Hi all, I was looking into Apretude as an option for one of my patients who has Medicare. However it looks like Medicare won't cover HIV PCR for the appropriate diagnoses for PrEP and will only cover it for HIV infection. Has anyone else run into this or have suggestions?
Will your Ryan White funding cover it?
They do cover HIV qual (vs HIV quant)! You just have to code it with Z20.6. Hope this helps!
Hi Benjamin! I posted this in the long-acting agents forum as well, but maybe others will see it here and possibly have success too!
I find this to be one of the most frustrating things! However, I had success in getting a prior auth for 7 HIV PCR tests for the first year for one patient. Apretude was already approved, so then I worked on the PA for CPT codes 87535 (qualitative) and 87536 (quantitative). I had to call a handful of times to explain why it was an issue and that the patient does not have HIV. They were wanting to use an Ab/Ag test, so I explained why that was not an appropriate option. I also explained that we need more than the typical Medicare approved frequency of once a year. After some back and forth they approved those two CPT codes for 7 times in a 12 month period! Unfortunately, that is my only person on Medicare that wanted Apretude so far so I don't have any other experience.
Hopefully this helps!