Tuberculosis Testing — CPB 0471 | AETNA Coverage Update

Aetna modified CPB 0471 for tuberculosis testing, effective December 18, 2025. Here's what billing teams need to know about updated coverage criteria, newly addressed testing methods, and the codes that trigger claims scrutiny.

Aetna, a CVS Health company, updated Clinical Policy Bulletin 0471 to address tuberculosis (TB) testing coverage across multiple test types — from the classic Mantoux skin test (CPT 86580) to interferon-gamma release assays (IGRAs) like the QuantiFERON-TB Gold (CPT 86480, 86481) and the T-SPOT TB test, plus newer biomarker-based technologies. The CPB 0471 Aetna system covers a wide range of testing scenarios, and understanding which test is covered under which patient population is the difference between clean claims and denied ones.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Tuberculosis Testing — CPB 0471
Policy Code	CPB 0471
Change Type	Modified
Effective Date	December 18, 2025
Impact Level	Medium
Specialties Affected	Infectious disease, pulmonology, primary care, occupational health, rheumatology, transplant medicine
Key Action	Audit charge capture for CPT 86480, 86481, 86580, and 0574U to confirm patient-level eligibility criteria are documented before billing

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Aetna Tuberculosis Testing Coverage Criteria and Medical Necessity Requirements 2025

The core structure of this coverage policy hasn't been reinvented — Aetna still follows CDC and Advisory Council for the Elimination of Tuberculosis (ACET) guidelines. But the policy now addresses a broader set of testing modalities, and the medical necessity criteria differ by test type. Getting those distinctions wrong drives claim denial.

Mantoux Tuberculin Skin Test (CPT 86580)

Aetna considers the Mantoux intradermal skin test a medically necessary preventive service when the patient falls into one of the ACET-defined risk categories. Those categories include:

That last category — the medical risk factors list — is long and clinically specific. Your documentation needs to call out the specific condition. "Immunocompromised" alone won't carry the claim. Name the condition and map it to the ICD-10.

QuantiFERON-TB Gold (CPT 86480) — In Place Of, Not In Addition To

This is the rule that catches billing teams off guard. Aetna covers the QuantiFERON-TB Gold test (QFT-G) as a medically necessary alternative to the Mantoux skin test — but only as a replacement, not as a supplement. You can bill one or the other for a given encounter. Bill both, and the second one gets denied.

The QFT-G applies in the same circumstances as the Mantoux: contact investigations, evaluation of recent immigrants with BCG vaccination history, and serial testing programs for health-care workers and others in ongoing surveillance.

QuantiFERON-TB (QFT) and T-SPOT TB Test (CPT 86480, 86481) for LTBI Screening

For latent TB infection (LTBI) screening specifically, Aetna covers the QFT or T-SPOT TB test (CPT 86481) when used for:

#	Covered Indication Copy
1	Initial and serial testing of persons with increased LTBI risk — injection-drug users, recent immigrants, residents and employees of prisons and jails
2	Initial and serial testing of persons at low current risk but with anticipated future high-risk exposure — health-care workers and military personnel
3	Testing of persons who are contacts of confirmed TB cases or who work or reside in settings where TB transmission has occurred

The IGRA tests have real clinical advantages for BCG-vaccinated patients. Aetna's policy acknowledges that. But "advantage" doesn't equal "additional covered service" when you've already billed the skin test for the same episode.

TNF-Alpha Inhibitor Patients — A High-Risk Billing Scenario

Patients on infliximab (J1745 and biosimilars Q5103, Q5104, Q5109), adalimumab (J0139 and biosimilars Q5140–Q5145), or etanercept (J1438) require TB screening before starting therapy. This is well-established clinically. The billing implication: make sure your TB test claim is clearly linked to the pre-biologic workup in your documentation. If a prior authorization is required for the biologic, the TB test should be part of that pre-auth record. Check plan-level requirements on prior authorization — this varies by employer group and product.

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Aetna Tuberculosis Testing Exclusions and Non-Covered Indications

The policy flags certain newer or less-established testing approaches as experimental, investigational, or unproven. Billing these without strong documentation support will result in denial.

Biomarker-Based Non-Sputum Tests and Electronic Nose Breath Analysis

CPT 0574U — a proprietary code for a CFP-10 serum or plasma assay — and whole-genome sequencing codes 81425, 81426, and 81427 fall into the biomarker-based non-sputum test category. Aetna does not consider these medically necessary for TB testing under current evidence. Don't bill these expecting routine reimbursement. If a physician orders one of these tests, document the clinical rationale carefully and check whether the plan has any exception pathway before submitting.

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Coverage Indications at a Glance

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Aetna Tuberculosis Billing Guidelines and Action Items 2025

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Tuberculosis Testing Under CPB 0471

Covered CPT Codes (When Selection Criteria Are Met)

Not Covered / Experimental CPT Codes

Covered HCPCS Codes (TNF-Alpha Inhibitor Pre-Screening Context)

Key ICD-10-CM Diagnosis Codes

The full ICD-10-CM code list for CPB 0471 includes 853 codes. The table above reflects the primary diagnosis groupings most relevant to TB testing claims. Review the full policy at app.payerpolicy.org/p/aetna/0471 for the complete list.

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