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National Coverage Determination (NCD) for Human Immunodeficiency Virus (HIV) Testing (Prognosis Including Monitoring) (190.13)

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Benefit Category
Diagnostic Laboratory Tests

Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

HIV quantification is achieved through the use of a number of different assays which measure the amount of circulating viral RNA.  Assays vary both in methods used to detect viral RNA as well as in ability to detect viral levels at lower limits.  However, all employ some type of nucleic acid amplification technique to enhance sensitivity, and results are expressed as the HIV copy number. 

Quantification assays of HIV plasma RNA are used prognostically to assess relative risk for disease progression and predict time to death, as well as to assess efficacy of antiretroviral therapies over time.

HIV quantification is often performed together with CD4+ T cell counts which provide information on extent of HIV induced immune system damage already incurred.


Indications and Limitations of Coverage

Indications

  1. A plasma HIV RNA baseline level may be medically necessary in any patient with confirmed HIV infection.
  2. Regular periodic measurement of plasma HIV RNA levels may be medically necessary to determine risk for disease progression in an HIV-infected individual and to determine when to initiate or modify antiretroviral treatment regimens.
  3. In clinical situations where the risk of HIV infection is significant and initiation of therapy is anticipated, a baseline HIV quantification may be performed. These situations include:
    1. Persistence of borderline or equivocal serologic reactivity in an at-risk individual.
    2. Signs and symptoms of acute retroviral syndrome characterized by fever, malaise, lymphadenopathy and rash in an at-risk individual.

Limitations

  1. Viral quantification may be appropriate for prognostic use including baseline determination, periodic monitoring, and monitoring of response to therapy.  Use as a diagnostic test method is not indicated.
  2. Measurement of plasma HIV RNA levels should be performed at the time of establishment of an HIV infection diagnosis.  For an accurate baseline, 2 specimens in a 2-week period are appropriate.
  3. For prognosis including anti-retroviral therapy monitoring, regular, periodic measurements are appropriate.  The frequency of viral load testing should be consistent with the most current Centers for Disease Control and Prevention guidelines for use of anti-retroviral agents in adults and adolescents or pediatrics.
  4. Because differences in absolute HIV copy number are known to occur using different assays, plasma HIV RNA levels should be measured by the same analytical method. A change in assay method may necessitate re-establishment of a baseline.
  5. Nucleic acid quantification techniques are representative of rapidly emerging and evolving new technologies. As such, users are advised to remain current on FDA-approval status.

Note: Scroll down for links to the quarterly Covered Code Lists (including narrative).


Cross Reference

Also see the Medicare Claims Processing Manual, Chapter 120, Clinical Laboratory Services Based on Negotiated Rulemaking.


Transmittal Number

17

Revision History

07/2002 - Implemented NCD. Effective date 11/25/02. Implementation date 1/01/03. (TN AB-02-110) (CR 2130)

07/2004 - Published NCD in the NCD Manual without change to narrative contained in PM AB-02-110. Coding guidance now published in Medicare Lab NCD Manual. Effective and Implementation dates NA. (TN 17) (CR 2130)


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