HCPCS G0475 is officially defined as "Hiv antigen/antibody, combination assay, screening." HCPCS G0475 is referenced in 9 tracked payer policy changes from Anthem BCBS, Harvard Pilgrim Health Care, and 4 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS G0475 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Effective January 1, 2027, HealthKeepers, Inc. (Anthem HealthKeepers Plus Medicaid in Virginia) will discontinue reimbursement for 44 specific procedure codes to align with the Virginia Department of Medical Assistance Services (DMAS) fee schedule. The practice must stop billing these codes for dates of service on or after that date, as claims for discontinued codes will be denied or subject to adjustment and recovery.
Point32Health (Harvard Pilgrim) is implementing extensive CPT code changes across multiple laboratory policies effective June 1, 2026, including removing 23 codes and adding 24 new codes across 11 different lab testing categories. A new prenatal testing policy for fetal aneuploidy is also being introduced.
Blue Cross NC updated multiple medical policies effective February 11, 2026, including changes to coverage criteria for STI testing, diabetes testing code additions, cervical cancer screening restrictions, and vaginitis testing limits. Several CPT codes were removed from covered services while new codes were added for specific conditions.
BlueCross BlueShield of South Carolina and BlueChoice HealthPlan released 33 medical policy updates and revisions effective November 2025. Key changes include: new psychological/neuropsychological testing policy (CAM 397), extended lumbar fusion revision surgery timeline (9-12 months vs 6-12 months), expanded HIV testing coverage with PrEP criteria, negative pressure wound therapy trial period extended from 14 to 30 days, multiple CPT code additions/removals in sexual health and infectious disease testing, and new minimal residual disease coverage for diffuse large B-cell lymphoma. Billing teams must immediately update claim submission rules, prior authorization triggers, and CPT code billing matrices across multiple service lines.
Aetna considers HIV testing medically necessary for screening persons for HIV infection according to the recommendations of the U.S. Preventive Services Task Force and the CDC, starting with an FDA-approved antigen/antibody combination immunoassay. Reactive specimens go to an FDA-approved HIV-1/HIV-2 antibody differentiation immunoassay and, when indicated, an FDA-approved HIV-1 nucleic acid test. Aetna does not cover home HIV test kits that do not require a physician's prescription under any plans.
Aetna considers HIV testing medically necessary for screening according to the recommendations of the U.S. Preventive Services Task Force and the CDC. Initial testing uses an FDA-approved antigen/antibody combination immunoassay, and further testing follows only for reactive results. Aetna does not cover home HIV test kits that do not require a physician's prescription under any plan, including the Confide Home HIV Test and the Home Access HIV Test System.
Health Net California eliminated prior authorization requirements for FDA-approved HIV PrEP medications and all CDC-recommended integral services. Billing teams must use Z29.81 as the primary diagnosis code for all PrEP-related services to ensure proper coverage without cost-sharing.
CalViva Health has issued updated billing guidelines for HIV Pre-exposure Prophylaxis (PrEP) services. All PrEP medications and integral services must be covered without cost-sharing, and providers must use primary diagnosis code Z29.81 with specific CPT codes for proper billing to avoid payment delays.
Health plans must cover all FDA-approved HIV PrEP medications and integral services without cost sharing, prior authorization, or step therapy (except when therapeutic equivalents exist). Billing teams must use Z29.81 as the primary diagnosis code for all PrEP-related services and follow specific CPT coding guidelines for oral and injectable PrEP protocols.
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