CurrentHumanaPolicy LAB2023044

Laboratory - HIV Genotyping and Phenotyping

Humana Medicare Advantage payment policy outlining reimbursement stance for HIV genotyping and phenotyping procedures and related codes for providers treating Humana members.

Policy Summary

PayerHumana

PolicyLaboratory - HIV Genotyping and Phenotyping

Policy CodePolicy LAB2023044

Change TypeNo material changes

Effective Date07/2023

Next Review Date04/2026

Key ActionReimburse HIV genotyping/phenotyping (CPT 87901, 87903, 87904, 87906); do not reimburse algorithm-based phenotype prediction (87900, 0219U).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Reimbursable codes

2Not reimbursable

MedAdvProduct scope

1Named proprietary test

Reimbursement Criteria

Reimbursement criteria

Stance on reimbursement for HIV genotyping and phenotyping codes and algorithm-based predictions.

ALL of the following

CPT 87901 — Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, reverse transcriptase, and protease regions.
CPT 87903 — Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug resistance tissue culture analysis, HIV-1; first through 10 drugs tested.
CPT 87904 — Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug resistance tissue culture analysis, HIV-1; each additional drug tested.
CPT 87906 — Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, other region (e.g., integrase, fusion).

Policy Summary

PayerHumana

PolicyLaboratory - HIV Genotyping and Phenotyping

Policy CodePolicy LAB2023044

Change TypeNo material changes

Effective Date07/2023

Next Review Date04/2026

Key ActionReimburse HIV genotyping/phenotyping (CPT 87901, 87903, 87904, 87906); do not reimburse algorithm-based phenotype prediction (87900, 0219U).

SourceLink

On This Page

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.

Codes and Reimbursement Stance

Covered CPT CodesCPT | mixedCovered

87901	Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, reverse transcriptase, and protease regions
87903	Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug resistance tissue culture analysis, HIV 1; first through 10 drugs tested
87904	Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug resistance tissue culture analysis, HIV 1; each additional drug tested
87906	Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, other region (e.g., integrase, fusion)

Not reimbursable / Experimental algorithm-based testsCPT | HCPCS | mixedNot Covered

87900	Infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics
0219U	Infectious agent (human immunodeficiency virus), targeted viral next-generation sequence analysis, algorithm reported as prediction of antiviral drug susceptibility (Sentosa® SQ)

Reimbursement stance — quick reference

Reimbursable CPT codesCPT 87901, CPT 87903, CPT 87904, CPT 87906 are reimbursable for patients with HIV.

Not reimbursable CPT/HCPCS codesCPT 87900 and HCPCS 0219U are not reimbursable (drug susceptibility phenotype prediction / proprietary algorithm).

Coverage contextApplies to Humana Medicare Advantage plans; claims subject to medical necessity, reasonableness, and plan requirements.

Reimbursement Determination and Provider Impact

Denial Risk

Reimbursement Determination — Non‑reimbursable Algorithm‑Based Tests

Reimbursement determination: HIV genotyping or phenotyping (CPT 87901, 87903, 87904, 87906) is reimbursable for patients with HIV. Non-reimbursable algorithm-based tests: Drug susceptibility phenotype prediction using genotypic comparison to known genotypic or phenotypic database (CPT 87900, 0219U) is not reimbursable. Ensure claims meet medical necessity, plan authorization/referral rules, and applicable Medicare Advantage NCD/LCD requirements to avoid denials.

Affected codes: CPT 87901, 87903, 87904, 87906 — reimbursable for patients with HIV
Affected codes: CPT 87900, 0219U — not reimbursable (algorithm-based phenotypic prediction)
Action: Verify HIV diagnosis and document medical necessity; confirm any required prior authorization or referral per plan rules
Billing guidance: Do not bill CPT 87900 or 0219U for drug susceptibility phenotype prediction claims expecting reimbursement under this policy

Key Definitions

Definition — HIV genotyping

DefinitionHIV genotyping (CPT 87901, CPT 87906) is infectious agent genotype analysis by nucleic acid (DNA or RNA) targeting HIV-1 regions such as reverse transcriptase, protease, or other regions (e.g., integrase, fusion).

Typical targetsReverse transcriptase (RT) and protease (PR) regions explicitly described for CPT 87901.

Other regionsAdditional HIV-1 regions (e.g., integrase, fusion) described for CPT 87906.

Definition — HIV phenotyping

Definition — phenotypingHIV phenotyping (CPT 87903, CPT 87904) is infectious agent phenotype analysis by nucleic acid (DNA or RNA) combined with drug resistance tissue culture analysis; 87903 covers first through 10 drugs tested and 87904 covers each additional drug tested.

MethodIncludes drug resistance tissue culture testing as part of phenotype analysis.

Coding note87903 reported for first through 10 drugs; 87904 reported separately for each additional drug tested.

Algorithm-based phenotype prediction (note)

What it isAlgorithm-based phenotype prediction (CPT 87900; HCPCS 0219U) uses genotypic comparison to databases or proprietary NGS algorithms to predict antiviral drug susceptibility.

ExamplesCPT 87900: infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics; 0219U: targeted viral NGS with algorithm-reported prediction (Sentosa® SQ).

Policy stanceThese algorithm-based predictions (87900, 0219U) are NOT REIMBURSABLE under this Medicare Advantage policy.