Does Z11.4 require prior authorization?

No, Z11.4 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

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`Z11.4`, Encounter for screening for human immunodeficiency virus [HIV]

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Documentation Required

For pregnant women, documentation of HIV testing discussion/notification (opt-out process), test results, and any repeat testing performed in the third trimester when applicable.
For point-of-care/oral testing (e.g., Orasure/OraQuick), documentation of test type, specimen source (oral fluid vs. blood), test operator/site, and any necessary confirmatory testing and linkage-to-care steps following a reactive result.
For OraQuick POC testing: reactive point-of-care results should be confirmed by laboratory-based confirmatory testing (implied by statement that reactive tests need confirmation by more specific Western blot).

Serum or plasma specimens submitted for testing after a reactive (preliminary positive) result from any rapid HIV test (per Note: 'Laboratories should use this same testing algorithm, beginning with an antigen/antibody combination immunoassay, with serum or plasma specimens submitted for testing after a reactive (preliminary positive) result from any rapid HIV test').

Key Coverage Criteria

For screening persons for HIV infection, according to the recommendations of the U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention;
Initial testing for HIV with a DA-approved antigen/antibody combination immunoassay that detects HIV-1 and HIV-2 antibodies and HIV-1 p24 antigen to screen for established infection with HIV-1 or HIV-2 and for acute HIV-1 infection. No further testing is required for specimens that are nonreactive on the initial immunoassay.
Further testing of specimens with a reactive antigen/antibody combination immunoassay result (or repeatedly reactive, if repeat testing is recommended by the manufacturer or required by regulatory authorities), if tested with an FDA-approved antibody immunoassay that differentiates HIV-1 antibodies from HIV-2 antibodies. [...]
Testing of specimens that are reactive on the initial antigen/antibody combination immunoassay and nonreactive or indeterminate on the HIV-1/HIV-2 antibody differentiation immunoassay when tested with an FDA-approved HIV-1 nucleic acid test (NAT) according to the following criteria: - A reactive HIV-1 NAT result and nonreactive HIV-1/HIV-2 antibody differentiation immunoassay result indicates laboratory evidence for acute HIV-1 infection; - A reactive HIV-1 NAT result and indeterminate HIV-1/HIV [...]
Note: Laboratories should use this same testing algorithm, beginning with an antigen/antibody combination immunoassay, with serum or plasma specimens submitted for testing after a reactive (preliminary positive) result from any rapid HIV test.
The Orasure oral HIV test kit (OraSure Technologies, Bethlehem, PA) for the same indications as standard HIV testing;

4 Active Policies

CIGNA-0530, Nucleic Acid Pathogen Testing

CIGNA-0398, Transvaginal Ultrasound, Non-Obstetrical

AETNA-CPB-0542, HIV Testing

AETNA-CPB-0650, Polymerase Chain Reaction Testing: Selected Indications

`Z11.4`, Encounter for screening for human immunodeficiency virus [HIV]

Prior Authorization

Documentation Required

Key Coverage Criteria

4 Active Policies

Related Codes

Have a follow-up question?

Z11.4, Encounter for screening for human immunodeficiency virus [HIV]

Prior Authorization

Documentation Required

Key Coverage Criteria

4 Active Policies

Related Codes

Have a follow-up question?

`Z11.4`, Encounter for screening for human immunodeficiency virus [HIV]