Herpes Simplex Virus - Screening and Diagnosis — CPB 0433 | AETNA Coverage Update

Aetna modified CPB 0433 for herpes simplex virus (HSV) screening and diagnosis, effective September 26, 2025. Here's what billing teams need to do.

Aetna, a CVS Health company, updated CPB 0433 — its HSV screening and diagnosis coverage policy — to redirect active-lesion diagnosis to CPB 0650 (Polymerase Chain Reaction Testing). The change affects CPT codes 86694, 86695, 86696, 87273, 87274, 87483, 87528, 87529, and 87530. If your team bills HSV testing for Aetna members, this policy split matters for how you document and route claims in 2025.

Quick-Reference Table

Aetna HSV Screening and Diagnosis Coverage Criteria and Medical Necessity Requirements 2025

The core change in CPB 0433 is a scope narrowing. Aetna now routes diagnosis of HSV infection in patients with active lesions or symptoms to a separate policy — CPB 0650, which governs qualitative PCR testing.

What stays under CPB 0433 is serologic testing and antigen detection. That means CPT 86694 (non-specific HSV antibody), 86695 (HSV type 1 antibody), 86696 (HSV type 2 antibody), 87273 (HSV type 2 antigen detection by immunofluorescence), and 87274 (HSV type 1 antigen detection by immunofluorescence) all remain under this coverage policy.

Nucleic acid detection codes 87528, 87529, and 87530 are also listed under CPB 0433, but the split is important: symptomatic, active-lesion diagnosis using PCR now lives under CPB 0650. If you bill 87529 (amplified probe technique) for a patient with active symptoms, Aetna will evaluate that claim under CPB 0650 criteria — not CPB 0433. Using the wrong policy as your reference for medical necessity documentation is a fast path to claim denial.

CPT 87530 — quantitative HSV detection — is explicitly not covered for the indications listed in CPB 0433. That's a hard exclusion. Document carefully if you're billing this code for any reason, and verify whether a different indication might qualify under CPB 0650.

CPT 87483, the central nervous system pathogen panel, is covered when selection criteria are met. This code covers a broad panel and is typically used in encephalitis workups — relevant given the ICD-10 codes in the G04.x range (encephalitis, myelitis, and encephalomyelitis) that Aetna ties to this policy.

Prior authorization requirements aren't explicitly detailed in this policy update, but HSV testing on complex panels like 87483 routinely triggers utilization review. Check your Aetna plan-level requirements before billing, especially for immunocompromised patients coded under D84.81, D84.822, or D84.89.

Aetna HSV Testing Exclusions and Non-Covered Indications

One code is explicitly excluded under CPB 0433: CPT 87530, infectious agent detection by nucleic acid, HSV quantification. Aetna lists this under "CPT codes not covered for indications listed in the CPB." That's unambiguous.

Quantitative HSV PCR (87530) has legitimate clinical uses — monitoring viral load in immunocompromised patients, for example — but Aetna's position in CPB 0433 is that this code doesn't meet medical necessity for the indications this policy governs. If your providers order 87530 routinely as part of an HSV workup, flag that for your medical director now. Billing it without a covered indication is a denial waiting to happen.

The real issue here is that active-lesion diagnosis is no longer a CPB 0433 question at all. That scope moved to CPB 0650. Any PCR testing ordered because a patient presents with active symptoms — not screening, not serologic confirmation — needs to clear the criteria in CPB 0650. Your billing team should pull that policy and read it alongside this one.

Coverage Indications at a Glance

Aetna HSV Billing Guidelines and Action Items 2025

The effective date is September 26, 2025. If your team hasn't adjusted workflows yet, do it now.

CPT, HCPCS, and ICD-10 Codes for HSV Screening and Diagnosis Under CPB 0433

Covered CPT Codes (When Selection Criteria Are Met)

Not Covered CPT Codes

Key ICD-10-CM Diagnosis Codes

The full policy covers 284 ICD-10-CM codes. The primary diagnostic categories are listed below. Your coding team should reference the full CPB 0433 policy for the complete code set.

The G04.x cluster is particularly relevant for CPT 87483 billing. Encephalitis workups in patients with suspected HSV CNS involvement are the primary clinical scenario where this panel code comes into play — and reimbursement depends on tightly matching the ICD-10 code to the documented clinical picture.