CurrentBlue Cross Blue Shield - TexasPolicy CPCPLABO1S

Hepatitis Testing

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Defines reimbursement and coverage criteria for laboratory testing related to hepatitis A, B, C, D (and related viral diagnostics) for Blue Cross Blue Shield of Texas members and providers ordering those tests.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyHepatitis Testing

Policy CodePolicy CPCPLABO1S

Change TypeMultiple additions and revisions (codes added, frequency and coverage clarifications)

Effective DateNov 7, 2025

Last ReviewJul 25, 2025

Next Review DateN/A

Key ActionWhen billing newly listed codes (e.g., 60567, 86692, 86708…), reference the policy to determine whether prior authorization is required.

SourceLink

POLICY UPDATE CHANGES

Individuals who are receiving immunosuppressant therapy were added to reimbursement information #1.

Frequency on reimbursement item #8 was revised to state antibody testing for HCV once every three months may be reimbursable for individuals with ongoing risk factors while risk factors persist.

Added language specifying considerations for immunocompromised individuals under reimbursement item #9.

Added CPT code 60567 to the policy's code set.

Revised reimbursement item #9 to include 'qualitative' nucleic acid testing for HCV and adjusted infant screening age from 2-17 to 2-6 months for one-time screening of perinatally exposed infants.

Added coverage language for hepatitis A testing: IgM anti-HAV or qualitative HAV RNA may be reimbursable for individuals with signs/symptoms of acute viral hepatitis who tested negative for HBV and HCV; quantitative HAV viral load testing is not reimbursable.

Added coverage language for hepatitis D testing for individuals positive for HBV: anti-HDV or qualitative HDV RNA may be reimbursable; quantitative HDV viral load testing is not reimbursable.

Added multiple CPT/diagnostic codes including 86692, 86708, 86709, 87380, 87523, 87516, 87799 (policy code list expanded).

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CurrentBlue Cross Blue Shield - TexasPolicy CPCPLABO1S

Hepatitis Testing

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Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyHepatitis Testing

Policy CodePolicy CPCPLABO1S

Change TypeMultiple additions and revisions (codes added, frequency and coverage clarifications)

Effective DateNov 7, 2025

Last ReviewJul 25, 2025

Next Review DateN/A

Key ActionWhen billing newly listed codes (e.g., 60567, 86692, 86708…), reference the policy to determine whether prior authorization is required.

SourceLink

POLICY UPDATE CHANGES

Individuals who are receiving immunosuppressant therapy were added to reimbursement information #1.

Frequency on reimbursement item #8 was revised to state antibody testing for HCV once every three months may be reimbursable for individuals with ongoing risk factors while risk factors persist.

Added language specifying considerations for immunocompromised individuals under reimbursement item #9.

Added CPT code 60567 to the policy's code set.

Revised reimbursement item #9 to include 'qualitative' nucleic acid testing for HCV and adjusted infant screening age from 2-17 to 2-6 months for one-time screening of perinatally exposed infants.

Added coverage language for hepatitis D testing for individuals positive for HBV: anti-HDV or qualitative HDV RNA may be reimbursable; quantitative HDV viral load testing is not reimbursable.

Added multiple CPT/diagnostic codes including 86692, 86708, 86709, 87380, 87523, 87516, 87799 (policy code list expanded).

Coverage and Reimbursement Criteria

Selected Reimbursement Criteria (updated)

Reimbursement clauses updated — examples extracted from the update history.

HCV antibody repeat testing in high-risk individuals: Antibody testing for HCV once every three months may be reimbursable for individuals with any of the following ongoing risk factors (while risk factors persist).once every three months

Frequency limited to period while risk factors persist

HCV qualitative NAT: Qualitative nucleic acid testing for HCV may be reimbursable in specified situations (policy item #9).qualitative NAT

Includes provisions for immunocompromised individuals

Perinatal infant HCV screening: One-time screening for perinatally exposed infants at age 2-6 months may be reimbursable.age 2-6 months

Revised from prior 2-17 month window

Hepatitis A testing in symptomatic individuals: 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.symptomatic & HBV/HCV negative

Quantitative HAV viral load testing is not reimbursable.

Hepatitis D testing for HBV-positive individuals: 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.HBV positive

Quantitative HDV viral load testing is not reimbursable.

Per this policy update, quantitative nucleic acid testing (viral load) for hepatitis A virus (HAV) and hepatitis D virus (HDV) is not reimbursable. Requests for these quantitative viral load tests may be denied and should not be submitted for reimbursement.

The policy includes several additional coverage statements added or revised in the update history: IgM anti‑HAV or qualitative HAV RNA testing may be reimbursable for individuals with signs and symptoms of acute viral hepatitis who have tested negative for HBV and HCV. For individuals who are HBV positive, anti‑HDV or qualitative HDV RNA testing may be reimbursable. The policy also clarifies that qualitative nucleic acid testing for HCV may be reimbursable in specified situations and adds a one‑time screening window for perinatally exposed infants at 2–6 months of age. Additionally, several CPT/diagnostic codes were added to the policy's code set; providers should reference the policy when billing these codes to determine prior authorization requirements.

Covered Indications for Testing

Symptomatic individuals with signs of acute viral hepatitis who tested negative for HBV and HCV

Covered when ALL of the following are met:

Clinical presentation: Individual has signs and symptoms consistent with acute viral hepatitis.

HBV/HCV testing negative: Recent testing demonstrates negative results for hepatitis B virus (HBV) and hepatitis C virus (HCV).

Permitted tests: One or more of the following tests are ordered: IgM anti-hepatitis A (HAV) OR qualitative HAV RNA testing.

Not reimbursable test types: Quantitative nucleic acid testing for HAV viral load is not reimbursable.

Billing Codes and Code Updates

Added/updated codesmixed

60567	code added to policy
86692	code added to policy
86708	code added to policy
86709	code added to policy
87380	code added to policy
87523	code added to policy
87516	code added to policy
87799	code added to policy

Perinatal infant screening age window

Recommended one-time screening age2-6 months

PopulationPerinatally exposed infants

Policy noteRevised from prior 2-17 month window to narrow age window

HCV antibody testing frequency for individuals with ongoing risk

Allowed testing frequencyOnce every three months

Applies toIndividuals with ongoing HCV risk factors

Condition

Testing Frequency Limits

HCV antibody testing frequency

Operational frequency ruleHCV antibody testing once every three months

ScopeFor individuals with ongoing risk factors; repeats allowed while risk persists

Implementation noteUse antibody testing frequency limit prior to ordering repeat tests; consider viral load testing when prior positive antibody exists

Provider Responsibilities and Billing Guidance

Billing Rule

Review policy for newly added billing codes and prior authorization

Several CPT/diagnostic codes were added to the policy; providers should review the policy to determine whether prior authorization is required before billing these codes.

Added codes include: 60567, 86692, 86708, 86709, 87380, 87523, 87516, 87799
Check the payer's prior authorization rules and this policy when submitting claims for these codes.

Note

Ensure orders are supported by clinical indication and follow frequency limits

Document clinical indication and ensure orders match covered situations described in the policy (e.g., symptomatic acute hepatitis, HBV-positive status, perinatal exposure, or ongoing HCV risk).

Ordering Requirements and Documentation

Billing Rule

Order support required — document clinical indication for qualitative NATs and infant screening

Orders for qualitative nucleic acid tests (NATs) or one-time HCV screening for perinatally exposed infants must be supported by clinical indication; document the clinical rationale on the order and in the medical record.

Support qualitative NAT orders with clinical indication such as symptoms of acute viral hepatitis, known HBV-positive status (for HDV testing), or perinatal exposure (for infant HCV screening).
For perinatally exposed infants, document age (2–6 months) to support one-time screening reimbursement.

Definitions and Test Types

Qualitative NAT

DefinitionQualitative nucleic acid testing detects presence or absence of viral RNA (non-quantitative)

Typical usesUsed to confirm active infection in specified clinical scenarios per policy (e.g., symptomatic individuals, HBV-positive individuals for HDV)

DocumentationOrder should be supported by clinical indication (symptoms, HBV status, perinatal exposure) to support reimbursement

Quantitative NAT

DefinitionQuantitative nucleic acid testing measures viral load (numeric RNA level)

Policy restrictionQuantitative NAT (viral load) for HAV and HDV is not reimbursable

Not Covered / Exclusions

Not covered: Quantitative nucleic acid testing for HAV and HDV viral load is not reimbursable. Specifically, the update states that quantitative testing for HAV viral load and quantitative testing for HDV viral load are excluded from reimbursement.

Background and Clinical Guidance References

This policy aligns reimbursement with contemporary clinical guidance and diagnostic strategy from major professional bodies. It references guidance from organizations such as the American Association for the Study of Liver Diseases (AASLD), the World Health Organization (WHO), and the European Association for the Study of the Liver (EASL), and applies those considerations to testing choices—for example, specifying when qualitative nucleic acid testing is appropriate and when repeat antibody testing versus viral load testing is indicated. The policy also notes standard laboratory certification considerations (e.g., CAP/CLIA) when applicable.