Authorization depends on medical necessity and member benefits

Coverage for hepatitis testing is subject to authorization and medical necessity and depends on the member’s benefit coverage at the time of the request; providers must ensure services meet authorization and medical necessity criteria before submitting claims.

• Coverage does not guarantee reimbursement; services must meet authorization and medical necessity guidelines and member’s state of residence may affect determinations.
• Providers are responsible for accurate documentation and appropriate coding per industry standards; failure may result in denial or recoupment.

Prior authorization — No prior authorization statements present

No specific prior authorization program requirements or prior-authorization-only tests are stated in the policy excerpts provided.

• The document enumerates procedure codes and guidance but does not list tests that universally require prior authorization in these sections.

HCV RNA and monitoring prior to/after therapy

Quantitative HCV RNA testing is recommended prior to initiation of DAA therapy and quantitative HCV viral load testing is recommended 12+ weeks after completion of therapy to document sustained virologic response (SVR).

• AASLD-IDSA: Quantitative HCV-RNA testing is recommended prior to initiation of antiviral therapy to document baseline viremia and 12+ weeks post-treatment to document SVR.
• CDC/AASLD guidance supports reflex NAT (HCV RNA) following a reactive antibody test and collection of samples in a single visit to expedite diagnosis and treatment.

HBV DNA testing for treatment eligibility

Laboratory-based HBV DNA NAT (quantitative or qualitative) is recommended after a positive HBsAg result to assess viral load for treatment eligibility and to monitor response; point-of-care HBV DNA assays may be used as an alternative where appropriate.

• WHO/AASLD guidance: use HBV DNA testing following HBsAg+ to determine treatment eligibility and for monitoring.
• Where available, reflex HBV DNA testing using an already-held sample or immediate collection after a positive HBsAg rapid test is an acceptable strategy.

Procedure codes listed (prior auth may apply)

The policy lists applicable CPT and HCPCS procedure codes for hepatitis testing; payers may require appropriate documentation or prior authorization per internal rules when these codes are billed.

• Codes enumerated include CPT 86692, 86704–86709, 87340–87341, 87380, 87516–87523, 87902, and HCPCS G0472/G0567.
• Providers should ensure supporting documentation aligns with the billed procedure codes to avoid denials.

Prior authorization — No requirements listed

No prior authorization requirements are described in the provided chunks; the excerpts do not specify tests that require prior authorization.

• The policy includes code lists and guidance but does not state specific prior-authorization rules in these sections.

Submit accurate documentation and code claims per standard guidelines

Providers must submit accurate documentation of services performed and code claims according to industry standard coding guidelines; noncompliance may result in claim denial or recoupment.

• Follow industry coding guidelines (CPT, HCPCS, ICD-10, NCCI, CCI edits, CMS manuals) when submitting claims.
• Oscar may deny or recoup payment if appropriate coding/billing guidelines or current reimbursement policies are not followed.

Step therapy — Not specified in excerpt

No step therapy requirements are described in the policy excerpts provided; the document does not impose a step-therapy sequence for hepatitis testing or treatment in these sections.

• The policy notes clinical and guideline recommendations but does not prescribe stepwise treatment prerequisites in the provided text.

Therapy initiation requirements — baseline testing and prompt DAA start

When acute HCV infection with quantifiable RNA is diagnosed, treatment should be initiated without awaiting spontaneous resolution; baseline quantitative HCV RNA and recommended baseline labs (CBC, INR, hepatic function panel, eGFR) should be documented within six months prior to DAA initiation.

• AASLD-IDSA: After diagnosis of acute HCV with viremia, initiate treatment without waiting for spontaneous resolution.
• Recommended pre-DAA labs within six months: CBC, INR, hepatic function panel, eGFR; quantitative HCV RNA and genotype testing prior to starting DAA as applicable.

Monitoring after DAA failure — disease progression and HCC surveillance

If patients fail DAA therapy and are not retreated (or fail subsequent DAA courses), assess disease progression every 6–12 months with hepatic function panel, CBC, and INR; patients with cirrhosis should undergo HCC surveillance every 6 months.

• AASLD recommendation: disease progression assessment every 6–12 months for patients not retreated after DAA failure.
• HCC surveillance with liver ultrasound ± AFP every 6 months for patients with cirrhosis.

Reflex testing for HDV in HBsAg-positive individuals

For HBsAg-positive individuals, perform anti-HDV testing and, if anti-HDV is positive, perform HDV RNA NAT where available; reflex anti-HDV followed by HDV RNA (where available) is an endorsed strategy to promote diagnosis and linkage to care.

• WHO/EASL: perform anti-HDV in all HBsAg-positive individuals and test HDV RNA in anti-HDV-positive persons using standardised sensitive RT-PCR.
• Reflex testing (anti-HDV then HDV RNA) may be used where available to improve diagnosis and linkage to care.

Step therapy — None in publication/history sections

No step therapy requirements are listed in the referenced publication and history sections of the policy.

• Publication history and references do not include step-therapy mandates in the provided excerpts.

Documentation and coding — document serology, NAT, and follow-up actions

Providers should document serologic and nucleic acid test results and interpretive actions: record HBV triple-panel results and corresponding clinical actions (linkage to care, vaccination, counseling on reactivation), and document results of HBsAg, anti-HBc, HBeAg/anti-HBe, HBV DNA, anti-HDV, and HDV RNA when performed to support diagnosis and management.

• Document HBV triple panel (HBsAg, anti-HBs, total anti-HBc) results and follow CDC interpretive actions.
• Document HBV DNA testing and linkage-to-care steps when HBsAg is positive; document anti-HDV and HDV RNA results where testing performed.

Sample collection and reflex testing documentation — single-visit collection and automatic reflex to NAT

Clinicians should collect all samples needed to diagnose hepatitis C during a single visit and order HCV RNA testing automatically when the HCV antibody is reactive; documentation should support sample collection and reflex testing.

• CDC operational guidance: collect samples to permit single-visit diagnosis and automatic reflex to NAT when antibody is reactive.
• Automatic laboratory reflex to NAT streamlines diagnosis without additional patient or clinician action.

HBV serology documentation — interpret results and record actions

Document HBV serology test results and corresponding interpretive actions per the CDC serologic interpretation chart; when HBsAg is positive, document linkage to care, vaccination needs, counseling, and further testing plans.

• Record test outcomes and actions (e.g., acute vs chronic infection, link to care, vaccination recommendations) based on HBsAg, anti-HBc, IgM anti-HBc, and anti-HBs results.
• Follow CDC guidance for post-vaccination testing and counseling as documented.

Pre-DAA therapy documentation — baseline labs and prior RNA/genotype

Before initiating direct-acting antiviral therapy, document baseline laboratory tests (CBC, INR, hepatic function panel, eGFR) within six months and record prior quantitative HCV RNA and genotype testing when relevant to treatment selection.

• Pre-DAA recommended labs include CBC, INR, hepatic function panel, and eGFR within six months prior to starting therapy.
• Document quantitative HCV RNA and genotype results if used to guide regimen selection.

HBV DNA testing/documentation — link to care and reflex testing where available

When HBsAg is positive, document linkage-to-care activities and HBV DNA testing (laboratory or POC) and note consideration of reflex HBV DNA testing where available to assess viral load for treatment eligibility and monitoring.

• Record whether HBV DNA testing was performed (quantitative/qualitative) and whether reflex HBV DNA was used to promote linkage to care.
• Document any treatment decisions or monitoring plans informed by HBV DNA levels.

Testing documentation — include serologic/NAT results and clinical context

Document results of serologic and nucleic acid testing (HBsAg, anti-HBc, HBeAg/anti-HBe, HBV DNA, anti-HDV, HDV RNA) and relevant clinical indicators (aminotransferase flares, liver disease severity) to support diagnostic and management decisions.

• Include clinical indicators such as aminotransferase elevations and assessments of liver disease severity alongside laboratory results.
• Ensure documentation supports decisions for treatment, monitoring, and HCC surveillance where applicable.

Publication history — policy dates and approval

Publication history entry recorded: 06/16/2026 — Original Documentation; Governance Approved. Providers should note the policy effective date and last review when applying guidance.

• Effective date: 10/01/2026; Last review: 06/16/2026.
• Publication history confirms original documentation and governance approval on 06/16/2026.

Coding and documentation compliance — denial risk for noncompliance

Claims may be denied or recouped if coding, billing, or current reimbursement policies are not followed; ensure claims align with applicable government coverage (LCDs, NCDs, state Medicaid) where those take precedence.

• Oscar may deny or recoup payment for inappropriate coding/billing.
• If this policy conflicts with government coverage, the government policy governs determinations and may lead to denial if nonconcordant.

Reflex NAT expectation — perform HCV RNA after reactive antibody

Laboratories and clinicians are expected to perform reflex NAT (HCV RNA) testing after a reactive HCV antibody result in accordance with CDC operational guidance; failure to do so is inconsistent with CDC recommendations.

• CDC: initiate HCV antibody testing with reflex to NAT for HCV RNA if antibody is reactive and collect samples to permit single-visit diagnosis.
• Automatic laboratory reflex to NAT is recommended to reduce time to diagnosis and treatment initiation.

HCV confirmatory testing — reflex RNA required to confirm active infection

Failure to perform reflex HCV RNA PCR after a positive anti-HCV antibody may prevent confirmation of active infection and could affect linkage to care; HCV RNA testing is recommended to establish current infection.

• AASLD-IDSA and CDC: HCV-antibody testing with reflex to HCV RNA PCR is recommended to establish active infection.
• HCV RNA testing is recommended for suspected recent exposures regardless of antibody result.

Repeat antibody testing discouraged — use viral load testing instead

Ordering repeat HCV antibody testing in a person with a prior positive HCV test is discouraged; guidelines recommend HCV viral load testing instead and unnecessary repeat antibody testing may be considered low-value or denied.

• AASLD: Repeat HCV antibody testing adds cost without clinical benefit; order HCV viral load testing to assess active versus resolved infection.
• WHO/AASLD discourage repeat antibody testing when prior positive exists.

Government policy precedence — follow LCD/NCD/state Medicaid rules

If this policy conflicts with applicable government coverage (e.g., LCDs, NCDs, state Medicaid), the government policy will be used to make determinations; claims inconsistent with government policies may be denied.

• Providers must follow applicable government coverage determinations where they take precedence over this policy.

No denial triggers specified in references/publication-history

Reference and publication-history sections do not specify denial triggers; no additional denial risks are identified in those sections of the policy.

• Publication history and reference lists are informational and do not list procedural denial triggers.