HIV Drug Susceptibility and Resistance Tests

Aetna covers HIV genotypic or phenotypic resistance testing to detect transmitted resistance in acute infection, to evaluate suboptimal suppression or virologic failure (i.e., rising plasma HIV RNA despite adequate ART after other causes excluded), and tropism testing (phenotypic or V3-loop genotypic) before using a CCR5 antagonist. Tests are not medically necessary when both assay types are performed simultaneously, for viral loads <1,000 copies/mL, after ART discontinuation (minor variants may be undetectable), or for indications not listed, although an alternate assay may be allowed by exception if virologic failure persists despite one negative test.

"During acute (new onset) HIV infection to determine if a drug-resistant viral strain was transmitted and plan regimen accordingly;"

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