CurrentHumanaPolicy LAB2023002

Laboratory Hepatitis Testing

Humana Medicare Advantage payment policy describing when specific hepatitis A, B, C and D laboratory tests (antibody, antigen, qualitative and quantitative nucleic acid tests, and genotype testing) are reimbursable and any frequency limits; applies to Humana Medicare Advantage products nationally except where Original Medicare LCDs govern.

Policy Summary

PayerHumana

PolicyLaboratory Hepatitis Testing

Policy CodePolicy LAB2023002

Change TypeNo material changes

Effective Date03/2023

Next Review Date

Key ActionConfirm and document a hepatitis B or C diagnosis where required before billing HBV DNA, HCV genotype, qualitative or quantitative HCV RNA testing as specified.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

once per lifetimeHCV antibody screening for individuals >18 years

up to 12/yearQualitative HCV RNA testing with confirmed HCV diagnosis

1/monthQuantitative HCV viral load (87522) frequency limit

pregnancyHCV antibody testing reimbursable for pregnant individuals

When Hepatitis Laboratory Tests Are Reimbursable

Reimbursable Hepatitis B testing

Tests reimbursable for individuals with confirmed HBV infection

ALL of the following

Confirmed diagnosis of hepatitis B virus (HBV)
IgM anti-HBc (CPT 86705) reimbursable
HBV DNA testing (CPT 87516, 87517) reimbursable

Reimbursable Hepatitis C antibody testing (86803, 86804)

HCV antibody testing reimbursable in any of the listed situations

ANY of the following

Policy Summary

PayerHumana

PolicyLaboratory Hepatitis Testing

Policy CodePolicy LAB2023002

Change TypeNo material changes

Effective Date03/2023

Next Review Date

Key ActionConfirm and document a hepatitis B or C diagnosis where required before billing HBV DNA, HCV genotype, qualitative or quantitative HCV RNA testing as specified.

SourceLink

On This Page

Reimbursable HCV RNA and genotype testing

Conditions under which nucleic acid and genotype tests are reimbursable

ALL of the following

HCV genotype testing (CPT 87902) reimbursable with confirmed Hepatitis C diagnosis

ANY of the following

Qualitative HCV RNA (CPT 87520, 87521) reimbursable with confirmed Hepatitis C (up to 12 tests/year)
Qualitative HCV RNA reimbursable as a one-time screen for perinatally exposed infants <1 year
Quantitative HCV viral load (CPT 87522) reimbursable once per month, not to exceed 7 tests in 18 months

Relevant CPT Codes and Coverage Status

Hepatitis BCPTCovered

86705	Hepatitis B core antibody (HBcAb) IgM antibody
87516	Infectious agent detection by nucleic acid; hepatitis B virus, amplified probe technique
87517	Infectious agent detection by nucleic acid; hepatitis B virus, quantification

Hepatitis C antibodyCPTCovered

86803	Hepatitis C antibody
86804	Hepatitis C antibody (alternate code listed in policy text)

Hepatitis C nucleic acid & genotypeCPTCovered

87520	HCV RNA qualitative, direct probe technique
87521	HCV RNA qualitative, amplified probe technique; includes RT when performed
87522	HCV RNA quantitative, includes RT when performed
87902	Infectious agent genotype analysis; hepatitis C virus

Hepatitis A and DCPTCovered

86708	Hepatitis A antibody
86709	Hepatitis A antibody IgM
86692	Antibody, hepatitis, delta agent
87380	Infectious agent antigen detection; hepatitis, delta agent

What Providers Must Do / Billing Rules

Documentation Required

Confirm diagnosis for HBV/HCV testing reimbursement

The policy requires clinical documentation of a confirmed diagnosis of hepatitis B or hepatitis C where specified before billing for HBV DNA, HCV genotype, qualitative or quantitative HCV RNA testing.

87516
87517
87902
87520
87521
87522

Billing Rule

Frequency limits for HCV testing

Adhere to the policy frequency limits for HCV testing: qualitative HCV RNA testing is limited when performed for confirmed Hepatitis C, quantitative viral load testing has monthly and 18-month limits, and HCV antibody screening frequency is constrained for adults.

Qualitative HCV RNA (87520, 87521): up to 12 tests per year with confirmed Hepatitis C.
Quantitative HCV RNA (87522): reimbursable once per month, not to exceed seven tests in 18 months.
HCV antibody screening (86803, 86804): once per lifetime for individuals over 18 years of age (unless other listed clinical criteria apply).

Billing Rule

Special population testing rules

Special population rules apply: qualitative HCV RNA testing may be reimbursed as a one-time screen for perinatally exposed infants under 1 year; HCV antibody testing is reimbursable for screening in pregnant individuals.

One-time qualitative HCV RNA screen for perinatally exposed infants < 1 year (87520, 87521).
HCV antibody screening reimbursable for pregnant individuals (86803, 86804).

This policy references that certain molecular nucleic acid procedure codes — 87516, 87517, 87520, 87521, and 87522 — are subject to Original Medicare Local Coverage Determinations administered by CGS, Noridian, Palmetto GBA, and Wisconsin Physicians Service. Providers should consult the applicable LCD for the Medicare jurisdiction that governs the claim to determine jurisdiction‑specific coverage criteria and guidance before billing these codes.

Numeric Limits and Frequency Thresholds

HCV Testing Frequency Limits

HCV antibody screening frequencyOnce per lifetime for individuals >18 years

Qualitative HCV RNA testing limitUp to 12 tests per year with confirmed HCV

Quantitative HCV viral load frequencyOnce per month, not to exceed 7 tests in 18 months

once per lifetimeHCV antibody screening for individuals >18 years

up to 12/yearQualitative HCV RNA testing with confirmed HCV diagnosis

1/monthQuantitative HCV viral load (87522) frequency limit

pregnancyHCV antibody testing reimbursable for pregnant individuals

Policy Scope and Clinical Context

Subject: Laboratory Hepatitis Testing. This Humana Medicare Advantage payment policy explains when laboratory tests for hepatitis A, B, C, and D — including antibody and antigen tests, qualitative and quantitative nucleic acid tests, and genotype testing — are reimbursable and identifies applicable frequency limits. The policy applies nationally to Humana Medicare Advantage products, except where Original Medicare Local Coverage Determinations (LCDs) establish jurisdiction‑specific criteria for certain nucleic acid codes.

The scope of the policy covers reimbursement rules for hepatitis testing such as IgM anti‑HBc (CPT 86705) and HBV DNA (CPT 87516/87517) for individuals with confirmed hepatitis B; HCV antibody testing (CPT 86803/86804) for screening (including once per lifetime for adults >18 and pregnancy) and for defined risk exposures; HCV genotype (CPT 87902) and HCV RNA testing (CPT 87520/87521 qualitative, CPT 87522 quantitative) with stated frequency limits; and hepatitis A (CPT 86708/86709) and hepatitis D testing (CPT 86692/87380) in the clinical situations described in this policy.

OpenPayer

Laboratory Hepatitis Testing

When Hepatitis Laboratory Tests Are Reimbursable

Relevant CPT Codes and Coverage Status

What Providers Must Do / Billing Rules

Numeric Limits and Frequency Thresholds

Policy Scope and Clinical Context

Defined Terms

Laboratory Hepatitis Testing

When Hepatitis Laboratory Tests Are Reimbursable

Relevant CPT Codes and Coverage Status

What Providers Must Do / Billing Rules

Numeric Limits and Frequency Thresholds

Policy Scope and Clinical Context

Defined Terms

Other Policies to Read With This One