Modifiedblue cross blue shield - tennesseePolicy N/A

Hepatitis Testing (A, B, C, D) — Coverage Criteria for Laboratory Testing

Coverage criteria for laboratory testing for hepatitis A, B, C, and D infections for members of BlueCross BlueShield of Tennessee, including who and when testing is covered or not covered.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyHepatitis Testing (A, B, C, D) — Coverage Criteria for Laboratory Testing

Policy CodePolicy N/A

Change TypeMaterial revisions to coverage criteria and added billing code

Effective DateN/A

Next Review DateN/A

Key ActionDocument immunosuppressant or immunocompromised status when ordering tests for newly covered populations and use added code G0567 where applicable.

SourceLink

POLICY UPDATE CHANGES

Added new CC2.b.xiv: 'xiv) For individuals who are receiving immunosuppressant therapy.'

Addition of three month frequency to CC8, now reads: '8) Antibody testing for HCV once every three months MEETS COVERAGE CRITERIA for individuals with any of the following ongoing risk factors (while risk factors persist):'

Addition of new CC9.c.: 'c) For individuals who are immunocompromised.'

Added CPT code G0567

Updated background, guidelines, and evidence-based scientific references.

OnceHBV triple panel (adults ≥18)

LifetimeHCV antibody (adults ≥18)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for Hepatitis Testing

HBV initial screening (adults)

Covered when ALL of the following are met for HBV screening (general):

Adult HBV lifetime screening: For all individuals 18 years of age and older, triple panel testing (HBsAg, anti-HBs, anti-HBc) once per lifetimeage >= 18

MEETS COVERAGE CRITERIA

HBV high-risk and follow-up testing

Covered HBV screening for asymptomatic, non-pregnant individuals when ANY high-risk condition is present:

HBV high-risk indications: Triple panel testing when any listed high-risk situation is met (born in or recently traveled to regions with HBV prevalence >= 2%; U.S.-born not vaccinated as infants whose parents were born in regions with HBV prevalence >= 8%; history of incarceration; HIV infection; history of sexually transmitted infections or multiple sex partners; men who have sex with men; household, needle-sharing, or sex partners of HBV-infected persons; injection-drug use; active or history of HCV infection; elevated liver enzymes; long-term hemodialysis; diabetes; healthcare/public safety workers exposed to blood or body fluids; receiving immunosuppressant therapy)presence of any listed risk

MEETS COVERAGE CRITERIA

Follow-up for anti-HBc+: If anti-HBc positive, follow-up IgM anti-HBc testing to distinguish acute versus chronic infectionanti-HBc positive

MEETS COVERAGE CRITERIA

Confirmation of vaccine seroconversion: Anti-HBs testing for confirmation of seroconversion after hepatitis B vaccinationpost-vaccination

MEETS COVERAGE CRITERIA

HBV DNA prior to immunosuppression: HBV DNA testing for individuals positive by initial antibody screening who will undergo immunosuppressive drug therapyplanning immunosuppressive therapy and positive antibody screen

MEETS COVERAGE CRITERIA

HCV screening, diagnostic, and treatment monitoring

Covered HCV testing criteria:

Adult HCV lifetime antibody screening: For all individuals 18 years of age and older, antibody testing for HCV infection once per lifetimeage >= 18

MEETS COVERAGE CRITERIA

One-time post-exposure HCV antibody testing: One-time, postexposure antibody testing for individuals with recognized conditions or exposures (including illicit intranasal or injectable drug use; clotting factor before 1987; history of hemodialysis; evidence of liver disease or persistently abnormal ALT; HIV infection; organ transplant before July 1992; blood transfusion before July 1992; notified exposure to donor who later tested positive; history of incarceration; unregulated tattoo; healthcare/public safety workers after needle stick/sharps/mucosal exposures; children born to an HCV-positive individual; current sexual partners of HCV-infected persons)any listed exposure/condition

MEETS COVERAGE CRITERIA

Periodic HCV antibody testing for ongoing risk:

HAV and HDV coverage

HAV and HDV testing stance:

HAV acute infection testing: Testing for IgM anti-HAV or qualitative HAV RNA for individuals with signs and symptoms of acute viral hepatitis who have tested negative for HBV and HCVacute hepatitis symptoms AND negative HBV/HCV

MEETS COVERAGE CRITERIA

HAV quantitative NAAT not covered: Quantitative nucleic acid testing for HAV viral load does not meet coverage criteriaquantitative HAV NAAT

DOES NOT MEET COVERAGE CRITERIA

HDV testing for HBV+ individuals: For individuals who have tested positive for HBV, testing for anti-HDV or qualitative HDV RNA meets coverage criteriaHBV positive

Revised Coverage Criteria (CC2.b.xiv, CC8, CC9.c)

Noted revisions to existing coverage criteria groups

CC2.b.xiv: For individuals who are receiving immunosuppressant therapy.

Added to existing CC2.b list per revision history

CC8 frequency: Antibody testing for HCV once every three months meets coverage criteria for individuals with ongoing risk factors (while risk factors persist).every 3 months

Revised frequency added to CC8

CC9.c: For individuals who are immunocompromised.

New subcriterion added to CC9

Quantitative nucleic acid testing for hepatitis A (HAV) and hepatitis D (HDV) viral load DOES NOT MEET COVERAGE CRITERIA. The policy explicitly states that quantitative NAAT for HAV viral load and quantitative NAAT for HDV viral load are not covered and may be denied when submitted for payment.

No additional exclusion language is provided in this excerpt beyond the specific HAV/HDV quantitative NAAT statements. The revision history documents operational updates to coverage groups (new immunosuppressed/immunocompromised indications and frequency changes) and the addition of CPT code G0567, but does not add any other general exclusions in the sections shown here.

The policy text explicitly states that quantitative nucleic acid testing for HAV viral load and quantitative nucleic acid testing for HDV viral load DOES NOT MEET COVERAGE CRITERIA. For HAV, qualitative HAV RNA or IgM anti-HAV testing is covered for symptomatic individuals after HBV/HCV exclusion, but quantitative HAV NAAT is not covered. For HDV, anti-HDV or qualitative HDV RNA testing is covered for individuals positive for HBV, while quantitative HDV NAAT is not covered.

The revision history does not include an explicit 'not medically necessary' statement in the excerpt provided. It does, however, document expanded explicit coverage for certain populations (addition of CC2.b.xiv for individuals receiving immunosuppressant therapy and CC9.c for immunocompromised individuals) and a change to permit HCV antibody testing every 3 months for persons with ongoing risk factors while those risks persist. Providers should be aware these operational changes affect who is covered and when testing may be allowed.

Billing Codes and Testing Frequency

Covered antibody CPT codesCPTCovered

86692	Antibody; hepatitis, delta agent.
86704	Hepatitis B core antibody (HBcAb); total.
86705	Hepatitis B core antibody (HBcAb); IgM antibody.
86706	Hepatitis B surface antibody (HBsAb).
86708	Hepatitis A antibody (HAAb).
86709	Hepatitis A antibody (HAAb), IgM antibody.
86803	Hepatitis C antibody.
86804	Hepatitis C antibody; confirmatory test (eg, immunoblot).

Covered antigen/NAAT/genotype HCPCS/CPT codesmixedCovered

87340	Infectious agent antigen detection; hepatitis B surface antigen (HBsAg).
87341	HBsAg neutralization.
87380	Infectious agent antigen detection; hepatitis, delta agent.
87516	Hepatitis B virus, amplified probe technique.
87517	Hepatitis B virus, quantification.
87520	Hepatitis C, direct probe technique.
87521	Hepatitis C, amplified probe technique, includes RT when performed.
87522	Hepatitis C, quantification, includes RT when performed.
87523	Hepatitis D (delta), quantification, including RT when performed.
87799	Infectious agent detection by nucleic acid, not otherwise specified; quantification, each organism.

1–10 of 14

1/2

Updated/Added CodesHCPCS

G0567

Added CPT/HCPCS code referenced in revision history

Testing frequency thresholds

HBV triple panel (HBsAg, anti-HBs, anti-HBc)Once per lifetime for all individuals 18 years of age and older

HCV antibody (adults)Once per lifetime for all individuals 18 years of age and older

HCV antibody (ongoing-risk individuals)Once every 3 months while ongoing risk factors persist (e.g., current injection drug use with equipment sharing; ongoing hemodialysis; engaging in high-risk sexual behavior)

Provider Actions, Billing & Documentation

Documentation Required

Benefit verification

Application of coverage criteria is dependent upon an individual's benefit coverage at the time of the request. Specifications pertaining to Medicare and Medicaid can affect coverage determinations — verify the member's plan and any applicable state or federal program rules prior to ordering or performing testing.

Confirm member benefit coverage and payer-specific rules at time of service
Refer to Medicare/Medicaid specifications in the 'Applicable State and Federal Regulations' section when applicable

Documentation Required

Indication documentation for new covered populations

Providers must document the clinical indication when ordering tests for newly covered populations (for example, individuals receiving immunosuppressant therapy or who are otherwise immunocompromised). Include relevant supporting details in the medical record: diagnosis, current immunosuppressive medications or therapies, dates of therapy, and any other risk factors that justify testing under the updated coverage criteria.

Document immunosuppressant therapy or immunocompromised status when applicable

Clinical Background and Rationale

Infectious hepatitis is inflammation of the liver caused by hepatitis viruses A, B, C, and D, each with distinct transmission routes and clinical courses. Hepatitis A (HAV) is primarily transmitted via the fecal–oral route and typically causes an acute, self-limited illness. Hepatitis B (HBV) and Hepatitis C (HCV) are bloodborne and can cause chronic infection; chronic HBV and HCV may progress to cirrhosis and hepatocellular carcinoma and are leading causes of liver transplantation. These clinical differences underpin the policy’s differing recommendations for antibody testing, qualitative nucleic acid testing, and the exclusion of quantitative viral load NAAT for HAV and HDV.

Definitions and Testing Modalities

HCV — Hepatitis C virus

TermHepatitis C virus (HCV): a bloodborne virus transmitted via sharing needles/equipment and inadequate infection control; can cause chronic liver disease, cirrhosis, and hepatocellular carcinoma

Screening guidanceAntibody testing for HCV once per lifetime for adults ≥18; additional targeted and periodic testing per coverage criteria

Diagnostic/monitoring usesQualitative NAAT to confirm active infection after a positive antibody; quantitative viral load for treatment monitoring and timing per DAA therapy schedule

HBV — Hepatitis B virus

TermHepatitis B virus (HBV): transmitted via percutaneous, mucosal, or nonintact skin exposure to infected blood/body fluids, mother-to-infant transmission, and sexual contact; chronic infection may lead to chronic liver disease

Screening

Policy Summary

Payerblue cross blue shield - tennessee

PolicyHepatitis Testing (A, B, C, D) — Coverage Criteria for Laboratory Testing

Policy CodePolicy N/A

Change TypeMaterial revisions to coverage criteria and added billing code

Effective DateN/A

Next Review DateN/A

Key ActionDocument immunosuppressant or immunocompromised status when ordering tests for newly covered populations and use added code G0567 where applicable.

SourceLink

On This Page

Billing Rule

Addition of code G0567

CPT/HCPCS code G0567 has been added to the policy code set. Use code G0567 where applicable for hepatitis C nucleic acid screening (amplified probe technique) and ensure claims reflect the correct code. Follow payer prior authorization and billing instructions if required.

Added code G0567 — Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, screening, amplified probe technique
Use G0567 on claims when performing the specified HCV screening test; verify prior authorization requirements

Denial Risk

Nonconcordant testing with updated criteria

Services that do not meet the updated coverage criteria (including changes to allowable testing frequency, newly specified covered populations, or required indications) are at increased risk for denial. Before ordering, ensure the requested test aligns with the current policy criteria — nonconcordant testing may be denied or subject to retrospective review.

Nonconcordant testing with updated criteria may be denied
Ensure frequency limits (for example, HCV antibody testing every three months for ongoing risk factors) and population-specific rules are met

Point-of-care HCV RNA test

DefinitionPoint-of-care HCV RNA test: an FDA-marketed rapid molecular assay permitting near‑patient detection of HCV RNA (rapid molecular/NAAT platforms referenced in CDC and manufacturer literature)

Use caseEnables near-patient detection of active HCV infection to confirm viremia following a positive antibody or for diagnostic purposes in specific populations

ReferencesCDC guidance and published evaluations of point-of-care assays and rapid molecular testing cited in policy references

Dried blood spot testing

DefinitionDried blood spot (DBS) testing: a sample collection method using capillary/fingerstick blood applied to filter paper evaluated for HCV RNA and antibody detection in community and resource-limited settings

EvidencePublished evaluations (eg, Aptima HCV Quant Dx and other studies) assess DBS performance for HCV RNA detection compared with venipuncture specimens

ApplicationsUsed to expand screening reach (eg, people who inject drugs) and facilitate specimen collection where venipuncture is impractical; results interpreted per assay validation