Additional Preventive Services
This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.
Human Immunodeficiency Virus (HIV) is an infection caused by a retrovirus that affects the immune system. HIV infection causes acquired immune deficiency syndrome (AIDS), a disease which severely compromises an individual’s immune system. It is currently generally accepted that antiretroviral therapy (ART) has significantly reduced HIV-associated morbidity and mortality throughout the world and the United States, and has transformed HIV disease for many, into a chronic, manageable condition. There is also evidence that the use of ART is associated with a substantially decreased risk for transmission of the virus to uninfected persons.
Effective January 1, 2009, the Centers for Medicare & Medicaid Services (CMS) is allowed to add coverage of “additional preventive services” through the national coverage determination (NCD) process if certain statutory requirements are met, as provided in 42 C.F.R. §410.64 (CMS began covering HIV screening effective December 8, 2009). One of those requirements is that the service(s) be categorized as a Grade A (strongly recommends) or Grade B (recommends) rating by the United States Preventive Services Task Force (USPSTF). The USPSTF gives a Grade A recommendation to screening for HIV in:
Indications and Limitations of Coverage
- All adolescents and adults between the ages of 15 to 65 years,
- Younger adolescents and older adults who are at increased risk of HIV infection, and,
- All pregnant women.
B. Nationally Covered Indications
Effective for claims with dates of service on and after April 13, 2015, CMS has determined that the evidence is adequate to conclude that screening for HIV infection for all individuals between the ages of 15 and 65 years, as recommended with a Grade of A by the USPSTF, is reasonable and necessary for early detection of HIV and is appropriate for individuals entitled to benefits under Part A or enrolled under Part B.
CMS shall cover screening for HIV with the appropriate U.S. Food and Drug Administration (FDA)-approved laboratory tests and point-of-care tests, used consistent with FDA-approved labeling and in compliance with the Clinical Laboratory Improvement Act (CLIA) regulations, when ordered by the beneficiary’s physician or practitioner within the context of a healthcare setting and performed by an eligible Medicare provider for these services, for beneficiaries who meet one of the following conditions:
1. Except for pregnant Medicare beneficiaries addressed below, a maximum of one, annual, voluntary screening for all adolescents and adults between the age of 15 and 65, without regard to perceived risk.
2. Except for pregnant Medicare beneficiaries addressed below, a maximum of one, annual, voluntary screening for adolescents younger than 15 and adults older than 65 who are at increased risk for HIV infection. Increased risk for HIV infection is defined as follows:
Men who have sex with men,
Men and women having unprotected vaginal or anal intercourse,
- Past or present injection drug users,
- Men and women who exchange sex for money or drugs, or have sex partners who do,
- Individuals whose past or present sex partners were HIV-infected, bisexual, or injection drug users,
- Persons who have acquired or request testing for other sexually transmitted infectious diseases,
- Persons with a history of blood transfusions between 1978 and 1985,
- Persons who request an HIV test despite reporting no individual risk factors,
Persons with new sexual partners,
- Persons who, based on individualized physician interview and examination, are deemed to be at increased risk for HIV infection. The determination of “increased risk” for HIV infection is identified by the health care practitioner who assesses the patient’s history, which is part of any complete medical history, typically part of an annual wellness visit and considered in the development of a comprehensive prevention plan. The medical recommendation should be a reflection of the service provided.
3. A maximum of three, voluntary, HIV screenings of pregnant Medicare beneficiaries: (1) when the diagnosis of pregnancy is known, (2) during the third trimester, and, (3) at labor, if ordered by the woman’s clinician.
C. Nationally Non-Covered Indications
Effective for claims with dates of service on and after April 13, 2015:
-Medicare beneficiaries with any known diagnosis of an HIV-related illness are not eligible for this screening test.
-Medicare beneficiaries between the ages of 15 and 65 who have had a prior HIV screening test within 1 year are not eligible for HIV screening (i.e., at least 11 full months must have elapsed following the month in which the previous test was performed in order for the subsequent test to be covered).
-Medicare beneficiaries younger than 15 or older than 65, at increased risk for HIV-related illnesses, who have had a prior HIV screening test within 1 year are not eligible for HIV screening (i.e., at least 11 full months must have elapsed following the month in which the previous test was performed in order for the subsequent test to be covered).
-Pregnant Medicare beneficiaries who have had three specified screening tests within each respective term of pregnancy are not eligible for further HIV screening during their pregnancy.
(This NCD last reviewed April 2015.)
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