CommercialCoverageMedium impact
HIV Testing (CPB 0542, reviewed 2025-11-26)
Aetna·Infectious Disease, Internal Medicine, Family Medicine +3 more·Medical Policy
Effective date
Nov 26, 2025
We identified it
Aug 18, 2026
Summary
Aetna has updated its HIV Testing Medical Clinical Policy Bulletin (CPB 0542) effective 2025-11-26, establishing coverage criteria for HIV screening and diagnostic testing using FDA-approved algorithms including antigen/antibody combination immunoassays, HIV-1/HIV-2 differentiation tests, and nucleic acid tests (NAT). The policy explicitly excludes coverage for home HIV test kits that do not require a physician's prescription. Billing teams must ensure claims are submitted only for physician-prescribed tests using the specified covered codes and testing algorithms.
Action Required
By 2025-11-26, the billing team must: (1) Verify that billing system is configured to cover ONLY the listed CPT codes (86689, 86701, 86702, 86703, 87389, 87390, 87391, 87534, 87535, 87536, 87806), HCPCS codes (G0432, G0433, G0435, G0475, S3645), and corresponding ICD-10 codes (B20, Z11.4, Z20.6, Z20.828, Z21) when submitted with appropriate documentation; (2) Implement a hard-stop rule to REJECT claims for home HIV test kits (including any non-physician-prescribed tests) and deny reimbursement; (3) Update billing software logic to require that HIV testing claims include evidence that tests were physician-prescribed and follow the specified testing algorithm (initial antigen/antibody combo test, followed by HIV-1/HIV-2 differentiation if reactive, followed by NAT if indicated); (4) Communicate to providers that home HIV tests like Confide and Home Access HIV Test System are NOT covered under any Aetna plan; (5) Train front-desk and billing staff to flag any claims for non-prescribed HIV tests for denial. Failure to implement these controls will result in claim denials and potential recoupment of improperly paid claims.