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Human Immunodeficiency Virus (HIV) — Coverage Criteria for Testing and Resistance Assays
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Defines coverage and medical necessity criteria for HIV screening, diagnostic testing, viral load monitoring, genotypic and phenotypic resistance testing, and limits for repeat testing; applies to providers submitting claims to Oscar Health.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Covered indications
Covered when the following conditions are met:
See policy III.1
See policy III.2
See policy III.3
See policy III.4
See policy III.5 a–c
See policy III.6 a–g
See policy III.7
Not medically necessary / Not covered
Not covered / does not meet criteria:
See policy III.9
See policy III.10
See policy III.11
See policy III.12
Coverage criteria per DHHS guidance
Covered when following DHHS recommendations for testing and monitoring are met
DHHS: timing for viral load monitoring
DHHS recommendations
DHHS: AI for >1,000; AIII for 501–1,000; CIII for 201–500
DHHS guidance on perinatal testing and newborn management
Guideline-based coverage criteria — grouped by clinical scenario
Covered when meeting guideline-based clinical indications described below (grouped by clinical scenario):
DHHS/IAS/others
AI for >1,000; AIII for 501–1,000; CIII for 201–500
DHHS: long‑acting agents guidance
References: DHHS, ACOG, SMFM
CDC/DHHS/IAS guidance
IDSA/International guidance
HIV-2 testing and monitoring (Initial and ongoing)
Covered when meeting the following clinical testing and monitoring recommendations for HIV-2:
BHIVA guidance
BHIVA recommendation
BHIVA monitoring guidance
BHIVA: resistance testing threshold
Screening with an antibody-only test that does not incorporate antigen detection is explicitly listed as not meeting criteria and therefore excluded from coverage. The policy also states that HIV antigen testing performed alone (independent of an antigen/antibody combination assay) does not meet criteria. Providers should order a combination antigen/antibody assay for screening rather than antibody-only or antigen-alone tests to meet coverage requirements.
A single cost-effectiveness analysis cited in the evidence review found that point-of-care HIV RNA viral load testing to guide mode of delivery for women without prenatal care was more costly and resulted in more HIV-infected neonates compared with routine cesarean delivery for all. The authors concluded the viral-load guided strategy was not cost-effective in that scenario; this finding limits the utility of point-of-care viral load testing as a replacement for routine cesarean delivery in women lacking prenatal care.
The International Antiviral Society guidance states that proviral resistance testing is not required prior to switching to 2-drug therapy unless there is documented or suspected treatment failure. For patients who have maintained viral suppression, switching from long-acting cabotegravir plus rilpivirine back to oral therapy can be done without proviral DNA resistance testing. If virologic failure is later confirmed, genotype resistance testing should be performed, preferably on the failing regimen or shortly after discontinuation.
Routine proviral DNA genotyping is not recommended for virologically suppressed persons. Guidance notes that proviral DNA genotypes may fail to detect prior resistance and can identify mutations of uncertain clinical relevance, so use of proviral genotyping in suppressed patients should be selective and interpreted cautiously rather than performed routinely.
The policy identifies routine combined genotyping plus phenotyping and automated phenotype prediction from genotypic database comparison as not meeting criteria. Phenotypic and genotypic assays both have limited sensitivity for low-level minority variants comprising <1–20% of the viral population, which constrains the value of routine combined testing and algorithmic phenotype prediction in many settings.
Both phenotypic and genotypic resistance assays have limitations detecting low-frequency variants. The document notes decreased sensitivity for minority variants that represent <1% to 20% of the viral population, meaning assays may miss clinically relevant low-level resistance and that results should be interpreted with awareness of these detection limits.
IAS guidance affirms that viral load measurement remains the primary laboratory method for baseline evaluation and monitoring, and that proviral resistance testing is not required for routine regimen switches in virologically suppressed patients unless there is documented or suspected failure. The guidance emphasizes performing resistance testing for confirmed virologic failure and considers testing while on failing therapy or soon after discontinuation to maximize yield.
Billing Codes and Key Numeric Thresholds
| No codes listed |
| 86701 | Antibody; HIV-1. |
| 86702 | Antibody; HIV-2. |
| 86703 | Antibody; HIV-1 and HIV-2, single result. |
| 87391 | Infectious agent antigen detection by immunoassay technique, qualitative or semiquantitative; HIV-1. |
| 87534 | Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, direct probe technique. |
| 87535 | Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, amplified probe technique, includes reverse transcription when performed. |
| 87536 | Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, quantification, includes reverse transcription when performed. |
| 87537 | Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, direct probe technique. |
| 87538 | Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, amplified probe technique, includes reverse transcription when performed. |
| 87539 | Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, quantification, includes reverse transcription when performed. |
| 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. |
| 87906 | Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, other region (eg, integrase, fusion). |
| 0219U | Infectious agent (human immunodeficiency virus), targeted viral next-generation sequence analysis (protease, RT, integrase), algorithm reported as prediction of antiviral drug susceptibility (Sentosa® SQ HIV-1 Genotyping Assay). |
| G0432 | Infectious agent antibody detection by enzyme immunoassay (EIA) technique, HIV-1 and/or HIV-2, screening. |
| G0433 | Infectious agent antibody detection by enzyme-linked immunosorbent assay (ELISA) technique, HIV-1 and/or HIV-2, screening. |
| G0435 | Infectious agent antibody detection by rapid antibody test, HIV-1 and/or HIV-2, screening. |
| G0475 | HIV antigen/antibody, combination assay, screening. |
| S3645 | HIV-1 antibody testing of oral mucosal transudate. |
Authorization, Documentation, and Operational Guidance for Providers
Authorization and medical necessity
Services must meet authorization and medical necessity guidelines and the member's benefit coverage at the time of request; coverage does not guarantee reimbursement.
Obtain genotypic resistance testing at entry to care and for virologic failure
Send genotypic drug-resistance testing at entry into care to guide initial ART selection and perform resistance testing for persons with virologic failure; ensure genotypic testing includes integrase when transmitted INSTI resistance is suspected or prior CAB-LA PrEP use.
- Do not delay ART initiation for results when starting same-day; modify regimen after results are available.
- For virologic failure, perform testing for HIV-RNA >200 copies/mL (stronger evidence at higher viral loads).
Prior authorization — none specified
No explicit prior authorization requirements are stated in the referenced policy excerpts.
Use listed CPT/HCPCS codes for test authorization
Use the listed CPT/HCPCS procedure codes when requesting authorization or submitting claims for HIV antibody/antigen, nucleic acid, and resistance/genotype testing.
Prior authorization not specified in this section
No prior authorization requirements are specified in these reference excerpts.
Provider actions — order tests per coverage criteria and document rationale
Providers must follow policy coverage criteria and guideline-based indications when ordering tests and document clinical rationale in the medical record.
- Order tests consistent with indicated scenarios (e.g., screening, confirmatory differentiation, NAT for indeterminate/acute cases, genotyping for treatment failure).
Viral load monitoring timeline per DHHS
Follow DHHS viral-load monitoring schedule: measure at baseline/when ART is initiated, at 4–8 weeks after initiation, then every 4–8 weeks until below detection; once suppressed and stable, monitor every 3–4 months (may extend to 6 months if suppressed >1 year and adherent).
- If changing ART for virologic failure, measure before change and 4–8 weeks after the modification, then every 4–8 weeks until suppressed.
Proviral resistance testing not routinely required before 2‑drug switches
Per IAS guidance, proviral resistance testing is not required before switching to two‑drug therapy unless there is documented or suspected treatment failure.
- If virologic failure is confirmed, perform genotype resistance testing preferably while on the failing regimen.
Resistance testing and HBV/HIV co‑infection guidance
Perform genotypic resistance testing at diagnosis and at virological failure in persons with HBV/HIV coinfection; ensure ART includes TDF or TAF unless there is tenofovir intolerance.
- Genotypic testing should guide ART selection; do not delay ART initiation while awaiting results.
Step therapy — none specified
No step therapy rules are included in the extracted document parts.
Claims documentation responsibility and coding accuracy
Providers are responsible for submitting accurate documentation of services performed and for appropriate coding according to standard coding guidelines; failure to follow coding/billing or reimbursement policies may lead to denial or recoupment.
- Ensure submitted CPT/HCPCS, ICD‑10, and other codes reflect the services performed and clinical indications.
Document quantitative RNA and antibody differentiation for peripartum evaluations
When diagnosing HIV or evaluating peripartum exposures, document quantitative HIV RNA testing and HIV‑1/HIV‑2 antibody differentiation; maternal HIV test results should be recorded in the newborn record and communicated to the infant's primary care provider.
- If maternal results are positive or unavailable at birth, perform infant NAT and initiate presumptive therapy as indicated.
Review prior and current resistance results when designing new regimens
Review and consider all prior and current drug‑resistance test results when constructing a new antiretroviral regimen.
Testing/monitoring documentation for suspected acute HIV‑2 or recent exposure
For suspected acute HIV‑2 or very recent exposure, if screening was negative within 3 months of exposure, retest at six weeks and three months with parallel HIV‑2 viral RNA and, if necessary, HIV‑2 proviral DNA; repeat HIV‑2 viral load per schedule after ART initiation or change.
- If pre‑treatment HIV‑2 viral load was detectable: measure at 1, 3, and 6 months after starting/changing ART, then every 3–6 months.
- If pre‑treatment HIV‑2 viral load was undetectable: measure at 1 month then every 6 months.
Reference list — informational only
The policy's reference list provides supporting literature for clinical recommendations but does not itself establish authorization requirements.
Denial risk for noncompliant coding/billing
Claims may be denied or recouped if appropriate coding/billing guidelines or current reimbursement policies are not followed; ensure documentation supports the clinical indication for testing.
Resistance testing may fail at low RNA levels — consider timing
Genotypic resistance testing may be unsuccessful at lower HIV‑RNA levels; despite potential failure, testing should still be considered in confirmed virologic failure (noted for >500 copies/mL may fail but is still recommended).
- For virologic failure, testing is recommended for HIV‑RNA >200 copies/mL with graded evidence by viral-load strata; testing may be unsuccessful at lower levels but remains advisable.
No explicit denial triggers in these sections
No explicit payer-side denial triggers were specified in the extracted policy excerpts.
HIV‑2 resistance testing threshold (≥500 copies/mL)
Perform resistance testing for HIV‑2 when the viral load meets the recommended threshold of ≥500 copies/mL; testing below that threshold may not meet recommended indications.
Reference list does not define denial triggers
No denial triggers are specified in the policy's reference list section.
Clinical Background and Evidence Summary
Human immunodeficiency virus is an RNA retrovirus that infects CD4+ T lymphocytes and can lead to progressive immunodeficiency and AIDS; HIV‑1 is the predominant global subtype while HIV‑2 is less common, typically associated with lower plasma viremia and slower clinical progression. Viral load (nucleic acid testing) is used for early detection, monitoring response to antiretroviral therapy, and assessing transmission risk, and resistance testing (genotypic and phenotypic) guides regimen selection and management in treatment failure.
Definitions and Assay Descriptions
Policy Revision History
Policy effective date set to 2026-10-01.
Policy last reviewed on 2026-06-16.
Policy effective date: 2026-10-01. Last review date: 2026-06-16.
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