CommercialCoverageHigh impact
HIV Drug Susceptibility and Resistance Tests (CPB 0316, reviewed 2026-05-21)
Aetna·Infectious Disease, Internal Medicine, Pharmacy·Pharmacy
Effective date
May 21, 2026
We identified it
Aug 19, 2026
Summary
Aetna's updated HIV Drug Susceptibility and Resistance Tests policy (CPB 0316, effective 2026-05-21) clarifies coverage criteria for phenotypic and genotypic resistance testing. Key changes: simultaneous phenotypic AND genotypic testing is NOT covered (considered duplicative), but alternate testing may be approved on exception basis for virologic failure; tropism testing (Trofile/V3-loop) is covered only before CCR5 antagonist initiation; testing is NOT covered for patients with viral loads <1,000 copies/ml, those who discontinued antiretrovirals, or for unapproved indications. CPT code 0219U is explicitly NOT covered.
Action Required
Immediately (effective 2026-05-21): Billing team must update billing system to implement the following coverage restrictions for Aetna claims: (1) DENY claims billing both phenotypic AND genotypic resistance tests simultaneously (CPT 87903/87904 AND 87901/87906 together) as duplicative; (2) DENY CPT 0219U (0219U Infectious agent targeted viral next-generation sequence analysis) for all indications; (3) DENY all resistance testing (CPT 87900, 87901, 87903, 87904, 87906) when viral load is documented as <1,000 HIV RNA copies/ml; (4) DENY resistance testing for patients who have discontinued antiretroviral therapy; (5) REQUIRE prior authorization for alternate resistance assay testing (phenotypic if genotypic was done, or vice versa) only when documented virologic failure exists despite prior testing showing no resistance; (6) ALLOW tropism testing (CPT 87900, 87901, 87906) ONLY with documentation that patient is being evaluated for CCR5 antagonist (e.g., maraviroc) initiation; (7) DENY tropism testing if performed during or after CCR5 antagonist therapy. Update claim scrubbing rules in billing software to auto-deny non-compliant claims. Providers must document viral load level, treatment history, and clinical indication on all resistance/tropism test orders. Add billing compliance checklist to laboratory requisition forms. Claims submitted without proper documentation will be denied.