Download Viral Load Assay or Polymerase Chain Reaction Testing

MEDICAL POLICY
SUBJECT: VIRAL LOAD ASSAY OR
EFFECTIVE DATE: 07/02/99
POLYMERASE CHAIN REACTION
ARCHIVED DATE: 02/28/01
TESTING TO MONITOR
EDITED DATE: 11/10/05, 11/16/06, 12/20/07, 11/20/08,
PROGRESSION OF HIV
12/17/09, 12/16/10, 12/15/11, 12/20/12,
POLICY NUMBER: 2.02.08
12/19/13, 11/20/14, 12/17/15, 11/17/16
PAGE: 1 OF: 2
CATEGORY: Laboratory Tests
 If a product excludes coverage for a service, it is not covered, and medical policy criteria do not apply.
 If a commercial product, including an Essential Plan product, covers a specific service, medical policy criteria
apply to the benefit.
 If a Medicare product covers a specific service, and there is no national or local Medicare coverage decision for
the service, medical policy criteria apply to the benefit.
POLICY STATEMENT:
Viral Load Assay is medically appropriate when the use of viral load assay is linked to treatment. The following are
examples of clinical use:
I. Assess prognoses in HIV-infected individuals,
II. Monitor disease progression in HIV-infected individuals
III. Initiate antiretroviral therapy in HIV-infected individuals,
IV. Change antiretroviral therapy in HIV-infected individuals, or
V. Delay antiretroviral therapy in HIV-infected individuals.
DESCRIPTION:
Viral load assay or polymerase chain reaction is a laboratory test used to monitor the progression of HIV. The
polymerase chain reaction can be used not only to detect the presence of viral sequences but also to provide a semiquantitative or a precise evaluation of the number of copies of genome present. The HIV life cycle permits both DNA
and RNA to be targeted. It is a rapid and simple quantitative assay for HIV RNA in plasma or sera that should prove
valuable in determining the natural history of infection, dissecting viral pathogenesis and monitoring the efficacy of
therapeutic intervention. By monitoring the level of virus, physicians are hopeful that they will be able to adjust therapy
in a more timely fashion and keep the viral load down at a level where the immune system is still functioning.
CODES:
Number
Description
Eligibility for reimbursement is based upon the benefits set forth in the member’s subscriber contract.
CODES MAY NOT BE COVERED UNDER ALL CIRCUMSTANCES. PLEASE READ THE POLICY AND
GUIDELINES STATEMENTS CAREFULLY.
Codes may not be all inclusive as the AMA and CMS code updates may occur more frequently than policy updates.
CPT:
86701
Antibody; HIV-1
86702
Antibody; HIV-2
86703
Antibody; HIV-1 and HIV-2, single result
87534
Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, direct probe technique
87535
Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, amplified probe
technique, includes reverse transcription when performed
87536
Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, quantification, includes
reverse transcription when performed
87537
Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, direct probe technique
87538
Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, amplified probe
technique, includes reverse transcription when performed
Proprietary Information of Excellus Health Plan, Inc.
A nonprofit independent licensee of the BlueCross BlueShield Association.
SUBJECT: VIRAL LOAD ASSAY OR
POLYMERASE CHAIN REACTION
TESTING TO MONITOR
PROGRESSION OF HIV
POLICY NUMBER: 2.02.08
CATEGORY: Laboratory Tests
87539
EFFECTIVE DATE: 07/02/99
ARCHIVED DATE: 02/28/01
EDITED DATE: 11/10/05, 11/16/06, 12/20/07, 11/20/08,
12/17/09, 12/16/10, 12/15/11, 12/20/12,
12/19/13, 11/20/14, 12/17/15, 11/17/16
PAGE: 2 OF: 2
Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, quantification, includes
reverse transcription when performed
Copyright © 2016 American Medical Association, Chicago, IL
HCPCS:
No codes
ICD9:
042
Symptomatic acquired immunodeficiency syndrome (AIDS)
079.53
Human immunodeficiency virus, type 2 [HIV-2]
647.60
Other viral diseases complicating pregnancy (including HIV-1 and II)
795.71
Nonspecific serologic evidence of human immunodeficiency virus [HIV]
V08
Asymptomatic HIV infection
B20
Human immunodeficiency virus (HIV) disease
B97.35
Human immunodeficiency virus, type 2 (HIV 2) as the cause of diseases classified elsewhere
O98.419
Viral hepatitis complicating pregnancy, unspecified trimester
O98.519
Other viral diseases complicating pregnancy, unspecified trimester
O98.719
Human immunodeficiency virus (HIV) disease complicating pregnancy, unspecified
trimester
R75
Inconclusive laboratory evidence of human immunodeficiency virus (HIV)
Z21
Asymptomatic human immunodeficiency virus (HIV) infection status
ICD10:
REFERENCES:
BlueCross BlueShield Association. Plasma HIV-1 RNA quantification for HIV-1 infection. Medical Policy Reference
Manual #2.01.22. 2009 Jul 09.
Holodniy M. Clinical application of reverse transcription-polymerase chain reaction for HIV Infection. Clinics Lab Med
1994 Jun;14(2):335-339.
Mascolini M. Can new HIV assays put more science and less art in antiviral prescribing? Jnl Phys Assoc AIDS Care.
1994 Aug:8-16.
Mascolini M. Viral load earns experts’ kudos at HIV surrogate marker conference. Jnl Phys Assoc AIDS Care 1994
Dec:15-18.
Saag MS, et a. HIV viral load markers in clinical practice. Nature Med 1996 Jun;2(6):625-629.
Sninsky JJ, et al. The application of quantitative polymerase chain reaction to therapeutic monitoring, AIDS 1993;7:S29S34.
KEY WORDS: HIV-1, HIV-2, HIV testing.
CMS COVERAGE FOR MEDICARE PRODUCT MEMBERS
There is currently a National Coverage Determination (NCD) for Human Immunodeficiency Virus (HIV) Testing
(Prognosis Including Monitoring). Please refer to the following NCD website for Medicare Members:
https://www.cms.gov/medicare-coverage-database/details/ncddetails.aspx?NCDId=46&ncdver=1&bc=AgAAgAAAAAAA&.
Proprietary Information of Excellus Health Plan, Inc.