Aetna considers human immunodeficiency virus (HIV) testing medically necessary for screening persons for HIV infection, according to the recommendations of the U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention.
Aetna considers initial testing for HIV with a DA-approved antigen/antibody combination immunoassay that detects HIV-1 and HIV-2 antibodies and HIV-1 p24 antigen medically necessary to screen for established infection with HIV-1 or HIV-2 and for acute HIV-1 infection. No further testing is required for specimens that are nonreactive on the initial immunoassay.
Aetna considers further testing of specimens with a reactive antigen/antibody combination immunoassay result (or repeatedly reactive, if repeat testing is recommended by the manufacturer or required by regulatory authorities) medically necessary, if tested with an FDA-approved antibody immunoassay that differentiates HIV-1 antibodies from HIV-2 antibodies. Reactive results on the initial antigen/antibody combination immunoassay and the HIV-1/HIV-2 antibody differentiation immunoassay should be interpreted as positive for HIV-1 antibodies, HIV-2 antibodies, or HIV antibodies, undifferentiated.
Aetna considers testing of specimens that are reactive on the initial antigen/antibody combination immunoassay and nonreactive or indeterminate on the HIV-1/HIV-2 antibody differentiation immunoassay to be medically necessary when tested with an FDA-approved HIV-1 nucleic acid test (NAT) according to the following criteria:
Note: Laboratories should use this same testing algorithm, beginning with an antigen/antibody combination immunoassay, with serum or plasma specimens submitted for testing after a reactive (preliminary positive) result from any rapid HIV test.
Aetna considers the Orasure oral HIV test kit (OraSure Technologies, Bethlehem, PA) medically necessary for the same indications as standard HIV testing.
Aetna considers the OraQuick Rapid HIV-1 Antibody point-of-care test kit (OraSure Technologies, Bethlehem, PA) an adequate alternative to laboratory HIV blood tests for medically necessary indications for HIV testing.
Note: Aetna does not cover home HIV test kits that do not require a physician's prescription under any plans. These include:
* The Confide Home HIV Test kit was withdrawn from the market in 1997 due to lack of consumer interest.Background
According to the U.S. Preventive Services Task Force (USPSTF, 2005), human immunodeficiency virus (HIV) testing is indicated in individuals with the following risk factors for HIV infection:
Persons who request an HIV test despite reporting no individual risk factors may also be considered at increased risk, since this group is likely to include individuals not willing to disclose high-risk behaviors.
The USPSTF (2005) states that there is good evidence of increased yield from routine HIV screening of persons who report no individual risk factors but are seen in high-risk or high-prevalence clinical settings.
High-risk settings include any of the following:
High-prevalence settings are defined by the Centers for Disease Control and Prevention (CDC) as those known to have a 1 % or greater prevalence of infection among the patient population being served. Where possible, clinicians should consider the prevalence of HIV infection or the risk characteristics of the population they serve in determining an appropriate screening strategy. Data are currently lacking to guide clinical decisions about the optimal frequency of HIV screening.
The USPSTF (2005) recommended that clinicians screen all pregnant women for HIV. The USPSTF made no recommendation for or against routinely screening for HIV in adolescents and adults who are not at increased risk for HIV infection.
In 2006, CDC revised its recommendations for HIV screening of patients in all healthcare settings. Major revisions include a recommendation for routine HIV screening for patients aged 13 to 64 years after the patient is notified that testing will be performed unless the patient declines (opt-out screening). The CDC recommended that persons at high-risk for HIV infection should be screened for HIV at least annually.
The American College of Physicians (ACP) and HIV Medicine Association developed a guidance statement on screening for HIV in health care settings (Qaseem et al, 2009). In accordance to the CDC's 2006 recommendation, the ACP/HIV Medicine Association stated that in all health-care settings, screening for HIV infection should be performed routinely for all patients aged 13 to 64 years. Healthcare providers should initiate screening unless prevalence of undiagnosed HIV infection in their patients has been documented to be less than 0.1 %. In the absence of existing data for HIV prevalence, healthcare providers should initiate voluntary screening until they establish that the diagnostic yield is less than 1 per 1,000 patients screened, at which point such screening is no longer warranted.
Recommendations for HIV screening in pregnant women were revised to include such screening in the routine panel of prenatal screening tests for all pregnant women (CDC, 2006). The CDC recommended that HIV screening after the pregnant woman is notified that testing will be performed unless the patient declines (opt-out screening). The CDC recommended repeat HIV testing in the third trimester for all women at high-risk for HIV, for women in jurisdictions with elevated HIV or AIDS incidence, and for women receiving healthcare in facilities with at least 1 diagnosed HIV case per 1,000 pregnant women per year.
In a Cochrane review, Bateganya et al (2007) discussed home-based HIV voluntary counseling and testing delivery models, which, given the low uptake of facility-based testing models, may be an effective method to get more patients on treatment and prevent new infections in developing countries. The authors concluded that home-based testing and/or delivery of HIV test results at home, rather than in clinics, appears to lead to higher uptake in testing. However, given the limited extant literature and the limitations in the included existing studies, there is insufficient evidence to recommend large-scale implementation of the home-based testing model.
The Orasure oral HIV test kit (OraSure Technologies, Bethlehem, PA) is an HIV test kit that uses oral mucosal transudate for testing rather than blood testing. The kit is manufactured by SmithKline Beecham Consumer Healthcare and is provided to physicians for use in their office. This HIV test kit requires physician involvement and is used for the same indications as standard HIV testing.
The OraQuick Rapid HIV-1 Antibody point-of-care test kit (OraSure Technologies, Bethlehem, PA) is a rapid, point-of-care test designed to detect antibodies to HIV-1 in fingerstick whole blood and venipuncture whole blood specimen within approximately 20 mins. In the clinical studies submitted to the U.S. Food and Drug Administration (FDA) by the manufacturer, OraQuick correctly identified 99.6 % of people who were infected with HIV-1 (sensitivity) and 100 % of people who were not infected with HIV-1 (specificity). As with all HIV screening tests, a reactive test result needs to be confirmed by an additional, more specific Western blot test.
In a Cochrane review, Bateganya et al (2010) examined the effect of home-based HIV voluntary counselling and testing (VCT) on uptake of HIV testing. These investigators searched MEDLINE (February 2007), EMBASE (February 2007), CENTRAL (February 2007), AIDSearch (February 2007), LILACS, CINAHL and Sociofile. They also contacted relevant researchers. The original review search strategy was updated in 2008. Randomized controlled trials comparing home-based HIV VCT with other testing models were used for this analysis. Two review authors independently selected studies, assessed methodological quality, and extracted data. They planned to conduct statistical analysis using the Review Manager software and calculate summary statistics (relative risks (RRs) with 95 % confidence intervals (CI)) for primary outcomes. Only 1 study from developing countries met the inclusion criteria and was included in the review. The study, a cluster randomized trial (10 clusters, n = 849) compared VCT uptake between an optional location (including home-based) and a local clinic location in a population-based HIV survey. The study showed a higher uptake of VCT among participants in the optional-location group. Uptake was significantly greater in the optional-location group in those who were pre-test counselled only (RR = 4.6; 95 % CI: 3.58 to 5.91); pre-test counselled and tested (RR = 4.6; 95 % CI: 3.51 to 5.92); and post-test counselled and received the test result (RR = 4.8; 95 % CI: 3.62 to 6.21). This study, however, had significant methodological problems limiting further analysis and interpretation. The authors concluded that although home-based HIV VCT has the potential to enhance VCT uptake in developing countries, insufficient data exist to recommend large-scale implementation of home-based HIV testing. They stated that further studies are needed to determine if home-based VCT is better than facility-based VCT in improving VCT uptake.
The USPSTF released updated recommendations for HIV screening in April, 2013, including two Grade A recommendations. The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults ages 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. The USPSTF also recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown.
In June, 2014 the CDC updated recommendations for screening for HIV to include an algorithm for a sequence of tests used in combination to improve the accuracy of the laboratory diagnosis of HIV. The recommendations concern testing of serum or plasma specimens. Previous CDC recommendations only employed tests for HIV antibodies, but the updated recommendations also include tests for HIV antigens and HIV nucleic acid. The recommendations have been issued because studies from populations at high risk for HIV demonstrated that antibody testing alone may miss a considerable percentage of HIV infections detectable by virologic tests. Advantages of these updated recommendations include improved accuracy of laboratory diagnosis of acute HIV-1 infection, equally accurate laboratory diagnosis of established HIV-1 infection, improved accuracy of laboratory diagnosis of HIV-2 infection, a decrease in the number of indeterminate results, and faster turnaround time for most test results (CDC, 2014).
|CPT Codes / HCPCS Codes / ICD-10 Codes|
|Information in the [brackets] below has been added for clarification purposes.  Codes requiring a 7th character are represented by "+":|
|ICD-10 codes will become effective as of October 1, 2015:|
|CPT codes covered if selection criteria are met:|
|86689||HTLV or HIV antibody, confirmatory test (e.g., Western Blot)|
|86701||Qualitative or semiquantitative immunoassay performed by multiple step methods for the detection of antibodies to infectious agents; HIV-1|
|86702||Qualitative or semiquantitative immunoassay performed by multiple step methods for the detection of antibodies to infectious agents; HIV-2|
|86703||Antibody; HIV-1 and HIV-2, single result|
|87389||HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies, single results|
|87390||Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; HIV-1|
|87391||Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; HIV-2|
|87534||Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, direct probe technique|
|87535||HIV-1, amplified probe technique, includes reverse transcription when performed|
|87536||HIV-1, quantification, includes reverse transcription when performed|
|87806||Infectious agent antigen detection by immunoassay with direct optical observation; HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies|
|HCPCS codes covered if selection criteria are met:|
|G0432||Infectious agent antigen detection by enzyme immunoassay (EIA) technique, qualitative or semi-quantitative, multiple-step method, HIV-1 or HIV-2, screening|
|G0433||Infectious agent antigen detection by enzyme-linked immunosorbent assay (ELISA) technique, antibody, HIV-1 or HIV-2, screening|
|G0435||Infectious agent antigen detection by rapid antibody test of oral mucosa transudate, HIV-1 or HIV-2, screening|
|S3645||HIV-1 antibody testing of oral mucosal transudate|
|ICD-10 codes covered if selection criteria are met:|
|B20||Human immunodeficiency virus [HIV] disease|
|Z11.4||Encounter for screening for human immunodeficiency virus [HIV]|
|Z20.6||Contact with and (suspected) exposure to human immunodeficiency virus [HIV]|
|Z20.828||Contact with and (suspected) exposure to other viral communicable diseases|
|Z21||Asymptomatic human immunodeficiency virus [HIV] infection status|