Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesInfectious DiseaseBlue KC HIV testing Coverage Policy Update | OpenP…
    Ask Trek AI about this page
    CurrentBlue KCPolicy POL-PP-286

    Human Immunodeficiency Virus (HIV)

    Customize your policy alerts

    Sign up for Blue KC Policy POL-PP-286 alerts

    Get alerted when Policy POL-PP-286 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Defines coverage and reimbursement criteria for HIV screening, confirmatory testing, nucleic acid testing, viral quantification, and HIV genotyping/phenotyping for Blue KC members; applies to providers submitting claims for testing and related laboratory services.

    Policy Summary
    PayerBlue KC
    PolicyHuman Immunodeficiency Virus (HIV)
    Policy CodePolicy POL-PP-286
    Change TypeRoutine review — no material changes
    Effective DateOct 1, 2025
    Last ReviewOct 1, 2026
    Next Review DateOct 1, 2026
    Key ActionObtain HIV genotyping/phenotyping prior to initiating doravirine therapy.
    SourceLink

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    11-65Eligible screening age
    90 daysAntibody/antigen repeat interval
    1 monthNAAT repeat interval
    Doravirine requiredDrug-specific genotyping
    Multiple codesCoding included

    Coverage and Medical Necessity Criteria

    Medically Necessary and Covered Testing

    Covered when criteria described below are met

    Screening for HIV: For individuals 11 to 65 years of age, initial and repeat screening for HIV infection may be reimbursed; repeat antibody/antigen testing should not be performed more often than once every 90 days.age 11-65; antibody repeat >=90 days

    See Note 1 for intervals and Note 2 for risk factors

    Screening for high-risk individuals and PrEP: Individuals initiating or receiving PrEP or with elevated risk factors may be screened using an antigen/antibody combination assay or rapid antibody test.per risk assessment

    Risk factors enumerated in Note 2

    Confirmatory and follow-up testing: For individuals with initial positive or indeterminate screening results, HIV-1/HIV-2 antibody differentiation assay and nucleic acid testing (qualitative or quantitative) may be reimbursed.positive or indeterminate screening; recent exposure

    NAAT should not be repeated more often than once monthly

    Baseline and monitoring quantification: Baseline plasma quantification may be reimbursed for at-risk individuals with equivocal serology or signs/symptoms of acute retroviral syndrome, or when initiation of therapy is anticipated. Plasma HIV-1 or HIV-2 RNA quantification may be reimbursed for monitoring disease progression, response to therapy, infants <18 months born to HIV-positive mothers, and predicting maternal-fetal transmission.clinical indications as listed

    Use same assay method for serial HIV RNA measurements when possible (see Note 3)

    Genotyping/Phenotyping: HIV genotyping or phenotyping may be reimbursed for specified clinical situations including: prior to initiating doravirine therapy (genotyping and phenotyping required); treatment failure; suboptimal viral load reduction; noncompliance; to guide treatment in acute or recent infection (within 6 months); antiretroviral‑naïve individuals entering treatment; and for pregnant individuals before ART initiation or with detectable HIV RNA. For treatment‑experienced individuals on failing regimens with suspected multidrug resistance, phenotyping may be reimbursed.specified clinical scenarios

    Prior authorization may be required for certain genotype/phenotype procedure codes

    The policy does not reimburse HIV antigen testing performed independent of an antigen/antibody combination assay. Standalone antigen assays that are not part of an antigen/antibody combo are excluded from coverage and may be denied.

    Additionally, routine combined genotyping and phenotyping is not reimbursed when performed as a matter of routine rather than for specified clinical indications. The policy also does not reimburse drug susceptibility phenotype prediction derived solely from genotypic comparisons to known databases.

    Rationale: these services are listed as not meeting coverage criteria due to a lack of sufficient published evidence demonstrating that routine combined genotyping/phenotyping or algorithmic phenotype prediction from genotypic database comparisons are required and beneficial for diagnosis or treatment. As a result, routine use of combined genotyping and phenotyping and predictive phenotyping using genotypic databases are not reimbursed.

    CPT/HCPCS and Laboratory Codes

    Antibody test codesCPTCovered
    86689Antibody; HTLV or HIV antibody, confirmatory test (e.g., Western Blot)
    86701Antibody; HIV-1
    86702Antibody; HIV-2
    86703Antibody; HIV-1 and HIV-2, single result
    Antigen and nucleic acid testing codesCPTCovered
    87389HIV-1 antigen(s) with HIV-1 and HIV-2 antibodies, single result (antigen/antibody combo)
    87390HIV-1 antigen
    87391HIV-2 antigen
    87534HIV-1 nucleic acid direct probe
    87535HIV-1 nucleic acid amplified probe, includes RT
    87536HIV-1 quantification, includes RT
    87537HIV-2 nucleic acid direct probe
    87538HIV-2 nucleic acid amplified probe, includes RT
    87539HIV-2 quantification, includes RT
    Genotype/phenotype and related molecular codesCPTCovered
    87806HIV-1 antigen(s) with HIV-1 and HIV-2 antibodies by rapid visual observation
    87900Infectious agent drug susceptibility phenotype prediction using genotypic bioinformatics
    87901Genotype analysis; HIV-1 reverse transcriptase and protease regions
    87903Phenotype analysis with drug resistance tissue culture analysis, HIV-1; first through 10 drugs
    87904Phenotype analysis, each additional drug tested
    87906Genotype analysis; HIV-1 other region (e.g., integrase, fusion)
    0219UTargeted viral NGS analysis (protease, RT, integrase) with algorithmic prediction of drug susceptibility (Sentosa® SQ HIV-1 Genotyping Assay)
    HCPCS/G codes and miscellaneous lab codesmixedCovered
    G0432Antibody detection by EIA technique, HIV-1 and/or HIV-2, screening
    G0433Antibody detection by ELISA technique, HIV-1 and/or HIV-2, screening
    G0435Rapid antibody test, HIV-1 and/or HIV-2, screening
    G0475HIV antigen/antibody combination assay, screening
    S3645HIV-1 antibody testing of oral mucosal transudate
    inv-08: Antibody/antigen testing repeat interval
    Repeat-interval policyAntibody and antibody/antigen testing should not be repeated more often than once every 90 days.
    Applicable testsAntibody and antigen/antibody combination assays used for HIV screening and follow-up.
    PurposeLimit frequency of repeat screening to avoid unnecessary repeat testing and reimbursement for stable-negative individuals.
    Reference noteSee Note 1 in policy: testing interval requirement applies to antibody and antibody/antigen assays.
    inv-09: Nucleic acid testing repeat interval
    Repeat-interval policy

    Provider Requirements, Documentation, and Billing Guidance

    Prior Authorization

    Genotype/phenotype reimbursement for specified indications

    HIV genotype and phenotype testing may be reimbursed only for specified clinical indications. These indications include prior to initiating doravirine therapy (both genotyping and phenotyping are required), individuals who have failed a course of antiviral therapy, individuals with suboptimal viral load reduction, individuals noncompliant with therapy, to guide treatment in acute or recent infection (within 6 months), antiretroviral-naïve individuals entering treatment, and all HIV-infected pregnant individuals before initiation of antiretroviral therapy or if they have detectable HIV RNA levels. Phenotyping may be reimbursed for treatment-experienced individuals on failing regimens suspected of multidrug resistance.

    • Prior to initiating doravirine therapy (genotype and phenotype required)
    • Treatment failure after antiviral therapy
    • Suboptimal viral load reduction
    • Noncompliance with therapy
    • Acute or recent infection (within 6 months)
    • Antiretroviral-naïve individuals entering treatment
    • Pregnant individuals: before ART initiation or if HIV RNA detectable
    • Treatment-experienced with suspected multidrug resistance (phenotype)

    Clinical Background

    Human immunodeficiency virus (HIV) is an RNA retrovirus that infects CD4 immune cells and causes progressive immune deterioration, increasing risk for opportunistic infections and HIV-associated malignancies. HIV-1 is the predominant global subtype while HIV-2 has regional importance.

    Clinical course and testing rationale: early infection can present with an acute retroviral syndrome (fever, malaise, lymphadenopathy, rash) that may prompt nucleic acid testing. Plasma HIV-1 or HIV-2 RNA quantification is used for baseline assessment when therapy initiation is anticipated or serology is equivocal, for monitoring disease progression and response to antiretroviral therapy, for infants <18 months born to HIV-positive mothers, and for assessing risk of maternal-fetal transmission.

    Key Definitions

    inv-16: Acute retroviral syndrome
    DefinitionAcute retroviral syndrome: clinical constellation characterized by fever, malaise, lymphadenopathy, and rash that can occur with early HIV infection.
    Clinical features that may prompt testingFever, malaise, generalized lymphadenopathy, and rash — especially in individuals with recent exposure risk or compatible history.
    Testing implicationSymptoms of acute retroviral syndrome are an indication for baseline HIV quantification (NAAT) when initiation of therapy is anticipated or serology is equivocal.
    DocumentationProviders should document signs/symptoms of acute retroviral syndrome when ordering nucleic acid testing or baseline quantification.
    inv-17: Baseline HIV quantification
    Definition
    Policy Summary
    PayerBlue KC
    PolicyHuman Immunodeficiency Virus (HIV)
    Policy CodePolicy POL-PP-286
    Change TypeRoutine review — no material changes
    Effective DateOct 1, 2025
    Last ReviewOct 1, 2026
    Next Review DateOct 1, 2026
    Key ActionObtain HIV genotyping/phenotyping prior to initiating doravirine therapy.
    SourceLink
    On This Page
    Coverage and Medical Necessity CriteriaCPT/HCPCS and Laboratory CodesProvider Requirements, Documentation, and Billing GuidanceClinical BackgroundKey Definitions
    Nucleic acid testing (qualitative or quantitative) should not be repeated more often than once every 1 month.
    Applicable testsNAATs including HIV-1/HIV-2 qualitative and quantitative RNA assays used for diagnosis, confirmation, or monitoring.
    PurposeEnsure appropriate use of molecular testing and align reimbursement with clinical necessity for interval-based retesting.
    Reference noteSee Note 1 in policy: monthly minimum interval for NAAT repeat testing.
    Documentation Required

    Clinical documentation to support molecular testing

    Genotyping and phenotyping must be documented in the medical record with clear clinical justification. Documentation should include the indication for testing (one of the covered indications above), clinical history relevant to HIV treatment (including prior antiretroviral exposure and adherence history), baseline HIV quantification or viral load when available, and any prior genotype/phenotype results. For initial positive or indeterminate screening results, include the exposure history and rationale for molecular testing. Lack of adequate clinical documentation may result in denial of reimbursement.

    • Include test indication, prior antiretroviral exposure, and adherence history
    • Provide baseline HIV RNA quantification when available
    • Attach prior genotype/phenotype results, if any
    • For initial positive/indeterminate results, document exposure history and rationale
    Prior Authorization

    Doravirine pre-therapy genotyping/phenotyping

    Doravirine requires pre-therapy genotyping and phenotyping prior to initiation. Reimbursement for doravirine will be contingent on receipt of genotype and phenotype results documented in the medical record showing rationale for selecting doravirine based on resistance testing.

    • Genotype and phenotype results must be obtained and documented before starting doravirine
    • Medical record must show resistance testing supports doravirine use
    Baseline HIV quantification: plasma HIV-1 or HIV-2 RNA measurement performed prior to or at initiation of therapy or when immediate treatment is anticipated.
    When to performAt-risk individuals with borderline or equivocal serologic reactivity; individuals with signs/symptoms of acute retroviral syndrome; and when initiation of antiretroviral therapy is anticipated.
    Additional indicationsAlso reimbursed for monitoring disease progression, monitoring response to therapy, infants <18 months born to HIV-positive mothers, and assessing maternal-fetal transmission risk.
    Repeat-interval considerationUse same assay method for serial HIV RNA measurements when possible; NAAT repeat testing should not be done more often than once every month.