CommercialCoverageMedium impact
Herpes Simplex Virus - Screening and Diagnosis (CPB 0433, reviewed 2026-07-01)
Aetna·Infectious Disease, OB-GYN, General Practice +4 more·Medical Policy
Effective date
Jul 1, 2026
We identified it
Aug 17, 2026
Summary
Aetna's updated HSV screening and diagnosis policy (CPB 0433, effective 2026-07-01) restricts coverage for serologic antibody testing in asymptomatic patients, including pregnant individuals, and excludes quantitative PCR testing (CPT 87530). Only qualitative PCR testing for symptomatic patients with active lesions or symptoms is covered; billing teams must ensure claims include appropriate diagnosis codes indicating active disease rather than screening.
Action Required
By July 1, 2026: Billing team must update claim submission protocols and billing system edits to deny coverage for CPT 87530 (HSV quantification) for all indications. For CPT 86694, 86695, 86696 (serologic antibody testing), implement system blocks preventing claims when diagnosis codes indicate asymptomatic screening (Z00.00-Z00.01, Z11.3, Z11.59, Z34.00-Z34.93, Z36.0-Z36.9, or other Z-codes listed as non-covered). Allow claims only when paired with active disease diagnosis codes (A60.00-A60.9, B00.0-B00.9, etc.). For CPT 87483 and 87529, flag claims with asymptomatic member indicators for denial. Train providers and coding staff that HSV testing for asymptomatic members—particularly pregnant patients—will not be reimbursed. For claims already submitted or pending before July 1, continue processing under prior policy; retroactive application is not indicated. Communicate policy changes to clinical staff and update encounter templates to discourage HSV antibody screening orders in asymptomatic populations. Failure to implement these edits will result in claim denials and potential overpayment recovery.