ModifiedHealthfirstPolicy N/A

Hepatitis Testing — Coverage Criteria for A, B, C, D (serologic and molecular testing)

Defines coverage criteria, indications, and limitations for laboratory testing for hepatitis A, B, C, and D (serologic and molecular) for Healthfirst members in North Carolina.

Policy Summary

PayerHealthfirst

PolicyHepatitis Testing — Coverage Criteria for A, B, C, D (serologic and molecular testing)

Policy CodePolicy N/A

Change TypeMultiple material updates (added coverage for immunosuppressed grouprevised perinatal age windowadded CPT G0567removed serial RNA monitoring)

Effective DateOct 15, 2025

Next Review DateN/A

Key ActionOrder reflex HCV RNA (qualitative NAT) automatically when an HCV antibody test is reactive and document indicated risk factors to support testing.

SourceLink

POLICY UPDATE CHANGES

Addition of new CC2bxiv: for individuals who are receiving immunosuppressant therapy.

Antibody testing for HCV once every three months MEETS COVERAGE CRITERIA for individuals with ongoing risk factors (while risk factors persist).

Addition of CPT code G0567 to coverage for qualitative nucleic acid testing for immunocompromised individuals.

CC9 edited to specify 'qualitative' nucleic acid testing for HCV in the listed situations, and CC9b (perinatally exposed infants) changed to age 2-6 months.

New coverage criteria for Hepatitis A testing: IgM anti-HAV or qualitative HAV RNA meets criteria for symptomatic individuals negative for HBV and HCV; quantitative HAV viral load does not meet coverage.

New coverage criteria for Hepatitis D testing: anti-HDV or qualitative HDV RNA meets criteria for HBV-positive individuals; quantitative HDV viral load does not meet coverage.

Former CC6 regarding monitoring HCV RNA every 4-8 weeks for spontaneous clearance was removed.

Added CPT codes 86704, 86705, 86706, 87340, 86692, 86708, 86709, 87380, 87516, 87523, 87799 to the policy coding list.

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.

onceHBV triple panel

onceHCV antibody (adult)

3 moHCV antibody (ongoing risk)

41 minCepheid Xpert runtime

~25Procedure codes listed

1New immunosuppressed CC

Coverage Criteria for Hepatitis A, B, C, and D Testing

Hepatitis B - Routine and Risk-Based Screening

Covered when the following conditions are met:

Adult routine: 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 MEETS COVERAGE CRITERIA

[[chunk 3]]

Annual HBV screening in asymptomatic non-pregnant individuals: Annual HBV screening meets coverage when high-risk situations are present including: infants born to HBsAg-positive individuals (HBsAg and anti-HBs), individuals born in or recently traveled to regions with HBV prevalence ≥2%, U.S.-born individuals not vaccinated as infants with parents from 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/sex partners of HBV-infected persons, injection-drug users, active or history of HCV infection, elevated liver enzymes, long-term hemodialysis, diabetes, healthcare/public safety workers exposed to blood/body fluids, and individuals receiving immunosuppressant therapy

[[chunk 3]]

Follow-up testing for anti-HBc positive: For individuals who test positive for anti-HBc, follow-up IgM anti-HBc testing to distinguish acute vs chronic infection MEETS COVERAGE CRITERIA

[[chunk 3]]

Post-vaccination seroconversion: Anti-HBs testing for confirmation of seroconversion after hepatitis B vaccination MEETS COVERAGE CRITERIA

[[chunk 31]]

HBV DNA testing before immunosuppression: HBV DNA testing is covered for individuals who test positive by initial antibody screening and who will undergo immunosuppressive drug therapy

[[chunk 31]][[chunk 57]]

Hepatitis C - Screening, Diagnosis, and Monitoring

Covered when the following conditions are met:

Adult routine antibody screening: For all individuals 18 years of age and older, antibody testing for HCV infection once per lifetime MEETS COVERAGE CRITERIA

[[chunk 5]]

One-time postexposure or risk-based testing: One-time postexposure antibody testing meets coverage for individuals with recognized exposures/conditions such as illicit intranasal or injectable drug use, clotting factor concentrates 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 of exposure from donor who later tested positive, history of incarceration, unregulated tattoo, healthcare/public safety worker needlestick/mucosal exposure, children born to HCV-positive individuals, current sexual partners of HCV-infected persons

[[chunk 5]]

Ongoing risk screening: Antibody testing for HCV once every three months meets coverage for individuals with ongoing risk factors while risk persists (current injection drug use with shared equipment, ongoing hemodialysis, engaging in high-risk sexual behavior)

Hepatitis A and D - Indications and Non-covered Tests

Covered when specific criteria are met; certain quantitative tests are not covered.

HAV acute infection testing: 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 meets coverage criteriasymptomatic

[[chunk 7]][[chunk 33]]

HAV quantitative NAT not covered: Quantitative nucleic acid testing for HAV viral load does not meet coverage criteria

[[chunk 7]]

HDV testing in HBV-positive individuals: For individuals who have tested positive for HBV, testing for HDV antibody (anti-HDV) or qualitative HDV RNA meets coverage criteriaHBV infection present

[[chunk 8]][[chunk 35]]

Hepatitis C screening and confirmatory testing

Covered when meeting CDC/USPSTF/AASLD-IDSA screening recommendations

CDC universal HCV testing: Hepatitis C screening at least once in a lifetime for all adults aged 18 years and older, except in settings with HCV RNA-positivity prevalence <0.1%age >=18

[[chunk 27]]

One-time testing for high-risk groups: One-time testing irrespective of age for people with recognized conditions or exposures (people who inject drugs, persons with HIV, selected medical conditions, hemodialysis patients, prior transfusion/organ recipients, health care exposures, infants born to HCV-positive people)

[[chunk 27]]

Reflex confirmatory testing: Initiate testing with an FDA-approved HCV antibody test with reflex to NAT for HCV RNA if antibody is reactive; collect samples to allow automatic HCV RNA testing when antibody is reactive

[[chunk 28]]

Hepatitis B screening and serologic panel

Covered when meeting CDC HBV screening recommendations

Adult HBV screening: Screen all adults aged 18 and older at least once using the triple panel (HBsAg, anti-HBs, total anti-HBc); offer testing to anyone who requests itage >=18

[[chunk 30]]

HBV testing for high-risk groups: Periodic testing for persons with ongoing risk (people from high-prevalence regions, persons who inject drugs, people with HIV, incarcerated persons, household contacts of HBV cases, dialysis patients, those with elevated liver enzymes)

[[chunk 30]]

Triple panel utility: Use triple panel for initial screening to identify active infection, resolved infection, susceptibility requiring vaccination, or vaccine nonresponse; follow-up testing individualized

[[chunk 31]][[chunk 32]]

HAV and HDV testing

Covered when meeting CDC testing guidance for acute HAV and HDV

HAV acute infection testing: Test for IgM anti-HAV in symptomatic patients suspected of acute HAV; HAV RNA in serum or stool may indicate acute infection; do not use IgG or total anti-HAV to diagnose acute illnesssymptomatic

[[chunk 33]][[chunk 34]]

HDV testing prerequisites: Test for HDV (total anti-HDV and HDV RNA) only in persons with current or past HBV infection or other HDV risk; HDV RNA required for confirmationHBV infection present

[[chunk 35]][[chunk 59]]

Non-covered quantitative NAT: Quantitative nucleic acid testing for HAV and HDV viral load does not meet coverage criteria

[[chunk 7]][[chunk 8]]

Screening and diagnostic criteria

Screening and diagnostic testing recommendations summarized from USPSTF, AASLD-IDSA, and WHO

HCV general screening: USPSTF: One-time HCV screening recommended for adults aged 18-79 using anti-HCV antibody testing followed by confirmatory HCV RNA PCR.

[[chunk 36]]

AASLD-IDSA one-time and periodic testing: AASLD-IDSA: one-time opt-out HCV testing for all individuals >=18; periodic repeat testing for persons with risk exposures and annual testing for people who inject drugs and certain high-risk groups.

[[chunk 37]]

Two-step HCV diagnosis: Anti-HCV antibody screening followed by HCV RNA nucleic acid testing to confirm active infection (WHO, AASLD-IDSA).

[[chunk 51]]

HBV screening tests:

HCV treatment and post-treatment monitoring

Pre-treatment and monitoring criteria for HCV therapy

Pre-DAA testing: Quantitative HCV RNA, INR, eGFR, and hepatic function panel are recommended prior to starting direct-acting antiviral therapy; genotype testing if nonpangenotypic agent planned.within 6 months prior to DAA initiation

[[chunk 42]]

Post-treatment SVR testing: Quantitative HCV viral load testing recommended >=12 weeks after completion of therapy to document sustained virologic response.>=12 weeks

[[chunk 42]]

Monitoring after treatment failure: For patients not retreated or who fail subsequent DAA courses, assess disease progression every 6-12 months with hepatic panel, CBC, and INR; surveillance for HCC with ultrasound +/- AFP every 6 months if cirrhosis present.

Pregnancy and pediatric testing

Special populations and pediatric/perinatal testing

Pregnancy: Test all pregnant individuals for HCV with each pregnancy as part of prenatal care; perform HCV RNA and liver tests if antibody-positive to assess mother-to-child transmission risk and disease severity; coordinate care with maternal-fetal medicine for those with cirrhosis.each pregnancy

[[chunk 44]]

Perinatally exposed children: Children born to persons with hepatitis C should be tested: antibody testing at/after 18 months; HCV-RNA testing can be considered as early as 2 months of age or in the first year; repetitive RNA testing before 18 months is not recommended.antibody >=18 months; RNA >=2 months optional

[[chunk 46]]

WHO testing strategy and populations

WHO recommended testing approaches and targeted populations

WHO general population testing: In settings with >=2% anti-HCV or HBsAg seroprevalence, all adults and adolescents should have routine access to serological testing.>=2% seroprevalence

[[chunk 51]][[chunk 54]]

WHO focused testing: Offer HBsAg and anti-HCV testing to key populations: MSM, sex workers, people who inject drugs, people in prisons, trans and gender-diverse people, people living with HIV/TB/STIs, and indigenous populations with higher prevalence.

[[chunk 52]][[chunk 55]]

WHO testing modalities: WHO recommends integration, decentralization, task-sharing, and offers point-of-care HCV RNA assays and self-testing as additional approaches to increase access.

[[chunk 51]][[chunk 52]]

Guideline-based screening, reflex testing, and confirmatory NAT

Covered when testing is consistent with guideline-based indications (WHO, AGA, EASL, IHS) and documented risk or clinical suspicion. Examples below follow the source wording and grouping.

WHO general population and high-prevalence settings: Offer HBsAg testing to all adults and adolescents in settings with high HBsAg seroprevalence; routine access and offer recommended where prevalence thresholds described by WHO apply.HBsAg seroprevalence threshold referenced

[[chunk 54]]

Routine testing in specific populations: Offer HBsAg (and anti-HCV where indicated) to: all pregnant women at least once early in pregnancy; all blood donors; healthcare workers not previously vaccinated; people with clinical suspicion of chronic viral hepatitis; adults and adolescents living with HIV, TB or STIs; indigenous populations with higher prevalence; those with healthcare exposure or invasive procedures outside healthcare.

[[chunk 55]][[chunk 56]]

Focused testing of affected populations: Offer HBsAg and anti-HCV serological testing to MSM, sex workers, PWID, trans and gender-diverse people, people in prison and other closed settings; test PrEP users for HBsAg around initiation; offer testing to sexual partners and close household contacts of HBV-infected persons; test infants born to HBsAg-positive mothers between 6-12 months.

Selected Coverage Criteria (HBV/HCV/HAV/HDV)

Covered when specified criteria/clinical situations are met (selected examples from revision history and criteria sections):

HBV triple panel once per lifetime: For all individuals 18 years of age and older, triple panel testing (HBsAg, anti-HBs, total anti-HBc) for HBV once per lifetime MEETS COVERAGE CRITERIA when high-risk situations are met (see list: birth in endemic regions, parents from high-prevalence regions, incarceration, HIV infection, history of STI or multiple partners, MSM, household/needle-sharing contacts of HBV cases, injection drug users, active or history of HCV, elevated liver enzymes, long-term hemodialysis, diabetes, healthcare/public safety workers exposed to blood/body fluids).

List items extracted across chunks 84-86.

HBV follow-up serology: For individuals who test positive for HBV by initial antibody screening; follow up serologic testing (anti-HBc, anti-HBs, IgM anti-HBc) MEETS COVERAGE CRITERIA.

HBV post-vaccination seroconversion: For confirmation of seroconversion after hepatitis B vaccination, anti-HBs testing MEETS COVERAGE CRITERIA.

Quantitative nucleic acid testing (viral load) for hepatitis A (HAV) and hepatitis D (HDV) is explicitly excluded from coverage. The policy states that while qualitative HAV RNA and IgM anti-HAV testing meet coverage criteria for symptomatic individuals (who have tested negative for HBV and HCV), quantitative NAT for HAV viral load DOES NOT MEET COVERAGE CRITERIA, and similarly, although anti-HDV or qualitative HDV RNA testing meets coverage for HBV-positive persons, quantitative NAT for HDV viral load DOES NOT MEET COVERAGE CRITERIA. Providers should not expect payment for requests for quantitative HAV or HDV viral load assays unless otherwise authorized.

The policy reiterates CDC guidance that IgG (or total) anti-HAV is not useful to diagnose acute hepatitis A. IgG anti-HAV indicates prior immunity from infection or vaccination and should not be used to evaluate suspected acute illness. For symptomatic patients with suspected acute HAV, the appropriate covered tests are IgM anti-HAV or qualitative HAV RNA, and clinicians should also consider ALT and total bilirubin to support the clinical diagnosis.

Consistent with AASLD guidance cited in the policy, do not repeat HCV antibody testing in individuals with a documented prior positive HCV antibody. Repeat antibody testing provides no clinical benefit; instead, order a quantitative HCV viral load (HCV RNA) to determine whether infection is active or resolved and to guide treatment decisions.

The policy excerpt does not list specific exclusions for laboratory-developed tests, but it notes regulatory context: laboratory-developed tests (LDTs) are regulated under CLIA as high-complexity tests and are not FDA-cleared or -approved. While FDA clearance is not required for clinical use of LDTs, providers and laboratories must follow applicable CLIA requirements when using LDTs; the policy does not specify additional payer-level exclusions for LDTs in this excerpt.

Policy stance is explicit: Quantitative nucleic acid testing (viral load) for HAV and HDV DOES NOT MEET COVERAGE CRITERIA. This exclusion is stated alongside covered indications for IgM anti-HAV/qualitative HAV RNA and for anti-HDV/qualitative HDV RNA, making quantitative viral-load assays for these viruses non-covered by default per this policy update.

For clarity and to avoid claim denials, the policy restates that quantitative NAT for HAV and HDV viral load is not covered. Although qualitative molecular assays and appropriate serologies remain covered in indicated clinical scenarios, requests for quantitative HAV or HDV viral-load testing will be subject to noncoverage under these criteria.

The policy includes guideline-based nuance regarding HBV screening among immunosuppressed patients: the AGA recommends screening (HBsAg and anti-HBc, followed by HBV DNA if positive) for patients at moderate or high risk who will undergo immunosuppressive therapy, but it suggests against routine screening in low-risk patients receiving immunosuppression (a weak recommendation). The Healthfirst criteria were updated to add immunosuppressant therapy as a covered risk group for HBV evaluation, aligning coverage with the need to identify patients at meaningful reactivation risk.

The policy reflects a guideline-driven change: monitoring HCV RNA serially to detect spontaneous clearance (previously performed every 4–8 weeks for 6–12 months) was removed. The revision notes that current guidance supports initiating HCV treatment without awaiting spontaneous resolution; consequently, the policy no longer supports routine serial RNA monitoring for spontaneous clearance and emphasizes timely treatment initiation and the use of HCV RNA testing for diagnosis and treatment monitoring as indicated.

Applicable Procedure and Test Codes

Applicable Codesmixed

No codes listed

Diagnostic and monitoring tests mentionedmixed

quantitative HCV RNA	Quantitative HCV-RNA viral load testing recommended prior to therapy and post-treatment
HCV-antibody	HCV-antibody testing with reflex HCV RNA for initial testing
HBsAg	Hepatitis B surface antigen test for screening
anti-HBs	Antibody to hepatitis B surface antigen for immunity assessment
anti-HBc	Antibody to hepatitis B core antigen to determine prior exposure (not routine)
hepatic function panel	Includes serum albumin, total/direct bilirubin, ALT, AST, alkaline phosphatase
INR	International normalized ratio
eGFR	Estimated glomerular filtration rate

Covered Serology 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).

Covered Antigen / Confirmatory / NAT CPT CodesCPTCovered

86709	Hepatitis A antibody (HAAb), IgM antibody.
86803	Hepatitis C antibody.
86804	Hepatitis antibody; confirmatory test (eg, immunoblot).
87340	Infectious agent antigen detection by immunoassay; hepatitis B surface antigen (HBsAg).
87341	Infectious agent antigen detection by immunoassay; HBsAg neutralization.
87380	Infectious agent antigen detection by immunoassay; hepatitis, delta agent.
87517	Infectious agent detection by nucleic acid (DNA or RNA); hepatitis B virus, quantification.
87520	Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, direct probe technique.
87521	Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, amplified probe technique, includes reverse transcription when performed.

Quantitative NAT, Genotype, and HCPCS Screening CodesmixedCovered

87522	Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performed.
87523	Infectious agent detection by nucleic acid (DNA or RNA); hepatitis D (delta), quantification, including reverse transcription, when performed.
87799	Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; quantification, each organism.
87902	Infectious agent genotype analysis by nucleic acid (DNA or RNA); Hepatitis C virus.
G0472	Hepatitis C antibody screening, for individual at high risk and other covered indication(s).
G0499	Hepatitis B screening in non-pregnant; high risk individual includes HBsAg, anti-HBs and anti-HBc followed by confirmatory test.
G0567	Infectious agent detection by nucleic acid; hepatitis C, screening, amplified probe technique (added for immunocompromised individuals).

Policy-referenced CPT/HCPCS Codes (Revision History)mixed

86692	unspecified antibody/serologic test (listed in revision history)
86708	hepatitis A antibody (listed in revision history)
86709	hepatitis A IgM (listed in revision history)
87380	hepatitis, delta agent antigen test (listed in revision history)
87516	HCV RNA molecular test (listed in revision history)
87523	HDV molecular detection assay (listed in revision history)
87799	unlisted microbiology procedure (listed in revision history)
86704	Hepatitis B core antibody (added)
86705	Hepatitis B core IgM antibody (added)
86706	Hepatitis B surface antibody (added)

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HCV antibody testing frequency for ongoing risk

HCV antibody testing frequency (ongoing risk)Every 3 months while risk factors persist

Applicable populationsIndividuals who currently inject drugs, persons receiving ongoing hemodialysis, or those engaging in high‑risk sexual behavior

Policy statusListed as a revised, material change in the 06/04/2025 revision history

Population seroprevalence threshold

Seroprevalence trigger>= 2% seroprevalence (use threshold to recommend routine population testing)

Provider Actions, Documentation, and Billing Guidance

Documentation Required

Coverage requires documented indication

Coverage for hepatitis testing and related molecular NAT requires a documented clinical indication in the medical record. Providers must document the reason for testing (screening indication, exposure history, risk factors, pregnancy status, symptoms, or pre-treatment evaluation) to support medical necessity and payment.

Document indication (screening, exposure, risk factor, pre-therapy evaluation) in the chart
Link lab results (antibody, antigen, RNA/DNA) to the clinical note or visit

Note

Reflex NAT recommended; single-visit sample collection

Order HCV screening as antibody testing with reflex to NAT (HCV RNA) when reactive; collect required samples in a single visit when possible to avoid delays. CDC recommends that laboratories automatically perform NAT testing for HCV RNA when an HCV antibody test is reactive to streamline diagnosis and linkage to care.

Order reflex HCV RNA (qualitative or quantitative) automatically with a reactive HCV antibody

Background and Guideline Basis

Hepatitis A, B, C, and D are distinct viral causes of liver inflammation with differing modes of transmission and clinical courses. HBV is transmitted perinatally, via blood and body fluids, and by sexual contact; it can become chronic and lead to cirrhosis and hepatocellular carcinoma. HCV is an RNA virus that may become chronic and is a leading indication for liver transplantation; nucleic acid testing (NAT) is the gold standard to detect active HCV infection and to monitor therapy. HAV does not cause chronic infection; testing focuses on acute cases using IgM anti-HAV or qualitative HAV RNA. HDV infects only persons with HBV and requires anti-HDV serology followed by qualitative HDV RNA to confirm active infection. These clinical distinctions underpin the policy’s coverage rules for serologic and molecular testing.

The policy bases its testing recommendations on international and national guidance, including the World Health Organization (WHO) 2024 operational testing guidance. WHO supports a two-step approach for HCV (antibody screening followed by confirmatory HCV RNA) and recommends expanded, person-centered testing strategies — including point-of-care HCV RNA assays where appropriate — in settings with higher seroprevalence. These international recommendations are cited in the policy as supporting the reflex NAT approach and the targeted screening strategies adopted in the coverage criteria.

Definitions and Key Terms

HCV genotype

Role of HCV genotype assessmentAssessment of HCV genotype is crucial to guide regimen selection, dosing, and duration of therapy

Clinical impactSome regimens are genotype‑specific; genotype informs choice between pangenotypic vs nonpangenotypic DAAs

TimingOne‑time genotype testing is required prior to initiation of DAA therapy when a nonpangenotypic agent is planned

Sustained virologic response (SVR) definition

SVR definitionUndetectable HCV RNA 12 weeks following completion of therapy

Clinical significanceSVR12 is used as a proxy for elimination of HCV RNA and treatment success

Policy Revision History and Material Changes

2025-06-04revision

Added immunosuppressant therapy as a covered high-risk group (new CC2bxiv) and added multiple CPT/HCPCS codes to the policy coding list (including 86704, 86705, 86706, 87340, 86692, 86708, 86709, 87380, 87516, 87523, 87799).

2025-06-04revision

Clarified NAT testing type and perinatal age window: CC9 edited to specify qualitative nucleic acid testing for HCV and perinatally exposed infants age window clarified to 2–6 months.

2025-06-04revision

Policy Summary

PayerHealthfirst

PolicyHepatitis Testing — Coverage Criteria for A, B, C, D (serologic and molecular testing)

Policy CodePolicy N/A

Change TypeMultiple material updates (added coverage for immunosuppressed grouprevised perinatal age windowadded CPT G0567removed serial RNA monitoring)

Effective DateOct 15, 2025

Next Review DateN/A

Key ActionOrder reflex HCV RNA (qualitative NAT) automatically when an HCV antibody test is reactive and document indicated risk factors to support testing.

SourceLink

On This Page

Confirmatory RNA testing: Qualitative nucleic acid testing for HCV meets coverage as follow-up for positive HCV antibody screening to differentiate active vs resolved infection and for one-time screening of perinatally exposed infants 2-6 months of age

[[chunk 5]][[chunk 28]]

Pre-treatment genotype testing: One-time HCV genotype testing prior to initiation of direct-acting antiviral (DAA) therapy to guide regimen selection MEETS COVERAGE CRITERIA

[[chunk 6]][[chunk 11]]

HCV viral load monitoring: Quantitative HCV viral load testing is covered prior to initiation of DAA therapy, at week 4 of therapy, at end of treatment, and at 12, 24, and 48 weeks after completion of treatmenttimepoints: pre-treatment, 4 weeks on therapy, end of treatment, 12/24/48 weeks post-treatment

[[chunk 6]][[chunk 42]]

HDV quantitative NAT not covered: Quantitative nucleic acid testing for HDV viral load does not meet coverage criteria

[[chunk 8]][[chunk 66]]

USPSTF HCV: USPSTF recommends HCV screening in adults aged 18-79 with anti-HCV antibody testing followed by confirmatory PCRage 18-79

[[chunk 36]]

AASLD-IDSA one-time testing: AASLD-IDSA recommends one-time routine opt-out HCV testing for all individuals aged 18 years and older and periodic testing for persons with ongoing risks; prenatal testing each pregnancyage >=18

[[chunk 37]]

HBV screening should use HBsAg and anti-HBs; anti-HBc may be used in certain populations (HIV, immunosuppression, dialysis) with follow-up testing as needed.

[[chunk 52]][[chunk 55]]

HBV DNA testing and reflex: Following a positive HBsAg, perform HBV DNA NAT (quantitative or qualitative) as preferred strategy to assess viral load for treatment eligibility and monitoring; POC HBV DNA assays may be used when appropriate; reflex HBV DNA testing using retained samples or immediate collection is recommended where available.

[[chunk 57]][[chunk 58]]

HDV testing among HBsAg-positive individuals: Perform anti-HDV serology at least once in all HBsAg-positive individuals; where anti-HDV positive, follow with HDV RNA NAT to confirm active infection; reflex anti-HDV after positive HBsAg may be used to promote diagnosis.

[[chunk 66]][[chunk 59]]

HCV testing and confirmation: Use anti-HCV antibody screening (POC or lab-based); confirm active infection with HCV RNA PCR when antibody positive; IHS recommends universal adult one-time screening and screening of all pregnant persons each pregnancy.

[[chunk 51]][[chunk 37]]

HBV prior to immunosuppression: For individuals who test positive for HBV by initial antibody screening and who will undergo immunosuppressive drug therapy, HBV DNA testing MEETS COVERAGE CRITERIA.

HCV antibody initial screening: Specified antibody screening is the allowed test for initial HCV screening in CC5, CC6, and CC7; reflex NAT testing allowed per CC8 and CC9.

HCV NAT follow-up and perinatal screening: Nucleic acid testing for HCV MEETS COVERAGE CRITERIA in these situations: a) as a follow-up for individuals positive by antibody to differentiate active vs resolved infection; b) one-time screening for perinatally exposed infants aged 2-6 months; c) qualitative NAT for immunocompromised individuals (added CPT G0567).

HCV serial antibody testing for ongoing risk: Antibody testing for HCV once every three months MEETS COVERAGE CRITERIA for individuals with ongoing risk factors while risk factors persist (CC8).every 3 months

HAV testing for symptomatic persons: 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 MEETS COVERAGE CRITERIA; quantitative HAV viral load DOES NOT MEET COVERAGE CRITERIA.

HDV testing for HBV-positive individuals: For individuals who have tested positive for HBV, testing for anti-HDV or qualitative HDV RNA MEETS COVERAGE CRITERIA; quantitative HDV viral load DOES NOT MEET COVERAGE CRITERIA.

Guideline basisWHO operational guidance and cited sources recommending routine access/offering where seroprevalence meets threshold

Populations impactedGeneral adult population in settings with elevated anti‑HCV or HBsAg seroprevalence

HBsAg seroprevalence screening trigger

HBsAg seroprevalence screening triggerRecommend routine HBsAg testing where HBsAg seroprevalence >= 2%

Follow-upPerform HBV DNA NAT (quantitative or qualitative) following a positive HBsAg to assess viral load for treatment eligibility

Guideline sourceAGA and WHO guidance cited for screening in populations exceeding prevalence thresholds

HCV antibody testing frequency for ongoing risk (revised)

Revised HCV antibody repeat frequencyOnce every three months for individuals with ongoing risk factors (while risks persist)

Revision noteChange implemented as a material revision in 06/04/2025 revision history (CC8 updated)

Examples of ongoing riskCurrent injection drug use with shared equipment; ongoing hemodialysis; continued high‑risk sexual behavior

Perinatally exposed infant NAT screening age window

Perinatal NAT screening window2–6 months of age for perinatally exposed infants (one‑time qualitative NAT)

PurposeDetect active HCV infection early and coordinate pediatric hepatitis C management if RNA detectable

Operational guidanceCDC recommends testing perinatally exposed infants with NAT at 2–6 months; coordinate care with pediatric hepatitis specialists

Collect serum/plasma (or appropriate specimen) for RNA testing at the initial visit when reflex testing is available

For perinatally exposed infants, collect samples for HCV RNA testing at 2–6 months per CDC guidance

Prior Authorization

Verify prior authorization for added/test codes

Prior authorization requirements are not explicitly specified in this section for most hepatitis laboratory tests; providers should follow payer rules and verify PA for newly added or less-common tests (for example, quantitative or specialty NATs, genotyping, or multiplex panels) before ordering. When in doubt, confirm PA requirements with Healthfirst.

Verify prior authorization for newly added procedure codes (e.g., 87523, 87902, or other specialty NAT/genotype codes)
Confirm PA requirements for quantitative HAV/HDV testing or other non-routine assays

Billing Rule

Billing / code use for hepatitis screening and NAT

Billing and code use must follow AMA/CMS CPT, HCPCS, and ICD-10 guidance and payor-specific rules. Use the correct CPT/HCPCS codes for antibody screening, confirmatory testing, qualitative vs quantitative NAT, and genotype testing. Incorrect code use may lead to claim denials or recoupment.

Use antibody screening codes (e.g., 86803) for initial HCV screening and report confirmatory/alternative codes (e.g., 86804) as appropriate
Report qualitative vs quantitative NAT with the correct codes (e.g., 87520/87521 for HCV detection, 87522 for HCV quantification)
Use genotype code 87902 for HCV genotype testing when performed
Follow NCCI, modifier and multiple-procedure rules to avoid denials

Documentation Required

Baseline testing expectations / Pre-therapy diagnostic steps

Baseline diagnostic testing is expected prior to initiating DAA therapy: obtain quantitative HCV RNA to document baseline viral load and, when prescribing a non-pangenotypic regimen, obtain HCV genotype (and subtype if relevant). Also obtain recommended pre-therapy labs (hepatic panel, INR, eGFR, CBC) within six months before starting therapy.

Quantitative HCV RNA (baseline viral load) prior to DAA initiation
HCV genotype and subtype if a non-pangenotypic DAA is considered
Baseline labs: hepatic function panel, INR, eGFR, complete blood count

Documentation Required

Genotype testing before DAA therapy

Genotype testing is required when a non-pangenotypic direct-acting antiviral will be used to guide regimen selection. Document genotype results in the chart to support therapy choice.

Order HCV genotype (CPT 87902) prior to selecting non-pangenotypic DAA regimens
Document genotype/subtype in the medical record to support medication selection

Documentation Required

HCV viral load testing for therapy authorization and SVR timing

Quantitative HCV RNA is recommended at end of treatment and at 12 or more weeks after completion of therapy to document sustained virologic response (SVR). Document timing and results of these tests in the medical record to support cure assessment and any therapy-related decisions.

Quantitative HCV RNA at end of treatment and ≥12 weeks post-treatment for SVR assessment
Document dates of DAA start/stop and corresponding viral load measurements

Documentation Required

Documentation for initial HBV evaluation; document positive HBsAg and link to reflex HBV DNA testing

Document initial HBV evaluation elements and link positive HBsAg results to reflex HBV DNA testing or collect samples for HBV DNA at the same visit when reflex testing is available. Include risk factors, alcohol use, family history, vaccination status, and baseline labs (CBC, liver chemistries, INR, HBV serologies) in the medical record.

For HBsAg-positive patients, perform reflex HBV DNA (quantitative or qualitative) or collect specimen for DNA testing immediately
Document history (coinfection risk with HCV/HDV/HIV), alcohol use, family history of HBV/HCC, vaccination status, and baseline labs in the chart

Denial Risk

Claims may be denied for incorrect coding or unsupported tests

Claims risk increases when incorrect procedure or modifier codes are submitted or when coding/billing guidelines are not followed. To reduce denial risk, follow CPT/HCPCS/ICD-10 guidance, NCCI edits, and payer-specific policies; ensure lab reports and clinical documentation support the codes billed.

Verify that qualitative vs quantitative NAT codes are billed correctly to reflect the service performed
Avoid billing quantitative HAV/HDV viral load codes (these tests are not covered per policy) unless coverage is confirmed
Maintain documentation tying tests to indications to support claim payment

Billing Rule

Required coding/billing practices to avoid denials/recoupment

Follow coding and billing best practices: adhere to AMA/CMS CPT, HCPCS, ICD-10, NCCI, and payer-specific guidance; use appropriate modifiers; and be aware that state-specific rules may affect coverage. Failure to comply could result in denials or recoupment.

Apply correct modifiers and global/multiple-procedure rules
Follow New York state and other applicable local guidance where relevant
Retain clinical documentation to defend medical necessity in case of claim review

Step Therapy

Step to treatment (clinical sequencing) — prompt treatment initiation

Clinical sequencing to move promptly from diagnosis to treatment is endorsed: do not delay DAA initiation waiting for spontaneous clearance. Ensure testing and documentation (antibody, reflex RNA, baseline quantitative RNA, genotype when needed) are completed promptly to facilitate rapid treatment start and authorization.

Do not wait for spontaneous clearance — proceed with evaluation and treatment per updated AASLD-IDSA guidance
Ensure HCV antibody, reflex RNA, quantitative baseline RNA, genotype (if needed), and pre-therapy labs are documented to support timely treatment initiation

>=12 weeks post‑treatment quantitative HCV RNA to document SVR

Sustained virologic response (SVR)

Consolidated SVR entrySustained virologic response (SVR) = undetectable HCV RNA 12 weeks after completion of therapy; used to document treatment success (SVR12)

Testing recommendation>=12 weeks post‑treatment quantitative HCV RNA recommended to confirm SVR

Policy referenceReferenced in pre‑ and post‑treatment monitoring coverage criteria

NAT definition

NAT definitionNucleic acid test (NAT) — qualitative or quantitative assay to detect HCV RNA (detects active infection and can quantify viral load)

UsesConfirm active infection after a reactive antibody test and for monitoring response to therapy

Timing sensitivityNAT can detect HCV RNA as early as 1–2 weeks after infection (earlier than antibody tests)

Two-step HCV testing

Two‑step HCV testingInitial anti‑HCV antibody test followed by HCV RNA NAT if antibody is reactive (reflex testing preferred)

Operational noteCDC recommends collecting samples in a single visit and ordering automatic HCV RNA testing when antibody is reactive to reduce time to diagnosis

PurposeDistinguish active infection (RNA detectable) from resolved infection (antibody positive, RNA undetectable)

HBsAg and anti-HBs screening definitions

HBsAg and anti‑HBs screeningUse HBsAg to detect current HBV infection and anti‑HBs to assess immunity (anti‑HBc may be used for prior exposure evaluation)

Interpretation utilityTriple panel (HBsAg, anti‑HBs, anti‑HBc) identifies active infection, past exposure, or susceptibility requiring vaccination

Follow‑upAnti‑HBc positive results warrant further testing (eg, IgM anti‑HBc) to distinguish acute vs chronic infection as indicated

Reflex HBV DNA / anti-HDV testing

Reflex HBV DNA / anti‑HDV testingReflex testing = automatic follow‑up molecular or serologic tests (eg, HBV DNA or HDV RNA) after a positive screening result to promote timely diagnosis

Operational noteWhere available, retain samples or collect additional samples in a single visit to enable reflex HBV DNA or anti‑HDV testing

Guideline basisWHO and EASL conditional recommendations support reflex strategies to improve diagnosis and linkage to care

Definitions section (policy)

Definitions sectionThis policy contains a Definitions section (additional term definitions are included in the full policy beyond this extract)

ScopeDefinitions cover key terms such as NAT, SVR, genotype, reflex testing, and screening thresholds

Reference noteSee full policy Definitions section for complete term list and formal definitions

Specified that quantitative HAV and HDV viral load testing does not meet coverage; added coverage stances allowing IgM anti-HAV or qualitative HAV RNA for symptomatic individuals and anti-HDV or qualitative HDV RNA for HBV-positive individuals.

2025-06-04revision

Changed frequency for repeat HCV antibody testing for individuals with ongoing risk to once every three months (CC8).

2025-06-04addition

Added CPT G0567 to the list of allowable codes for qualitative nucleic acid testing for immunocompromised individuals (referenced for CC9.c).

2023-12-06off-cycle_review

Updated guideline section and modified CC9 to add NAT for HCV screening of perinatally exposed infants (previously adjusted age window 2–17 months).

2025-10-15policy_effective_dateLatest

Policy effective date recorded (operational/legal metadata).