CurrentCentenePolicy CG.CP.MP.05

CONCERT INFECTIOUS DISEASE: PRIMARY CARE & PREVENTATIVE SCREENING

Defines medical necessity criteria for outpatient screening tests: high-risk HPV genotyping for cervical cancer screening, low-risk HPV genotyping (investigational), hepatitis C antibody and nucleic acid/PCR testing, and Group B Streptococcus (GBS) vaginal-rectal screening in pregnancy.

Policy Summary

PayerCentene

PolicyCONCERT INFECTIOUS DISEASE: PRIMARY CARE & PREVENTATIVE SCREENING

Policy CodePolicy CG.CP.MP.05

Change TypeRevisions and additions to criteria and coding (material changes present)

Effective Date

Next Review Date

Key ActionProviders must ensure tests meet the policy medical necessity criteria (age, pregnancy gestational age, risk factors, prior test results) prior to ordering; claims may be reviewed for adherence to criteria.

SourceLink

POLICY UPDATE CHANGES

Changed policy statement verbiage from 'may be considered medically necessary' to 'are considered medically necessary' for several criteria sections.

Added criteria option: member exposed to HCV perinatally and is between 2 months and 17 months of age.

Added CPT code 87626 and HCPCS code G0476 to coding tables.

Removed CPT codes 0500T, 87081, 87149 and 87150 from policy reference table.

3Screening types covered (HPV/HCV/GBS)

5HPV high-risk genotyping interval (years)

Coverage Summary

Scope: Outpatient infectious disease screening policy covering three main areas: human papillomavirus (HPV) testing, hepatitis C virus (HCV) testing, and group B Streptococcus (GBS) vaginal-rectal screening in pregnancy. For HPV, genotyping of high-risk HPV types is considered medically necessary for individuals born with a cervix who meet age and risk criteria (including ages 30–65 years with preserved cervix and selected risk history) and is allowed once every 5 years in the absence of increased risk; low-risk HPV genotyping is investigational. For HCV, both antibody screening tests and nucleic acid/PCR testing are addressed: antibody screening is medically necessary when preconditions are met (no prior known positive antibody or known chronic infection and meeting listed age, pregnancy, exposure, or risk criteria); nucleic acid/PCR testing is medically necessary for specified indications including immunocompromised status, suspected exposure within the past 6 months, initial positive antibody (including automatic reflex PCR), monitoring before/during/after DAA therapy, perinatally exposed infants 2–17 months of age, and in persons with prior SVR who have ongoing risk. For GBS, vaginal-rectal screening is medically necessary for pregnant individuals at gestational age 36 weeks 0 days to 37 weeks 6 days. The policy stance is mixed: several screening types and indications are covered while other uses (e.g., low-risk HPV genotyping, many other HCV/GBS indications) are considered investigational.

Key Policy Thresholds

HPV genotyping intervalOnce every 5 years (in absence of increased risk factors)

GBS screening gestational window36 weeks 0 days to 37 weeks 6 days

HCV exposure window for PCRSuspected exposure within the past 6 months

Perinatal HCV PCR testing age2 months to 17 months of age for HCV RNA PCR (or anti-HCV at ≥18 months per other criteria)

Human Papillomavirus (HPV) Genotyping — Medical Necessity

Hepatitis C (HCV) Screening & PCR — Medical Necessity

Group B Streptococcus (GBS) Screening — Medical Necessity

Coding

HPV high-risk CPT codesCPTCovered

87624	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types, pooled result
87625	HPV, types 16 and 18 only, includes type 45, if performed
87626	HPV, separately reported high-risk types and high-risk pooled result(s)

HPV high-risk CPT codesHCPCSCovered

G0476

Infectious agent detection; HPV high-risk types for cervical cancer screening, must be performed in addition to pap test

HPV low-risk CPT codeCPTNot Covered

87623

Infectious agent detection by nucleic acid; HPV, low-risk types

Hepatitis C antibody and confirmatory CPT codesCPTCovered

86803	Hepatitis C antibody
86804	Hepatitis C antibody; confirmatory test (eg, immunoblot)

Hepatitis C nucleic acid / PCR CPT codesCPTCovered

87520	Infectious agent detection by nucleic acid; hepatitis C, direct probe technique
87521	Hepatitis C, amplified probe technique, includes reverse transcription when performed
87522	Hepatitis C, quantification, includes reverse transcription when performed

Group B Streptococcus CPT codeCPTCovered

87653

Infectious agent detection by nucleic acid; Streptococcus, group B, amplified probe technique

Provider Actions & Billing Guidance

Prior Authorization

Medical necessity verification for screening tests

Providers must verify that ordered screening tests meet the policy medical necessity criteria prior to ordering. Claims may be reviewed for adherence to criteria. Verify age, pregnancy/gestational age, relevant risk factors, and prior test results before ordering screening tests.

Age
Gestational age (when pregnant)
Risk factors
Prior HCV/HIV/HPV test results

Documentation Required

Document history and risk status

Document that the member does NOT have a known past positive HCV antibody test result and does NOT have a known history of chronic HCV when ordering HCV antibody screening. When indicated, document relevant risk factors or pregnancy status to support medical necessity.

Background & Evidence

Background and rationale: Screening recommendations reflect public health goals to prevent disease and reduce morbidity and mortality. The policy aligns with major guideline sources: USPSTF recommendations for cervical cancer screening options (hrHPV alone every 5 years among ages 30–65 or cytology/cotesting schedules), CDC guidance on appropriate uses and limitations of HPV testing, and AAFP/other guidance discouraging low-risk HPV testing. For HCV, USPSTF and CDC endorse broad antibody screening with reflex confirmatory HCV-RNA testing, and IDSA/AASLD explicitly recommend initial HCV-antibody testing with reflex PCR and quantitative HCV-RNA for monitoring and treatment decisions (including pre-treatment baseline and post-treatment SVR testing). For GBS, ACOG recommends antepartum screening at 36 0/7 – 37 6/7 weeks of gestation, with culture or NAAT methods acceptable when enrichment steps are used. The policy updates also reflect administrative changes (clarified medical necessity wording and added perinatal PCR criteria) to support reflex PCR testing and align coverage with these guideline-based algorithms.

label	value
USPSTF cervical screening recommendation
Screen 30-65 years: hrHPV alone every 5 years or cytology every 3 years or cotesting every 5 years
ACOG GBS screening recommendation
Antepartum screening at 36 0/7 - 37 6/7 weeks unless GBS bacteriuria or prior GBS-infected newborn

Definitions:

SVR — Sustained virologic response: eradication of HCV, used to denote cure after antiviral therapy and defined by guideline-recommended viral load testing post-therapy.

DAA — Direct-acting antiviral: class of medications used to treat chronic HCV infection; quantitative HCV-RNA testing is recommended prior to and after DAA therapy per guidance.

Revision History

11/24revised (material)Latest

Policy statement verbiage changed from 'may be considered medically necessary' to 'are considered medically necessary' for: Group B Streptococcus Screening Tests of Vaginal-Rectal Specimens; Genotyping of High Risk Human Papillomavirus (HPV) Types for Cervical Cancer Screening; and Hepatitis C Nucleic Acid/PCR Tests. (Annual review; Approval Date 02/25.)

11/24added (material)Latest

For Hepatitis C Nucleic Acid/PCR Tests, added criteria option: 'The member was exposed to HCV perinatally and is between 2 months and 17 months of age.'