WellCare HPV HCV GBS screening Policy Update

Coverage Criteria for Infectious Disease Screening

High-risk HPV genotyping (medically necessary)

Genotyping of High Risk HPV types for cervical cancer screening is considered medically necessary when ALL of the following apply:

Eligibility by anatomy and age: Member is an individual born with a cervix AND age 30–65 yearsage 30-65

from policy

Clinical exceptions for those 30–65: One of the following: has NOT had a hysterectomy with removal of the cervix; OR has a history of high-grade precancerous lesion (CIN2 or CIN3); OR has a history of cervical cancer

from policy

Alternate age/risk group: Member born with a cervix who is younger than 30 years OR older than 65 years AND is at increased risk for cervical cancer (examples: immunocompromised, HIV infection, in‑utero DES exposure, history of cervical lesion or cervical cancer)age <30 or >65 with high-risk factors

from policy

Screening interval: HPV genotyping of high‑risk types is considered medically necessary once every 5 years in the absence of increased risk factorsonce every 5 years

from policy

Low-risk HPV genotyping (investigational)

Genotyping of low‑risk HPV types:

Investigational statement: HPV genotyping of low‑risk types is considered investigational

from policy

Unsupported indications (examples): Investigational for evaluation of genital warts or for general sexually transmitted infection screening (i.e., indications outside the specified high‑risk cervical cancer screening criteria)

from policy

HCV antibody screening (medically necessary)

Hepatitis C antibody screening tests are considered medically necessary when ALL of the following apply:

Exclusions prior positive/chronic: Member does NOT have a known past positive HCV antibody test AND does NOT have a known history of chronic HCV infection

from policy

Indications for antibody screening (one or more apply): Member is pregnant; OR member is an asymptomatic adult age 18–79 years; OR member is a child ≥18 months who was perinatally exposed to HCV and has not been previously tested; OR member is younger than 18 or older than 79 years and is at increased risk for HCV infection (examples: current injection drug use, liver disease, chronic hemodialysis, HIV infection, HIV PrEP use, sexual partners of HCV‑infected individuals, organ transplant donor/recipient); OR member requests screeningage 18-79 for routine adults; child ≥18 months for perinatal exposure

from policy

HCV nucleic acid/PCR testing (medically necessary)

Hepatitis C nucleic acid/PCR tests are considered medically necessary when ANY of the following are met:

Indications for HCV nucleic acid/PCR testing: Member is immunocompromised (e.g., receives chronic hemodialysis); OR member has suspected HCV exposure within the past 6 months (regardless of antibody status); OR member has an initial HCV antibody positive test; OR member is undergoing monitoring for chronic HCV infection (to start direct‑acting antiviral therapy, while receiving treatment, or after completion); OR member was exposed to HCV perinatally and is between 2 months and 17 months of age; OR member has a history of HCV with sustained virologic response (SVR) AND has ongoing risk factors for reinfectionvaries by indication

from policy; quantitative HCV‑RNA recommended for baseline and monitoring per IDSA/AASLD guidance

Not routine reflex: Automatic PCR reflex from initial antibody screening for routine screening is considered investigational (PCR as automatic reflex is not covered outside listed indications)

from policy

GBS screening (medically necessary)

Group B Streptococcus (GBS) screening of vaginal‑rectal specimens is considered medically necessary 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

from policy and ACOG guidance

Investigational exclusions (examples): GBS screening of vaginal‑rectal specimens is considered investigational for pregnant members with GBS bacteriuria during the current pregnancy OR with a history of a prior GBS‑infected newborn

from policy

Coverage statement revisions

Policy-wide wording and coding updates were made affecting coverage statements and referenced codes:

Verbiage revision: Policy statement verbiage changed from 'may be considered medically necessary' to 'are considered medically necessary' for Group B Streptococcus screening tests of vaginal‑rectal specimens and genotyping of high‑risk HPV types for nucleic acid/PCR tests.

operational change noted in revision log

Coding table additions: CPT code 87626 and HCPCS code G0476 were added to the policy's coding tables — providers should verify any prior authorization requirements for these codes.

operational/coding change noted in revision log

Additional coverage clarifications: High-risk HPV genotyping is covered only as described in the high-risk HPV criteria — i.e., for individuals born with a cervix meeting the age and risk-based requirements or other listed indications. Testing of HPV types outside those high-risk indications (including routine evaluation of genital warts or general STI screening) is investigational and may be denied. Low-risk HPV genotyping is explicitly labeled investigational in the policy. Group B Streptococcus (GBS) vaginal–rectal screening is covered in the specified gestational window; screening for pregnancies with current GBS bacteriuria or prior GBS-infected newborn is labeled investigational and not covered under those indications.

Coverage caveat: Inclusion of a CPT or HCPCS code in this clinical policy does not guarantee coverage for every patient or indication. Coverage is determined by the member’s specific benefit plan and applicable state and federal requirements. Providers must verify eligibility, applicable plan coverage terms, and any prior authorization requirements before submitting claims.

Examples of investigational testing approaches: Routine reflex HCV PCR performed automatically from an initial antibody screen (PCR as an automatic reflex in all settings) is considered investigational unless the member meets a listed HCV PCR indication (e.g., immunocompromised status, suspected recent exposure, initial antibody positive, monitoring during/after therapy, or perinatal age window). Low-risk HPV genotyping (testing to identify non-oncogenic HPV types for genital wart evaluation or routine STI panels) is considered investigational. Performing GBS screening outside the specified antenatal window of 36 weeks 0 days to 37 weeks 6 days, or for pregnancies with current GBS bacteriuria or prior GBS-infected newborn, is considered investigational.

Referenced CPT / HCPCS Codes and Coding Notes

Referenced test/procedure codesCPT | HCPCS | mixed

86803	Hepatitis C antibody
86804	Hepatitis C antibody; confirmatory test (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
87624	Infectious agent detection by nucleic acid (DNA or RNA); Human
87625	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV) types 16 and 18 only; includes type 45, if performed
87626	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), separately reported high-risk types and high-risk pooled result(s)
87653	Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique

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Referenced CPT Codes (examples — informational)CPT

86803	Hepatitis C antibody
86804	Hepatitis C antibody; confirmatory test immunoblot
87520	Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, direct probe technique

Referenced CPT Codes (detailed list)CPT

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
87624	Infectious agent detection by nucleic acid (DNA or RNA); Human
87625	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV) types 16 and 18 only, includes type 45 if performed
87626	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), separately reported high-risk types and pooled results (added to CPT table)
87653	Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique

Referenced HCPCS CodesHCPCS

G0476

Infectious 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

GBS screening gestational window

Gestational screening window36w0d–37w6d

ContextAntepartum vaginal-rectal specimen screening for Group B Streptococcus

Investigational exceptionsGBS screening is investigational for pregnancies with GBS bacteriuria or prior GBS-infected newborn

Perinatal HCV exposure testing age window (revision)

Age window (per revision)2 months to 17 months

ContextApplies to HCV nucleic acid/PCR testing for infants perinatally exposed to HCV

Provider and Billing Actions / Prior Authorization Notes

Prior Authorization

Coding to support authorization

Include procedure codes on the prior authorization request and on claims to support medical necessity. Providers should ensure submitted claims list the CPT/HCPCS codes that correspond to the service authorized and retain supporting clinical documentation.

Include referenced CPT and HCPCS codes on the prior authorization request and on claims.
Attach or retain clinical documentation that supports medical necessity for the billed code(s).

Prior Authorization

Verify prior authorization for newly added codes

Verify that a prior authorization is obtained when billing newly added or updated codes (for example, CPT 87626 and HCPCS G0476). Do not assume coverage based solely on code addition — confirm plan-specific prior authorization requirements before performing services.

Verify prior authorization requirements for CPT 87626 and HCPCS G0476 prior to testing.
Contact the payer or use payer portal to confirm authorization status for newly added codes.

Background and Policy Scope

Background: Human papillomavirus (HPV) includes high-risk types associated with cervical cancer and low-risk types associated with genital warts; genotyping for high-risk HPV is intended to support cervical cancer screening in the defined age/risk groups, while low-risk HPV genotyping is labeled investigational. Hepatitis C virus (HCV) is a blood-borne infection for which antibody screening (with reflex to RNA testing when indicated) is recommended in adults and in certain pregnancy and perinatal contexts; HCV RNA (PCR) testing is used for confirmation, diagnosis in immunocompromised or recently exposed persons, and for monitoring antiviral therapy. Group B Streptococcus (GBS) commonly colonizes the vagina and rectum and is screened in pregnancy near term to identify candidates for intrapartum prophylaxis to prevent neonatal disease; this policy specifies a gestational screening window of 36 weeks 0 days to 37 weeks 6 days.

Definitions and Test Descriptions

High-risk HPV genotyping — definition

PurposeIdentify oncogenic (high-risk) HPV types for cervical cancer screening

Primary age/risk boundaryIndividuals born with a cervix, age 30–65 years (with exceptions)

Alternate indicationIndividuals <30 or >65 years who are at increased risk (immunocompromised, HIV, in‑utero DES exposure, history of cervical lesion or cancer)

Frequency guidanceOnce every 5 years in absence of increased risk factors

HCV nucleic acid/PCR testing — definition

Test typesQualitative and quantitative HCV RNA (nucleic acid/PCR) assays

Policy Revision History and Change Log

2024-11-20policy_review

Annual review updated policy statement verbiage from 'may be considered medically necessary' to 'are considered medically necessary' for Group B Streptococcus screening and high-risk HPV genotyping; added perinatal HCV exposure criterion (age 2 months to 17 months).

2024-11coding_update

CPT code 87626 was added to the CPT coding table and HCPCS code G0476 was added to a new HCPCS table; background and references updated.

2024-03administrative_change

OpenPayer

Infectious disease screening: HPV, HCV, GBS testing

Coverage Criteria for Infectious Disease Screening

Referenced CPT / HCPCS Codes and Coding Notes

Provider and Billing Actions / Prior Authorization Notes

Background and Policy Scope

Definitions and Test Descriptions

Policy Revision History and Change Log