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    v1.0.28
    OpenPayerPolicy UpdatesInfectious Diseasepartners_health_management HPV HCV GBS Coverage Up…
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    Modifiedpartners_health_managementPolicy CG.CP.MP.05

    Concert Infectious Disease: Primary Care & Preventative Screening

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    Defines medical necessity criteria for outpatient screening tests for human papillomavirus (HPV), hepatitis C virus (HCV), and group B streptococcus (GBS) for members/enrollees of the payer network.

    Policy Summary
    Payerpartners_health_management
    PolicyConcert Infectious Disease: Primary Care & Preventative Screening
    Policy CodePolicy CG.CP.MP.05
    Change TypeMaterial revisions to coverage language, expanded perinatal HCV eligibility, coding additions
    Effective Date
    Last ReviewNov 1, 2024
    Next Review DateNov 20, 2025
    Key ActionConfirm appropriate billing codes per the policy coding tables when ordering tests and follow plan prior authorization rules.
    SourceLink
    POLICY UPDATE CHANGES

    Changed policy statement verbiage from 'may be considered medically necessary' to 'are considered medically necessary' for Group B Streptococcus screening of vaginal-rectal specimens, genotyping of high-risk HPV types for cervical cancer screening, and Hepatitis C Nucleic Acid/PCR tests.

    Added criteria option: 'The member was exposed to HCV perinatally and is between 2 months and 17 months of age' for Hepatitis C Nucleic Acid/PCR Tests.

    Added CPT code 87626 and HCPCS code G0476 to the coding tables.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    3areas covered
    30-65hrHPV age range
    18-79HCV screening age (USPSTF)
    36w0d-37w6dGBS gestational window
    87626/G0476coding additions

    Coverage Criteria for HPV, HCV, and GBS Screening

    High-risk HPV genotyping — medically necessary criteria

    Covered when ALL of the following are met:

    Primary conditions

    • Additional qualifying findings (any one suffices): 1) Has NOT had a hysterectomy with removal of the cervix OR 2) Has history of high-grade precancerous lesion (CIN 2 or 3) OR 3) Has history of cervical cancer

      These are alternative qualifiers referenced under section I.A and A.1-3

    Alternate risk-based coverage: Member born with a cervix younger than 30 or older than 65 AND is at increased risk for cervical cancerage <30 or >65 plus increased risk

    Examples of increased risk: immunocompromised, HIV infection, in-utero DES exposure, history of cervical lesion or cancer

    Interval: Genotyping of high-risk types is covered once every 5 years in absence of increased risk factorsonce every 5 years

    Section II

    Low-risk HPV genotyping

    Coverage stance: Human papillomavirus genotyping of low-risk types is considered investigational

    Low-risk HPV genotyping is investigational for all indications

    Hepatitis C antibody screening — medically necessary criteria

    Covered when ALL of the following are met:

    Exclusion of prior known infection: Member does NOT have a known past positive HCV antibody test result AND does NOT have a known history of chronic HCV infectionno prior positive antibody; no known chronic HCV

    A quantitative HCV-RNA test rather than an HCV-antibody test is recommended to assess for HCV recurrence

    Qualifying indications (any one suffices): 1) The member is pregnant OR 2) The member is an asymptomatic adult between ages 18 and 79 OR 3) The member is a child ≥18 months who was perinatally exposed and has not been previously tested OR 4) The member is <18 or >79 AND is at increased risk for HCV infection (eg, past/current injection drug use, liver disease, chronic hemodialysis, HIV, HIV PrEP use, partners of HCV-infected individuals, organ transplant donors/recipients) OR 5) The member requests screening (regardless of age or disclosure of risk)

    Details and risk examples in section I.C.1-5

    Hepatitis C nucleic acid/PCR testing — medically necessary criteria

    Covered when ANY of the following are met:

    Indications: A) Member is immunocompromised (e.g., receives chronic hemodialysis) OR B) Suspected HCV exposure within the past 6 months (regardless of antibody status) OR C) Initial HCV antibody positive test (including automatic reflex PCR) OR D) Undergoing monitoring for chronic HCV infection (pre/during/post direct-acting antiviral therapy) OR E) Member was exposed to HCV perinatally and is between 2 months and 17 months of age OR F) History of HCV infection with eradication/SVR AND ongoing risk factors for reinfection

    Automatic reflex PCR from a positive antibody test is described as the most appropriate option for initial screening; quantitative testing recommended for recurrence assessment

    Group B Streptococcus vaginal-rectal screening — medically necessary criteria

    Covered when ALL of the following are met:

    Pregnancy and timing: Member is pregnant AND pregnancy is between 36 weeks 0 days and 37 weeks 6 days gestation36w0d-37w6d

    ACOG antepartum screening guidance

    Hepatitis C Screening and Testing

    Covered when meeting any of the following testing recommendations from CDC and IDSA/AASLD:

    Hepatitis C screening/testing options: 1) Universal HCV screening for all pregnant individuals during each pregnancy unless setting HCV RNA-positivity prevalence is <0.1%. 2) One-time HCV testing for people with recognized conditions or exposures (eg, people with HIV; people who ever injected drugs; people who ever received maintenance hemodialysis; people with persistently abnormal ALT; prior transfusion/organ transplant recipients as specified). 3) Routine periodic testing for people with ongoing risk factors while risk persists (eg, current injection drug use with equipment sharing; maintenance hemodialysis). 4) Any person requesting HCV testing should receive it regardless of disclosure of risk.

    Sources: CDC and IDSA/AASLD guidance

    HCV Testing Modality and Monitoring

    Covered when testing follows recommended modalities and timing:

    Initial and follow-up HCV testing: Initial HCV testing: HCV-antibody testing with reflex to HCV RNA PCR is recommended. For persons exposed within prior 6 months with negative antibody, perform HCV-RNA or repeat antibody ≥6 months after exposure; consider HCV-RNA for immunocompromised. Quantitative HCV-RNA testing is recommended prior to initiation of antiviral therapy. Quantitative HCV-RNA testing is recommended ≥12 weeks after completion of therapy to document sustained virologic response (SVR). For persons at risk of reinfection, use HCV-RNA testing because antibody may remain positive.

    IDSA/AASLD and CDC recommendations

    Perinatal HCV Testing

    Covered when testing perinatally exposed infants as recommended:

    Perinatal HCV testing: 1) NAT for HCV RNA at age 2–6 months to identify infants who may develop chronic infection. 2) Infants and children aged 7–17 months perinatally exposed and not previously tested should receive NAT for HCV RNA. 3) Policy explicitly includes coverage option for members exposed perinatally aged 2 months to 17 months.

    CDC recommendations and policy revision

    Group B Streptococcus Screening

    Covered when performed according to ACOG antepartum screening guidance:

    GBS screening timing and method: Pregnant individuals should undergo antepartum GBS screening at 36 0/7–37 6/7 weeks gestation unless intrapartum prophylaxis is already indicated because of GBS bacteriuria during the pregnancy or a history of a previous GBS-infected newborn. NAAT-based testing with an 18–24 hour enrichment step is an acceptable alternative to culture for antepartum screening.

    ACOG Committee Opinion #797; NAAT sensitivity equivalent or superior when enrichment step included

    High-risk HPV genotyping is considered investigational when used for indications other than those specifically listed as medically necessary in this policy, including evaluation of genital warts or as part of general sexually transmitted infection screening. Coverage is limited to the defined cervical cancer screening indications and intervals; genotyping outside those criteria is investigational.

    Genotyping of low-risk HPV types is considered investigational for all indications and is not covered under this policy.

    Hepatitis C antibody and nucleic acid (PCR) testing are considered investigational for indications not explicitly listed in their respective coverage sections. This investigational designation does not apply to symptomatic individuals or to those meeting the specific age, risk, pregnancy, exposure, confirmatory, or monitoring criteria detailed in the policy. For initial screening, automatic reflex to quantitative HCV-RNA PCR from a positive antibody test is described as the most appropriate confirmatory approach.

    Group B Streptococcus (GBS) vaginal-rectal screening is considered investigational when performed for pregnant members who have documented GBS bacteriuria during the current pregnancy or for those with a history of a prior GBS-infected newborn. GBS screening is also investigational for indications outside the specified late-pregnancy screening window.

    Universal Hepatitis C screening of pregnant individuals during each pregnancy is recommended except in settings where the prevalence of HCV RNA-positivity is 0.1%. In such very low-prevalence settings (<0.1% HCV RNA-positivity), universal screening during pregnancy is excepted.

    This policy explicitly states that genotyping of low-risk HPV types is considered investigational (not medically necessary) and therefore not covered for any clinical indication.

    Inclusion of CPT/HCPCS codes in the policy's coding tables is provided for informational purposes only and does not by itself guarantee coverage. Providers should confirm current billing codes and coverage requirements with the plan prior to claim submission; coding updates (for example, addition of CPT 87626 and HCPCS G0476) have been made to the tables and may affect billing.

    Example Codes and Key Coding Details

    Hepatitis C Nucleic Acid/PCR Tests (examples)mixed
    Hepatitis C Viral RNA, Quantitative, Real-Time PCR (Quest Diagnostics)Hepatitis C Nucleic Acid/PCR Test (example listed)
    Prenatal Infectious Disease Screening Tests (examples)mixed
    Group B Streptococcus Colonization Detection Culture (Labcorp)GBS culture of vaginal-rectal specimen (example listed)
    Hepatitis C Antibody Screening Tests (examples)mixed
    Hepatitis C Virus (HCV) Antibody Cascade to Quantitative PCR and Genotyping (Labcorp)HCV antibody screening with reflex to PCR/genotyping (example listed)
    Human Papillomavirus (HPV) Tests (examples)mixed
    Human Papillomavirus (HPV) (Aptima) (Labcorp)High-risk HPV genotyping example
    HPV Low Risk (Pacific Medical)Low-risk HPV genotyping example
    HCPCS HPV screeningHCPCS
    G0476Infectious agent detection by nucleic acid (DNA or RNA); human papillomavirus (HPV), high-risk types for cervical cancer screening, must be performed in addition to pap test
    Hepatitis C antibody and some NAATCPT
    86803Hepatitis C antibody.
    86804Hepatitis C antibody; confirmatory test (eg, immunoblot).
    87520Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, direct probe technique
    Hepatitis C NAAT (additional)CPT
    87521Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, amplified probe technique, includes reverse transcription when performed.
    87522Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performed.
    HPV NAAT (examples)CPT
    87623Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44).
    87624Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (pooled result).
    87625Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed.
    87626Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), separately reported high-risk types (eg, 16, 18, 31, 45, 51, 52) and high-risk pooled result(s).
    GBS NAATCPT
    87653Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique
    HPV low-risk NAATCPT
    87623Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44).
    NAAT / HPV / GBS codesCPT
    87521Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, amplified probe technique, includes reverse transcription when performed.
    87522Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performed.
    87653Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique
    87626Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), separately reported high-risk types (eg, 16, 18, 31, 45, 51, 52) and high-risk pooled result(s).
    87623Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44).
    87624Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (pooled result).
    87625Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed.
    HCPCS HPV screeningHCPCS
    G0476Infectious agent detection by nucleic acid (DNA or RNA); human papillomavirus (HPV), high- risk types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) for cervical cancer screening, must be performed in addition to pap test
    HCPCS HPV screeningHCPCS
    G0476Infectious agent detection by nucleic acid (DNA or RNA); human papillomavirus HPV), high- risk types (e.g., 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) for cervical cancer screening, must be performed in addition to pap test
    HPV genotyping interval — key thresholds
    IntervalGenotyping of high-risk HPV types is covered once every 5 years (in absence of increased risk factors)
    Age rangeCovered for individuals born with a cervix aged 30–65 years
    Coverage conditionMust not have had a hysterectomy with removal of the cervix unless other qualifying history applies (e.g., history of high‑grade precancerous lesion or cervical cancer)
    GBS screening gestational window — key thresholds
    Gestational windowAntepartum GBS screening of vaginal‑rectal specimens is covered at 36 weeks 0 days through 37 weeks 6 days gestation

    Provider Documentation, Billing, and Operational Notes

    Prior Authorization

    Confirm test-specific coding

    Confirm the specific laboratory test and billing code before ordering — the policy lists example tests (e.g., Labcorp and Quest examples) and corresponding CPT/HCPCS codes in the coding tables; verify the exact test name and code to ensure correct claim submission.

    Billing Rule

    Coding updates and PA implications

    Be aware that coding updates were added to the policy and inclusion of codes does not by itself guarantee coverage; follow plan prior authorization rules and reference up-to-date coding guidance before claim submission.

    • Policy added CPT code 87626 and HCPCS code G0476 to coding tables.
    • Codes listed (e.g., 86803, 86804, 87520, 87521, 87522, 87653, 87626, G0476) are informational only.

    Background and Scope

    Human papillomavirus (HPV), hepatitis C virus (HCV), and Group B Streptococcus (GBS) are common infectious disease concerns for primary care and prenatal screening. High-risk HPV types are associated with cervical cancer and genotyping of high-risk types is covered only for specified cervical cancer screening indications and intervals. HCV is a blood-borne infection for which universal adult screening is recommended; confirmation and monitoring require nucleic acid/PCR testing in specific clinical scenarios (for example, reflex PCR after a positive antibody, suspected recent exposure, immunocompromised patients, monitoring before/during/after antiviral therapy, and perinatally exposed infants). GBS colonizes the genital tract and antepartum screening of vaginal-rectal specimens in late pregnancy (the defined gestational window) identifies women who should receive intrapartum prophylaxis to reduce neonatal infection risk. The policy limits coverage to the clinical indications and timing described and designates other uses as investigational.

    Definitions and Test Methodology

    inv-40: High-risk HPV (hrHPV) definition
    DefinitionHigh‑risk HPV (hrHPV) refers to HPV types associated with oncogenic risk and cervical cancer and are the targets of genotyping for cervical cancer screening
    Clinical useUsed in routine cervical cancer screening (high‑risk HPV testing or co‑testing)
    ExamplesGenotyping targets high‑risk types such as HPV 16, 18, 31, 45, 51, 52 per coding list (policy lists 87626 and related codes)
    inv-41: HCV nucleic acid/PCR definition
    DefinitionHCV nucleic acid/PCR: quantitative or qualitative testing for hepatitis C viral RNA used for confirmatory diagnosis, recent‑exposure testing, and monitoring around treatment
    Initial testing roleReflex HCV‑RNA PCR is recommended following a positive HCV‑antibody test for initial screening
    Policy Summary
    Payerpartners_health_management
    PolicyConcert Infectious Disease: Primary Care & Preventative Screening
    Policy CodePolicy CG.CP.MP.05
    Change TypeMaterial revisions to coverage language, expanded perinatal HCV eligibility, coding additions
    Effective Date
    Last ReviewNov 1, 2024
    Next Review DateNov 20, 2025
    Key ActionConfirm appropriate billing codes per the policy coding tables when ordering tests and follow plan prior authorization rules.
    SourceLink
    On This Page
    Coverage Criteria for HPV, HCV, and GBS ScreeningExample Codes and Key Coding DetailsProvider Documentation, Billing, and Operational NotesBackground and ScopeDefinitions and Test Methodology
    Pregnancy requirementMember must be pregnant at time of screening
    Investigational exceptionsGBS screening is investigational for pregnant members with GBS bacteriuria during current pregnancy or with prior GBS‑infected newborn
    SVR testing interval — HCV monitoring thresholds
    SVR testing intervalQuantitative HCV viral load testing is recommended 12 or more weeks after completion of therapy to document sustained virologic response (SVR)
    PurposeSVR testing at ≥12 weeks post‑therapy is used to document cure of chronic HCV infection
    Ongoing surveillanceFor patients with ongoing risk factors, annual quantitative HCV‑RNA testing is recommended to assess for recurrence
    Step Therapy

    Reflex quantitative HCV‑RNA PCR after positive antibody

    Order reflex quantitative HCV RNA PCR from a positive HCV antibody as the preferred initial diagnostic approach; the policy states automatic reflex PCR from antibody testing is considered the most appropriate option for initial HCV screening.

    Prior Authorization

    HCV testing sequence: baseline, pre‑treatment, and SVR monitoring

    Follow the recommended HCV testing sequence: initial HCV‑antibody testing with reflex to HCV RNA PCR for confirmation, obtain a quantitative HCV‑RNA prior to initiating direct‑acting antiviral (DAA) therapy, and perform quantitative HCV‑RNA testing 12 or more weeks after completion of therapy to document SVR.

    • If exposed within prior 6 months and antibody negative, use HCV‑RNA or repeat antibody ≥6 months after exposure; consider RNA testing for immunocompromised persons.
    • For persons at risk of reinfection, use HCV‑RNA testing because antibody may remain positive.
    Documentation Required

    HCV PCR documentation expectations

    Document the clinical rationale when ordering HCV PCR testing: support immunocompromised status, suspected exposure timing, a positive HCV antibody result, intent for monitoring (pre/during/post DAA therapy), perinatal exposure age range, or history of prior HCV with ongoing reinfection risk.

    Documentation Required

    HPV and GBS documentation expectations

    When ordering HPV genotyping or antepartum GBS screening, include documentation of patient age and anatomy (presence of a cervix), relevant history of high‑grade precancerous lesion or cervical cancer for HPV, or gestational age for GBS to demonstrate eligibility under the policy.

    • HPV genotyping: member born with a cervix aged 30–65 years (or alternate risk‑based criteria) and interval (once every 5 years) applies.
    • GBS screening: document pregnancy and gestational age within 36w0d–37w6d.
    Documentation Required

    Document baseline quantitative HCV‑RNA prior to therapy

    Obtain quantitative HCV‑RNA testing prior to initiating antiviral therapy to document baseline viral load and record the timing relative to exposure when relevant for follow‑up testing strategies.

    Denial Risk

    HPV genotyping investigational outside listed indications

    Do not order HPV genotyping for indications outside those listed — high‑risk HPV genotyping is investigational for evaluation of genital warts, general STI screening, or other unlisted indications and therefore not covered.

    Denial Risk

    HCV antibody screening investigational outside criteria

    Hepatitis C antibody screening tests are considered investigational (not covered) for indications not specified in the policy; ensure the member meets listed age, pregnancy, risk, or request criteria before ordering.

    Denial Risk

    HCV PCR investigational outside specified indications

    Hepatitis C nucleic acid/PCR testing is investigational for indications not specified in the policy — order PCR only when the member meets listed criteria (e.g., immunocompromised status, recent exposure, initial antibody positive, monitoring, perinatal exposure aged 2–17 months, or ongoing reinfection risk).

    Denial Risk

    GBS screening investigational outside gestational criteria

    Perform antepartum GBS screening only within the specified gestational window and not when intrapartum prophylaxis is otherwise indicated; GBS screening of vaginal‑rectal specimens is investigational outside 36w0d–37w6d or for listed exceptions (current GBS bacteriuria or prior GBS‑infected newborn).

    Note

    Inclusion of codes does not guarantee coverage

    Note that inclusion or exclusion of CPT/HCPCS codes in the policy coding tables is informational and does not guarantee coverage; providers must reference the most current professional coding guidance and plan prior authorization rules before submitting claims.

    Monitoring roleQuantitative HCV‑RNA is recommended prior to DAA therapy and to document SVR >=12 weeks after therapy
    inv-42: Group B Streptococcus (GBS) vaginal-rectal screening definition
    DefinitionGBS vaginal‑rectal screening: culture or detection testing of vaginal‑rectal specimens in late pregnancy to identify maternal colonization that may affect newborn risk during delivery
    TimingAntepartum screening typically performed at 36 0/7–37 6/7 weeks gestation
    Methodology noteNAAT-based testing with an 18–24 hour enrichment step is an acceptable alternative to culture
    inv-43: Initial HCV testing (HCV-antibody with reflex HCV RNA PCR)
    DefinitionInitial HCV testing: HCV‑antibody testing with reflex to HCV RNA PCR is the recommended approach for initial screening
    Reflex rationaleAutomatic reflex to PCR from a positive antibody test is described as the most appropriate initial option
    Alternative for recent exposureFor suspected exposure within prior 6 months, perform HCV‑RNA or repeat antibody >=6 months after exposure; consider HCV‑RNA for immunocompromised
    inv-44: GBS NAAT methodology — enrichment step and sensitivity note
    MethodologyGBS NAAT with an 18–24 hour enrichment (incubation) step in enrichment broth before NAAT analysis offers sensitivity equivalent or superior to culture
    Practical implicationNAAT performed without the enrichment step may be less sensitive than culture-based methods
    AcceptabilityNAAT with enrichment is an acceptable alternative to culture for antepartum screening per ACOG guidance