ModifiedWellCarePolicy CG.CP.MP.05

Coverage Criteria: HPV genotyping, Hepatitis C testing, and Group B Streptococcus screening

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Outpatient medical necessity criteria for HPV genotyping (high- and low-risk), hepatitis C antibody and nucleic acid/PCR testing, and group B streptococcus (GBS) vaginal-rectal screening; applies to members/enrollees of the health plan.

Policy Summary

PayerWellCare

PolicyCoverage Criteria: HPV genotyping, Hepatitis C testing, and Group B Streptococcus screening

Policy CodePolicy CG.CP.MP.05

Change TypeOperational coding updates

Effective Date

Next Review Date

Key ActionDocument clinical rationale and relevant patient details (age, presence of a cervix, gestational age, prior HCV status or risk factors) when ordering tests to support medical necessity.

SourceLink

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ModifiedWellCarePolicy CG.CP.MP.05

Coverage Criteria: HPV genotyping, Hepatitis C testing, and Group B Streptococcus screening

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Policy Summary

PayerWellCare

PolicyCoverage Criteria: HPV genotyping, Hepatitis C testing, and Group B Streptococcus screening

Policy CodePolicy CG.CP.MP.05

Change TypeOperational coding updates

Effective Date

Next Review Date

Key ActionDocument clinical rationale and relevant patient details (age, presence of a cervix, gestational age, prior HCV status or risk factors) when ordering tests to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Added CPT code table and moved the 'coding implications' section.

Removed CPT and ICD-10 codes from policy reference table.

Corrected CPT code descriptions and removed specific codes (0500T, 87081, 87149, 87150).

3diseases covered (HPV, HCV, GBS)

30-65HPV age range

18-79HCV screening age

36 0/7-37 6/7GBS gestational window

9CPT codes listed

Medical Necessity Coverage Criteria

Genotyping of High Risk Human Papillomavirus (Initial)

HPV high-risk genotyping is medically necessary when specific age and risk conditions are met.

Eligible populations: Human papillomavirus (HPV) genotyping of high risk types may be considered medically necessary when: (A) the member was born with a cervix and is between 30 and 65 years AND (1) has NOT had a hysterectomy with removal of the cervix OR (2) has a history of high-grade precancerous lesion (CIN2/3) OR (3) has a history of cervical cancer; OR (B) the member was born with a cervix and is younger than 30 or older than 65 AND is at increased risk for cervical cancer (e.g., immunocompromised, HIV infection, in‑utero diethylstilbestrol exposure, history of cervical lesion or cervical cancer).age and risk-based

See USPSTF and CDC screening guidance.

HPV genotyping — Interval

Frequency for repeat testing when no increased risk.

Interval: HPV high-risk genotyping is considered medically necessary once every 5 years in the absence of increased risk factors for cervical cancer.every 5 years

Consistent with cotesting/HPV-alone intervals.

Genotyping of Low Risk Human Papillomavirus

Low-risk HPV testing is addressed separately.

Not supported: Current evidence does not support human papillomavirus (HPV) genotyping of low risk types.N/A

Low-risk HPV testing is not indicated because infection is not associated with disease progression and does not change management.

Hepatitis C Antibody Screening

Hepatitis C antibody screening is medically necessary when conditions below are met.

Baseline eligibility: Member does NOT have a known past positive HCV antibody AND does not have a known history of chronic HCV infection AND meets at least one of the following: is pregnant; OR is an asymptomatic adult aged 18–79 years; OR is younger than 18 or older than 79 AND is at increased risk for HCV infection (e.g., past or current injection drug use, liver disease, chronic hemodialysis, HIV infection, HIV PrEP use, men who have sex with men, partners of HCV‑infected individuals, organ transplant donor/recipient); OR requests screening regardless of age or disclosed risks.age/risk/request-based

Reflects USPSTF/CDC guidance and includes screening upon request.

Hepatitis C Nucleic Acid/PCR Tests

Hepatitis C nucleic acid/PCR testing is medically necessary for specific exposures, diagnostic, and monitoring purposes.

Indications for HCV RNA/PCR: Considered medically necessary when any of the following apply: 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 reflex from antibody screening); OR D) monitoring for chronic HCV infection (prior to, during, or after direct‑acting antiviral therapy); OR E) history of HCV with eradication/SVR AND ongoing risk factors for reinfection.time- and risk-based

Quantitative HCV‑RNA preferred for baseline, recurrence assessment, and SVR monitoring.

Group B Streptococcus Screening

Group B Streptococcus screening of vaginal-rectal specimens is medically necessary in pregnancy at a narrow gestational window.

GBS antepartum screening: Member is pregnant AND the pregnancy is between 36 weeks 0 days and 37 weeks 6 days gestation.36 0/7 - 37 6/7 weeks

Do not perform antepartum screening in pregnancies with current GBS bacteriuria or a history of a previous GBS‑infected newborn; intrapartum prophylaxis indications differ.

Coverage for the laboratory tests and indications described in this policy is limited to the specific clinical scenarios and criteria listed. Current evidence does not support HPV high-risk genotyping, HPV low‑risk genotyping, hepatitis C antibody or nucleic acid/PCR testing, or Group B Streptococcus (GBS) vaginal‑rectal screening for indications outside the clinical criteria and gestational windows specified in this document. Requests for testing outside these stated indications may be denied.

When state Medicaid coverage provisions conflict with this clinical policy, state Medicaid coverage provisions take precedence. Providers and reviewers should refer to the applicable state Medicaid manual for coverage rules that supersede this policy.

For Medicare members/enrollees, applicable Medicare policy documents must be considered. Prior to applying the criteria in this policy, reviewers should review relevant National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles available from CMS, as those determinations take precedence over this policy when applicable.

Explicitly not supported by the current evidence in this policy are: HPV genotyping of low‑risk types; HPV high‑risk genotyping for indications other than those listed (for example, evaluation of genital warts or routine STI screening); hepatitis C antibody or HCV nucleic acid/PCR testing when not meeting the specified age, risk, exposure, diagnostic, or monitoring criteria; and GBS vaginal‑rectal screening outside the antepartum gestational window of 36 0/7 to 37 6/7 weeks or in situations where GBS bacteriuria or prior GBS‑infected newborns indicate intrapartum management instead of antepartum screening.

Coding and Billing

CPT codes referencedCPT

86803	Hepatitis C antibody;
86804	Hepatitis C antibody; confirmatory test (eg, immunoblot).
87520	Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, direct probe technique.
87521	Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, amplified probe technique, includes reverse transcription when performed.
87522	Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performed.
87623	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44).
87624	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68).
87625	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed.
87653	Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique

Age / gestation thresholds

HPV high-risk genotyping age rangeAges 30 to 65 years (also may be considered for persons <30 or >65 if at increased risk)

HPV genotyping intervalOnce every 5 years when no increased risk factors are present (e.g., immunocompromised, HIV, in‑utero DES exposure, prior cervical lesion or cancer)

Hepatitis C antibody screening age rangeAsymptomatic adults aged 18 to 79 years (one-time universal screening); pregnant persons also eligible

HCV testing for other agesPersons younger than 18 or older than 79 years may be screened if at increased risk or on patient request

Group B Streptococcus (GBS) gestational windowPregnancy gestational age between 36 weeks 0 days and 37 weeks 6 days

Provider Actions, Documentation, and Billing Notes

Billing Rule

Referenced CPT Codes — Confirm Prior to Claim Submission

Confirm referenced CPT codes prior to claim submission. Codes listed in this policy are for informational purposes only; inclusion or exclusion does not guarantee coverage. Providers should reference the most current professional coding guidance and payer billing rules before submitting claims.

Affected CPT examples in this policy: 86803, 86804, 87520, 87521, 87522, 87623, 87624, 87625, 87653
Providers must verify coding and billing guidance against current CPT manuals and payer requirements prior to claim submission

Prior Authorization

Prior Authorization and Plan Terms

Prior authorization and benefit determinations are governed by the member's plan terms. This clinical policy provides a medical necessity framework but does not replace or supersede the terms, conditions, exclusions, limitations or prior authorization rules set forth in the member's evidence of coverage, certificate of coverage, policy, or contract.

Background and Rationale

Human papillomavirus (HPV) includes high‑risk types that are associated with cervical cancer and low‑risk types that are typically associated with benign lesions such as genital warts. Routine cervical cancer screening applies to individuals born with a cervix; HPV high‑risk genotyping is intended to identify oncogenic types (for example, HPV 16, 18, and other high‑risk types) to inform screening and management according to age and risk. By contrast, testing for low‑risk HPV types is not supported because such infections are not associated with progressive cervical disease and do not change clinical management. Additionally, Group B Streptococcus commonly colonizes the vaginal tract and antepartum screening at 36 0/7–37 6/7 weeks identifies candidates for intrapartum prophylaxis, while hepatitis C (HCV) is a blood‑borne infection for which one‑time universal antibody screening is recommended for adults in the specified age range, with nucleic acid testing used for confirmation and monitoring when indicated.

Definitions

HPV high‑risk genotyping — definition and use

Definition — HPV high‑risk genotypingNucleic acid-based genotyping that detects oncogenic (high‑risk) HPV types (used for cervical cancer screening and surveillance in persons with a cervix).

IndicationsMedically necessary for persons born with a cervix aged 30–65 (without hysterectomy) or any age if at increased risk (e.g., immunocompromised, HIV, in‑utero DES exposure, history of CIN2/3 or cervical cancer).

Interval guidanceConsidered medically necessary once every 5 years in absence of increased risk factors.

HPV low‑risk genotyping stanceCurrent evidence does not support genotyping of low‑risk HPV types because detection does not change management (see separate definition).

HPV low‑risk genotyping — definition / rationale

Statement — Low‑risk HPV genotyping

Policy Summary

PayerWellCare

PolicyCoverage Criteria: HPV genotyping, Hepatitis C testing, and Group B Streptococcus screening

Policy CodePolicy CG.CP.MP.05

Change TypeOperational coding updates

Effective Date

Next Review Date

Key ActionDocument clinical rationale and relevant patient details (age, presence of a cervix, gestational age, prior HCV status or risk factors) when ordering tests to support medical necessity.

SourceLink

On This Page

Follow the member's plan-level prior authorization requirements and submission processes
Coverage decisions are subject to plan benefits, exclusions, and applicable state and federal requirements

Denial Risk

Denial Triggers for Out-of-Criteria Testing

Requests for testing that fall outside the medical necessity criteria outlined in this policy may be denied. Ensure documentation supports the indication and that testing frequency and patient characteristics meet the policy criteria.

Denial triggers include: testing for indications explicitly stated as not supported by current evidence, testing more frequently than allowed (e.g., HPV genotyping more often than every 5 years absent increased risk), or lack of documentation supporting risk status or pregnancy gestational age for GBS
Prior positive test results or known chronic infection where screening is not indicated can be grounds for denial

Documentation Required

Required Clinical Documentation for HCV Testing

Document clinical information that supports HCV testing decisions. Include prior HCV antibody status, known history of chronic HCV infection or prior eradication (SVR), risk factors for infection or reinfection, exposure history and timing, immunocompromised status, and indication for testing (screening, confirmatory, monitoring prior to or during DAA therapy).

If antibody testing is negative but exposure occurred within past 6 months, document exposure timing and rationale for HCV-RNA or repeat antibody testing
For monitoring or management (including prior to DAA initiation), document need for quantitative HCV-RNA (baseline viral load) per guideline recommendations
If prior positive antibody or known chronic HCV, document history, treatment status, and ongoing risk factors for reinfection

Documentation Required

Required Clinical Documentation for HPV and GBS Testing

Document clinical information that supports HPV and GBS testing. For HPV genotyping, document presence of a cervix, patient age, prior history of CIN2/3 or cervical cancer, or other increased risk factors as applicable. For Group B Streptococcus (GBS) screening, document pregnancy status and gestational age (36 0/7 to 37 6/7 weeks) when ordering tests.

HPV: record that the member was born with a cervix, age between 30–65 for routine 5‑year genotyping, or specific risk factors if outside that age range
GBS: record estimated gestational age and pregnancy details to confirm appropriate screening window

Note

Follow Coverage Documents

Follow the member's coverage documents and applicable state guidelines when applying this policy. This clinical policy is a guide to medical necessity and does not constitute a contract or guarantee of payment.

Providers must adhere to the evidence of coverage, certificate of coverage, policy, contract of insurance, and state-specific rules that apply to the member
When discrepancies exist between this policy and legal/regulatory requirements, law and regulation prevail

Note

HCV Testing Reflex and Monitoring Expectations

HCV testing commonly uses an HCV-antibody test with an automatic reflex to HCV-RNA PCR for confirmation. Quantitative HCV-RNA testing is recommended prior to starting direct-acting antiviral (DAA) therapy to establish baseline viral load and is appropriate for monitoring during and after treatment or when assessing suspected recent exposure or reinfection risk.

Reflex algorithm: HCV-antibody positive → automatic reflex to HCV-RNA PCR (considered appropriate for initial screening)
Quantitative HCV-RNA (viral load) is recommended prior to DAA initiation and for monitoring treatment response or suspected reinfection
For recent exposures (<6 months) or immunocompromised patients, consider direct HCV-RNA testing even if antibody is negative

Note

Provider Reminder — Submission and Authorization

Provider action highlight: Ensure all required documentation and any prior authorization are submitted in accordance with plan requirements; confirm coding, indications, and testing frequency match policy criteria to avoid claim denials.

Submit clinical notes that explicitly justify the test based on the policy criteria
Verify prior authorization status when plan requires it and retain documentation of approvals

Current evidence does not support human papillomavirus (HPV) genotyping of low‑risk types.

RationaleLow‑risk HPV types are not associated with progression to cervical cancer and testing does not change clinical management.

Coverage implicationRequests for low‑risk HPV genotyping are not supported by this policy and may be denied if submitted outside listed indications for high‑risk testing.