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Genotyping and Phenotyping Clinical Coverage Policy No.:1S-1 For HIV Drug Resistance Testing

Service Code
87903 (CPT) Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug resistance tissue culture analysis, HIV 1; first through 10 drugs tested
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Human Immunodeficiency Virus (HIV) is a ribonucleic acid (RNA) virus characterized by a high replication rate throughout all stages of infection. There are four types of HIV: HIV-1, HIV-2, Human T-cell Lymphotropic Virus (HTLV) type 1, and HTLV type 2. In HIV-1, the reverse transcription enzyme required for replication is error prone, resulting in a high rate of mutations. Viral replication continues in the presence of selective drug(s). This is called drug resistance, and it is one of the most common reasons for failure of HIV therapy. HIV drug resistance testing assesses the HIV strain(s) infecting an individual to determine each strain’s resistance to specific antiretroviral drugs. Two methods are available for testing resistant HIV strains: genotypic and phenotypic. Both isolate the virus from the beneficiary. Genotype tests detect specific mutations in the genome of a beneficiary’s viral isolate that are associated with antiretroviral resistance. Phenotype tests assess how well the beneficiary’s virus grows in the presence of different concentrations of antiretroviral drugs and compares these concentrations with a viral strain used as a control.

Limits

Genotype and phenotype testing for HIV drug resistance is not covered in the following circumstances.

  • a. The viral load is less than 1,000 copies/ml.
  • b. Combined genotype and phenotype testing for HIV drug resistance is considered investigational but could be considered medically necessary in a complex case where the physician believes both types of testing might provide additional useful information, not provided by one or the other. This will be determined on a case-by-case basis, and with medical documentation supporting why both tests are necessary.The test must be ordered by a treating physician or other qualified treating non-physician practitioner within the scope of their license and in compliance with Medicaid requirements.Coverage is limited to no more than two HIV-1 drug-resistant tissue tests in a 12-month period. If additional testing is needed within a 12-month period, an exception may be requested and must include medical necessity documentation.

The service may be billed on professional or institutional claims.

Place of Service

Inpatient, Outpatient, Office

Additional Service Specifics

CPT 86701 or 86703 is performed initially. CPT 86702 is performed when the results of 86701 are negative and clinical suspicion of HIV-2 exists. CPT 86689 is performed only on samples that show repeated positive results by 86701, 86702, or 86703. Note: The laboratory performing the test(s) shall bill for the service.

How to Submit

N/A - No authorization is required

Resources

Genotyping and Phenotyping Clinical Coverage Policy No.:1S-1 For HIV Drug Resistance Testing

Service Code
87904 (CPT) Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug resistance tissue culture analysis, HIV 1; each additional drug tested (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Human Immunodeficiency Virus (HIV) is a ribonucleic acid (RNA) virus characterized by a high replication rate throughout all stages of infection. There are four types of HIV: HIV-1, HIV-2, Human T-cell Lymphotropic Virus (HTLV) type 1, and HTLV type 2. In HIV-1, the reverse transcription enzyme required for replication is error prone, resulting in a high rate of mutations. Viral replication continues in the presence of selective drug(s). This is called drug resistance, and it is one of the most common reasons for failure of HIV therapy. HIV drug resistance testing assesses the HIV strain(s) infecting an individual to determine each strain’s resistance to specific antiretroviral drugs. Two methods are available for testing resistant HIV strains: genotypic and phenotypic. Both isolate the virus from the beneficiary. Genotype tests detect specific mutations in the genome of a beneficiary’s viral isolate that are associated with antiretroviral resistance. Phenotype tests assess how well the beneficiary’s virus grows in the presence of different concentrations of antiretroviral drugs and compares these concentrations with a viral strain used as a control.

Limits

Genotype and phenotype testing for HIV drug resistance is not covered in the following circumstances.

  • a. The viral load is less than 1,000 copies/ml.
  • b. Combined genotype and phenotype testing for HIV drug resistance is considered investigational but could be considered medically necessary in a complex case where the physician believes both types of testing might provide additional useful information, not provided by one or the other. This will be determined on a case-by-case basis, and with medical documentation supporting why both tests are necessary.The test must be ordered by a treating physician or other qualified treating non-physician practitioner within the scope of their license and in compliance with Medicaid requirements.Coverage is limited to no more than two HIV-1 drug-resistant tissue tests in a 12-month period. If additional testing is needed within a 12-month period, an exception may be requested and must include medical necessity documentation.

The service may be billed on professional or institutional claims.

Place of Service

Inpatient, Outpatient, Office

Additional Service Specifics

CPT 86701 or 86703 is performed initially. CPT 86702 is performed when the results of 86701 are negative and clinical suspicion of HIV-2 exists. CPT 86689 is performed only on samples that show repeated positive results by 86701, 86702, or 86703. Note: The laboratory performing the test(s) shall bill for the service.

How to Submit

N/A - No authorization is required

Resources

Infectious agent enzymatic activity other than virus (eg, sialidase activity in vaginal fluid)

Service Code
87905 (CPT) Infectious agent enzymatic activity other than virus (eg, sialidase activity in vaginal fluid)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, other region (eg, integrase, fusion)

Service Code
87906 (CPT) Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV-1, other region (eg, integrase, fusion)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Infectious agent genotype analysis by nucleic acid (DNA or RNA); cytomegalovirus

Service Code
87910 (CPT) Infectious agent genotype analysis by nucleic acid (DNA or RNA); cytomegalovirus
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Infectious agent genotype analysis by nucleic acid (DNA or RNA); Hepatitis B virus

Service Code
87912 (CPT) Infectious agent genotype analysis by nucleic acid (DNA or RNA); Hepatitis B virus
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Infectious agent genotype analysis by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), mutation identification in targeted region(s)

Service Code
87913 (CPT) Infectious agent genotype analysis by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]), mutation identification in targeted region(s)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to EviCore

HIV Tropism Assay

Service Code
87999 (CPT) Unlisted microbiology procedure
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Chemokine receptor 5 (CCR5) and chemokine receptor 4 (CXCR4) are the major chemokine coreceptors used by the human immunodeficiency virus (HIV) to enter into human cells. The HIV tropism assay is a diagnostic test used to determine the viral tropism of HIV-1. The assay can determine whether the HIV infection is CCR5, CXCR4, or dual-or mixed-tropic (D-/Mtropic). Using a small blood sample, this assay amplifies a beneficiary’s HIV genome to make HIV particles specific to the individual beneficiary. These HIV particles are used to infect CCR5- and CXCR4- expressing cell lines. Once the virus infects the cell and undergoes a single round of replication, a receptor gene gives a visible signal that identifies the beneficiary’s viral tropism. A CCR5 co-receptor antagonist is indicated for combination antiretroviral treatment of a beneficiary infected with only CCR5-tropic HIV-1 detectable, who has evidence of viral replication and HIV-1 strains resistant to multiple anti-retroviral agents. CCR5 co-receptor antagonist works by binding to a specific chemokine receptor (CCR5), thus preventing HIV from entering the cell. Note: HIV Tropism testing with a highly sensitive tropism (phenotypic) assay is required for the appropriate use of a CCR5 co-receptor antagonist.

Unit Value

1 unit = 1 test

Limits

CCR5 co-receptor antagonist provides a novel mechanism to inhibit the HIV viral replication cycle. HIV tropism (phenotypic) assay can help determine whether a CCR5 co-receptor antagonist may be an appropriate drug for the beneficiary. Testing must be ordered by a qualified treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicaid requirements.

Note: HIV Tropism testing with a highly sensitive tropism (phenotypic) assay is required for the appropriate use of a CCR5 co-receptor antagonist.Medicaid will cover a maximum of 1 unit (test) per 12-month period

Exclusions

Medicaid shall not cover HIV tropism (phenotypic) assay for all of the following:

  • a. the beneficiary does not meet the specific criteria of this policy;
  • b. when using other HIV co-receptor (genotypic) assay techniques; and
  • c. to predict disease progression (irrespective of co-receptor antagonist treatment).

Place of Service

Inpatient, Outpatient, Physician's office

How to Submit

N/A - No authorization is required

Resources

Necropsy (autopsy), gross examination only; without CNS

Service Code
88000 (CPT) Necropsy (autopsy), gross examination only; without CNS
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Necropsy (autopsy), gross examination only; with brain

Service Code
88005 (CPT) Necropsy (autopsy), gross examination only; with brain
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Necropsy (autopsy), gross examination only; with brain and spinal cord

Service Code
88007 (CPT) Necropsy (autopsy), gross examination only; with brain and spinal cord
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Necropsy (autopsy), gross examination only; infant with brain

Service Code
88012 (CPT) Necropsy (autopsy), gross examination only; infant with brain
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Necropsy (autopsy), gross examination only; stillborn or newborn with brain

Service Code
88014 (CPT) Necropsy (autopsy), gross examination only; stillborn or newborn with brain
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Necropsy (autopsy), gross examination only; macerated stillborn

Service Code
88016 (CPT) Necropsy (autopsy), gross examination only; macerated stillborn
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Necropsy (autopsy), gross and microscopic; without CNS

Service Code
88020 (CPT) Necropsy (autopsy), gross and microscopic; without CNS
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Necropsy (autopsy), gross and microscopic; with brain

Service Code
88025 (CPT) Necropsy (autopsy), gross and microscopic; with brain
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Necropsy (autopsy), gross and microscopic; with brain and spinal cord

Service Code
88027 (CPT) Necropsy (autopsy), gross and microscopic; with brain and spinal cord
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Necropsy (autopsy), gross and microscopic; infant with brain

Service Code
88028 (CPT) Necropsy (autopsy), gross and microscopic; infant with brain
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Necropsy (autopsy), gross and microscopic; stillborn or newborn with brain

Service Code
88029 (CPT) Necropsy (autopsy), gross and microscopic; stillborn or newborn with brain
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Necropsy (autopsy), limited, gross and/or microscopic; regional

Service Code
88036 (CPT) Necropsy (autopsy), limited, gross and/or microscopic; regional
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required