PCR for positive/initially reactive results.Age 18-79 per USPSTF; other high-risk groups per AASLD-IDSA

USPSTF and AASLD-IDSA recommendations

HCV pre-treatment testing: Prior to DAA therapy obtain CBC, INR, hepatic function panel, eGFR, and quantitative HCV RNA; if non-pangenotypic DAA planned, obtain genotype/subtype.within 6 months prior to starting DAA for some tests

AASLD-IDSA recommendations

HCV post-treatment testing: Obtain quantitative HCV RNA testing 12 or more weeks after completion of therapy to document sustained virologic response (SVR).>=12 weeks post-therapy

AASLD-IDSA

HCV screening and confirmation: Screen per IHS: adults >=18 at least once, all pregnant persons each pregnancy, and people at higher risk; a positive HCV antibody requires laboratory-based HCV RNA PCR to confirm active infection.

If HCV RNA positive, refer for DAA therapy.