ModifiedBlue Cross Blue Shield - TexasPolicy CPCPLABO15

Hepatitis Testing

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Governs reimbursement and coverage criteria for laboratory testing for hepatitis A, B, C, and D, including which tests may be reimbursable and clinical situations that justify testing.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyHepatitis Testing

Policy CodePolicy CPCPLABO15

Change TypeCoverage clarifications and additions (Hepatitis A, DHCV NAT specification)

Effective DateMay 15, 2025

Last ReviewFeb 5, 2025

Next Review DateN/A

Key ActionVerify plan-specific prior authorization and document clinical indication when ordering hepatitis A, B, C, or D testing.

SourceLink

POLICY UPDATE CHANGES

Reimbursement information updated to clarify qualitative nucleic acid testing for HCV and to modify infant screening age window from 2-17 months to 2-6 months.

New language added specifying reimbursement rules for hepatitis A testing (IgM anti-HAV or qualitative HAV RNA reimbursable in certain acute presentations; quantitative HAV viral load not reimbursable).

New language added specifying reimbursement rules for hepatitis D testing (anti-HDV or qualitative HDV RNA may be reimbursable; quantitative HDV NAT not reimbursable; specific CPT codes listed).

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ModifiedBlue Cross Blue Shield - TexasPolicy CPCPLABO15

Hepatitis Testing

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Governs reimbursement and coverage criteria for laboratory testing for hepatitis A, B, C, and D, including which tests may be reimbursable and clinical situations that justify testing.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyHepatitis Testing

Policy CodePolicy CPCPLABO15

Change TypeCoverage clarifications and additions (Hepatitis A, DHCV NAT specification)

Effective DateMay 15, 2025

Last ReviewFeb 5, 2025

Next Review DateN/A

Key ActionVerify plan-specific prior authorization and document clinical indication when ordering hepatitis A, B, C, or D testing.

SourceLink

POLICY UPDATE CHANGES

Reimbursement information updated to clarify qualitative nucleic acid testing for HCV and to modify infant screening age window from 2-17 months to 2-6 months.

New language added specifying reimbursement rules for hepatitis D testing (anti-HDV or qualitative HDV RNA may be reimbursable; quantitative HDV NAT not reimbursable; specific CPT codes listed).

1x lifetimeHCV adult antibody

1x lifetimeHBV triple panel

annualAnnual HBV screening (when indicated)

2-6 moInfant HCV screening window

not reimbursableQuantitative HAV/HDV NATs

Coverage Criteria for Hepatitis Testing

Hepatitis B — covered indications

Covered when criteria below are met for Hepatitis B testing

HBV adult lifetime screening: For all individuals 18 years of age and older, triple panel testing (hepatitis B surface antigen [HBsAg]; hepatitis B surface antibody [anti-HBs]; total antibody to hepatitis B core antigen [anti-HBc]) once per lifetime may be reimbursable.once per lifetime

[[chunk 3]]

HBV annual screening / high-risk screening: Annual HBV infection screening for asymptomatic, non-pregnant individuals may be reimbursable when specific high‑risk situations are present (examples include: infants born to HBsAg‑positive individuals; birth in or recent travel to geographic regions with HBsAg prevalence >= 2%; U.S.‑born individuals whose parents were born in regions with HBsAg 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/sexual contacts of HBV‑infected individuals; injection‑drug users; elevated liver enzymes; active or prior HCV infection; long‑term hemodialysis; healthcare or public‑safety workers with blood/body fluid exposure; individuals with diabetes).annual when indicated

enumerated in text [[chunk 3]]

HBV follow-up testing and treatment‑related testing: For individuals who test positive for anti‑HBc, follow‑up IgM anti‑HBc testing to distinguish acute versus chronic infection may be reimbursable. Anti‑HBs testing may be reimbursable to confirm seroconversion after vaccination. For individuals who will undergo immunosuppressive therapy or when clinically indicated, HBV DNA testing may be reimbursable.as clinically indicated

[[chunk 3]]

Hepatitis C — covered indications and monitoring

Covered when criteria below are met for Hepatitis C testing

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

[[chunk 5]]

HCV one‑time post‑exposure or risk‑based testing: One‑time or post‑exposure antibody testing for HCV may be reimbursable for individuals with recognized exposures or conditions (examples: illicit intranasal or injectable drug use; receipt of clotting factor concentrates produced before 1987; history of hemodialysis; evidence of liver disease or persistently abnormal ALT; HIV infection; organ transplant before July 1992; receipt of blood transfusion before July 1992; history of incarceration; occupational exposures to HCV‑positive blood; unregulated tattoos; children born to HCV‑positive individuals; current sexual partners of HCV‑infected persons).one-time or as exposure occurs

[[chunk 5]]

HCV periodic screening for ongoing risk:

Hepatitis A and D — covered indications

Covered when criteria below are met for Hepatitis A and D testing

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

[[chunk 7]]

HAV quantitative testing not reimbursable: Quantitative nucleic acid testing for HAV viral loads is not reimbursable.N/A

[[chunk 7]]

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

HCV qualitative NAT — covered in specified situations

Covered when meeting specific clinical indications:

HCV qualitative NAT reimbursement: Qualitative nucleic acid testing for HCV may be reimbursable in the situations enumerated by the policy (item #9 was updated to specify 'qualitative').

Refer to policy item #9 and related situational list [[chunk 6]][[chunk 22]]

Hepatitis A testing

Covered when ALL of the following are met:

HAV acute presentation testing: For individuals with signs and symptoms of acute viral hepatitis 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 HAV viral load testing is explicitly not reimbursable (see policy items and update) [[chunk 7]][[chunk 22]]

Hepatitis D testing

Covered when ALL of the following are met:

HDV 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.

Quantitative HDV nucleic acid testing is not reimbursable (see policy update listing specific non‑reimbursable CPT codes) [[chunk 8]][[chunk 22]]

Quantitative nucleic acid testing to measure hepatitis A viral load is not reimbursable. The policy specifies that for individuals with signs and symptoms of acute viral hepatitis who are negative for HBV and HCV, testing for IgM anti-hepatitis A (HAV) or qualitative HAV RNA may be reimbursable, but quantitative HAV viral load testing is not reimbursable.

The policy update adds explicit non‑reimbursement language: quantitative nucleic acid testing for HAV and for HDV viral loads is not reimbursable. While qualitative HDV and HAV testing may be reimbursable in defined clinical situations, quantitative NATs for these viruses are designated as not reimbursable under the updated reimbursement information.

The update identifies specific CPT-level references associated with non‑reimbursement of quantitative hepatitis A and D nucleic acid tests. The policy lists the following codes in association with non‑reimbursement of quantitative HAV/HDV NATs: 86709, 87380, 87523, 87516, 87799.

Specific Covered Indications

HBV triple panel (HBsAg; anti-HBs; anti-HBc total) for adults >=18 once per lifetime and for high-risk individuals as specified.

HBV triple panel — adults >=18 (one‑time): For all individuals 18 years of age and older, triple panel testing (HBsAg; anti‑HBs; anti‑HBc total) once per lifetime may be reimbursable.once per lifetime

[[chunk 3]]

HBV triple panel for high‑risk individuals: Triple panel testing may be reimbursable for high‑risk situations as enumerated in the policy (see list of high‑risk criteria including geographic prevalence, household/contact exposures, incarceration, HIV, dialysis, healthcare workers exposed to blood/body fluids, diabetes, etc.).annual when indicated (where specified)

[[chunk 3]]

HCV antibody testing for adults >=18 once per lifetime; one-time or periodic testing for persons with exposures or ongoing risk factors.

Coding and Procedure Codes

Procedure Codes (illustrative list noted)mixed

No codes listed

Not reimbursable quantitative NAT codes (HAV/HDV)CPTNot Covered

86709	Hepatitis D antibody or related (listed as non-reimbursable quantitative NAT code)
87380	Hepatitis A RNA or related (listed as non-reimbursable quantitative NAT code)
87523	Viral hepatitis panel or NAT related (listed in non-reimbursable list)
87516	Hepatitis viral test code (included in non-reimbursable list)
87799	Unlisted microbiology procedure (included in non-reimbursable list)

Geographic HBV prevalence threshold

Geographic HBV prevalence thresholdRegions with HBsAg prevalence >= 2%; for U.S.-born individuals not vaccinated as infants, parental birth region >= 8%

Context for useApplies when assessing need for HBV triple panel (HBsAg; anti-HBs; anti-HBc) in adults and high-risk individuals

Example high-risk indication tied to thresholdInfants born to HBsAg-positive individuals or persons born in/returned from regions >=2% prevalence

Perinatal HCV infant screening age

Perinatal HCV infant screening ageOne-time screening for perinatally exposed infants at age 2-6 months

Purpose

Frequency and Limit Rules

HBV triple panel for adults >=18

Test compositionHBsAg; anti-HBs; anti-HBc (total)

Covered populationAll individuals 18 years of age and older

Frequency limitOnce per lifetime

Additional reimbursable indicationsAnnual screening for asymptomatic, non-pregnant high-risk individuals when criteria met (see policy)

HCV antibody testing for adults >=18

TestHCV antibody testing

Covered populationAll individuals 18 years of age and older

Provider Actions and Billing Guidance

Prior Authorization

Prior Authorization Required

Prior authorization may be required for certain laboratory tests and lab management services. Verify member coverage and product-specific prior authorization rules before ordering tests.

Check plan documents (Certificate of Benefits, Summary Plan Description) for product-specific PA requirements.
Prior authorization rules vary by product — not all requirements apply to every plan.

Denial Risk

Prior authorization and non-reimbursable quantitative NATs

Quantitative nucleic acid testing (NAT) for hepatitis A (HAV) and hepatitis D (HDV) is not reimbursable. Reimbursement is limited to qualitative NAT or serologic testing when clinically indicated.

Quantitative NAT is non-reimbursable for HAV and HDV (see coding guidance for affected CPT codes).

Ordering Requirements

Note

Review product-specific ordering and authorization rules

Providers should review plan documents to determine which ordering and prior-authorization requirements apply for the member's product; do not assume all policy criteria or reimbursement rules apply uniformly across products.

Step Therapy

Order tests consistent with indicated clinical scenarios

Order tests consistent with the clinical scenarios specified in the policy and document the indication (e.g., symptomatic acute viral hepatitis negative for HBV/HCV for HAV testing; HBV-positive status for HDV testing; perinatal exposure and infant age 2-6 months for HCV qualitative NAT).

For HAV: document signs/symptoms of acute viral hepatitis and negative HBV/HCV testing.
For HDV: document HBV-positive status.
For perinatal HCV screening: document infant is 2-6 months of age and perinatally exposed.

Not Covered / Not Reimbursable Tests

Quantitative hepatitis A viral load testing is explicitly stated as not reimbursable. For symptomatic individuals negative for HBV and HCV, reimbursement may be considered only for IgM anti-HAV or qualitative HAV RNA, not for quantitative HAV NATs.

Quantitative HAV viral load testing and quantitative HDV nucleic acid testing are specified as not reimbursable in the policy update. The document associates these non‑reimbursement determinations with the following CPT codes: 86709, 87380, 87523, 87516, 87799, and notes that these codes may trigger denial or non‑payment when billed for quantitative HAV/HDV NATs.

Background

This policy provides testing recommendations and reimbursement guidance for hepatitis A, B, C, and D laboratory tests, including screening, diagnostic follow‑up, and monitoring. The update clarifies that qualitative NAT is the reimbursable modality for certain HCV, HAV, and HDV clinical indications, while specific quantitative HAV and HDV NATs (codes: 86709, 87380, 87523, 87516, 87799) are designated as not reimbursable under the revised reimbursement information.

Definitions

HBV triple panel

DefinitionHBV triple panel consists of hepatitis B surface antigen (HBsAg); hepatitis B surface antibody (anti-HBs); and total antibody to hepatitis B core antigen (anti-HBc)

Clinical useUsed for lifetime screening of adults >=18 and for identification of immunity, acute or past infection

Related follow-up testsIgM anti-HBc to distinguish acute vs chronic infection; anti-HBs for confirmation of seroconversion after vaccination

HCV NAAT / viral load

DefinitionHCV NAAT / viral load: qualitative and quantitative nucleic acid testing to detect HCV RNA and measure viral load for diagnosis and treatment monitoring

IndicationsQualitative NAAT for diagnosis after positive antibody and for perinatal infant screening; quantitative viral load testing for treatment monitoring at specified timepoints

Revision History

2025-05-15effective_dateLatest

Policy effective date when reimbursement information updates (clarified HCV qualitative NAT language; changed perinatal screening age window to 2-6 months; added hepatitis A and D testing rules; specified non-reimbursable quantitative HAV/HDV NAT codes).

2025-02-05last_review

Document last reviewed and updated with literature review; summary of changes leading to May 15, 2025 effective date recorded in policy update history.

2024-09-13

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyHepatitis Testing

Policy CodePolicy CPCPLABO15

Change TypeCoverage clarifications and additions (Hepatitis A, DHCV NAT specification)

Effective DateMay 15, 2025

Last ReviewFeb 5, 2025

Next Review DateN/A

Key ActionVerify plan-specific prior authorization and document clinical indication when ordering hepatitis A, B, C, or D testing.

SourceLink

On This Page

Routine periodic antibody testing may be reimbursable for individuals with ongoing risk factors while risks persist (examples: ongoing hemodialysis; current injection drug use with sharing of equipment; high‑risk sexual behavior).

HCV NAAT and treatment monitoring: Qualitative HCV nucleic acid testing (NAT) is reimbursable as follow‑up after a positive antibody test to differentiate active versus resolved infection, and for one‑time screening of perinatally exposed infants aged 2–6 months. HCV genotype testing prior to initiation of direct‑acting antiviral (DAA) therapy and quantitative HCV viral load testing prior to, during (after 4 weeks), at end of treatment, and at 12, 24, and 48 weeks after completion of treatment may be reimbursable per the timelines described.per timeline

[[chunk 6]][[chunk 22]]

HCV antibody testing — adults >=18 (one‑time): For all individuals 18 years of age and older, antibody testing for HCV infection once per lifetime may be reimbursable.once per lifetime

[[chunk 5]]

HCV one‑time testing for exposures: One‑time, post‑exposure or risk‑based antibody testing may be reimbursable for recognized exposures/conditions (see policy list).one‑time or as exposure occurs

[[chunk 5]]

HCV periodic testing for ongoing risk: Routine periodic antibody testing may be reimbursable for individuals with ongoing risk factors while those risks persist.while risk persists

[[chunk 5]]

HCV NAAT (qualitative/quantitative) for diagnosis, monitoring therapy, and for perinatally exposed infants (2-6 months).

HCV NAAT for diagnosis and follow‑up: Qualitative nucleic acid testing (NAT) for HCV is reimbursable as follow‑up after a positive antibody screening to distinguish active versus resolved infection.as indicated

[[chunk 6]][[chunk 22]]

Perinatal HCV NAAT screening: One‑time qualitative NAAT for HCV is reimbursable for perinatally exposed infants aged 2–6 months.one-time (2–6 months)

[[chunk 6]][[chunk 22]]

HCV genotype and quantitative viral load for treatment: HCV genotype testing prior to DAA initiation and quantitative HCV viral load testing prior to treatment, after 4 weeks of therapy, at end of treatment, and at 12, 24, and 48 weeks post‑treatment may be reimbursable for monitoring and management of antiviral therapy.per timeline

[[chunk 6]]

HAV IgM or qualitative HAV RNA for symptomatic individuals negative for HBV/HCV; HDV antibody or qualitative HDV RNA for HBV-positive individuals.

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

[[chunk 7]][[chunk 22]]

HDV testing for HBV‑positive individuals: For individuals who have tested positive for HBV, testing for HDV antibody (anti‑HDV) or qualitative HDV RNA may be reimbursable.HBV positive individuals

[[chunk 8]][[chunk 22]]

Perinatally exposed infants one-time HCV screening at age 2-6 months

Perinatal HCV screening age window: One‑time screening for perinatally exposed infants with qualitative HCV NAT at age 2–6 months is reimbursable.one-time (2–6 months)

Policy update changed prior 2–17 month window to 2–6 months per CDC guidance [[chunk 6]][[chunk 22]]

Individuals with signs/symptoms of acute viral hepatitis negative for HBV/HCV

Acute viral hepatitis evaluation—HBV/HCV negative: For individuals presenting with signs or symptoms of acute viral hepatitis who have tested negative for HBV and HCV, IgM anti‑HAV or qualitative HAV RNA testing may be reimbursable to evaluate hepatitis A as the etiology.symptomatic acute hepatitis

[[chunk 7]][[chunk 22]]

Individuals positive for HBV

Testing for individuals positive for HBV: For individuals who have tested positive for HBV, testing for HDV antibody (anti‑HDV) or qualitative HDV RNA may be reimbursable to assess for hepatitis D co‑infection.HBV positive individuals

Quantitative HDV NATs are not reimbursable per policy update [[chunk 8]][[chunk 22]]

Use qualitative HCV NAAT to differentiate active vs resolved infection in perinatally exposed infants

Change from prior guidanceWindow updated from 2-17 months to 2-6 months per CDC update referenced in policy

Frequency limitOnce per lifetime

Additional usesOne-time or periodic testing for persons with exposures or ongoing risk factors per policy indications

HBV screening for asymptomatic, non-pregnant high-risk individuals

Target groupAsymptomatic, non-pregnant individuals at high risk for HBV

FrequencyAnnual when indicated

High-risk scenarios (examples)Birth/travel to regions with HBV prevalence >=2%; U.S.-born with parents from regions >=8%; history of incarceration; HIV infection; injection-drug use; MSM; household or needle-sharing contacts of HBV-infected individuals; elevated liver enzymes; long-term hemodialysis; healthcare/public safety workers exposed to blood; diabetes

HCV screening for perinatally exposed infants

Screening windowOne-time screening for perinatally exposed infants at 2-6 months of age

Test modalityQualitative HCV nucleic acid test (NAAT) as specified in policy

PurposeDifferentiate active infection from resolved maternal antibody in infants born to HCV-positive individuals

Qualitative HAV/HDV testing or IgM anti-HAV (for suspected acute viral hepatitis after negative HBV/HCV) may be reimbursable when clinically indicated.

Documentation Required

Required documentation

Providers must submit accurate and complete documentation to support medical necessity and reimbursement. Claims lacking required documentation, incorrect coding, or use of non-reimbursable quantitative NAT codes may be denied.

Submit clinical indication, test performed, specimen source, and relevant prior test results.
Use appropriate CPT/HCPCS/ICD-10 codes and follow industry coding guidance (CPT, ICD-10-CM, HCPCS).

Documentation Required

Supporting documentation for reimbursement

Supporting documentation should be available upon request to substantiate reimbursement for qualitative NATs and serologic testing for hepatitis A, hepatitis D, and other viral hepatitis testing.

Include symptom description, prior negative HBV/HCV results when applicable, and timing (e.g., age for perinatally exposed infants).
For perinatally exposed infants, follow age-based guidance (one-time screening for infants 2–6 months).

Billing Rule

Documentation and coding accuracy

Ensure claims are coded accurately and reflect the test performed (qualitative vs quantitative). Do not bill quantitative NAT codes for HAV or HDV when policy indicates non-reimbursable.

Verify CPT codes for qualitative NATs and antibody/IgM tests; avoid non-reimbursable codes (quantitative NAT codes) for HAV/HDV.
Maintain documentation to support code selection and medical necessity; respond to requests for additional records promptly.

Denial Risk

Non-reimbursable quantitative HAV/HDV NAT codes

Non-reimbursable quantitative HAV/HDV NAT codes include quantitative viral load CPT/HCPCS codes when used for HAV or HDV testing. Providers should use qualitative test codes or serology codes where clinically appropriate.

Do not bill quantitative viral load codes for HAV or HDV (quantitative NAT) — these will be non-reimbursable.
When in doubt, confirm the appropriate code and reimbursement status with the plan prior to billing.

Timing for monitoringQuantitative HCV viral load: prior to DAA initiation; after 4 weeks of therapy; at end of treatment; and at 12, 24, and 48 weeks post-treatment

Qualitative NAT

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

Policy distinctionPolicy update clarifies item #9 to specify 'qualitative' NAT for HCV reimbursement situations

Use casesQualitative NATs described for HCV diagnosis after positive antibody, perinatal infant screening, HAV/HDV diagnostic testing in acute or HBV-positive contexts

Earlier update entry listed in policy history preceding the new policy effective 01/01/2025 (listed in update history).

2025-01-01new_policy_effective

New policy entry noted as effective 01/01/2025 in the policy update history prior to the May 15, 2025 reimbursement clarifications.