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December 2016 Texas Medicaid Provider Procedures Manual

Radiology and Laboratory Services Handbook : 2 Independent Laboratory : 2.2 Services, Benefits, Limitations, and Prior Authorization : 2.2.12 Human Immunodeficiency Virus (HIV) Drug Resistance Testing

Standard treatment regimens for HIV therapy require a combination of three or more drugs. Standard therapy continues if a reduction in viral load is achieved. Incomplete virus suppression favors the development of a drug resistance and jeopardizes the success of future therapy. Testing for drug resistance as a prerequisite to further therapy is indicated under such circumstances.
To ensure accurate testing results, the client must be on appropriate antiretroviral therapy at the time of testing or have discontinued the drug regimen within the past four weeks.
Testing for antiretroviral drug resistance is indicated in certain clinical situations. These indications include any of the following:
Individuals who have an initial (new onset) acute HIV infection, to determine if a drug-resistant viral strain was transmitted and to plan a drug regimen accordingly.
Documentation must be maintained in the client’s medical record to support medical necessity for the HIV drug-resistance testing. Specific documentation requirements are dependent on the rationale for the testing. Documentation must include, but is not limited to, the date the drug regimen was initiated, the dosage and frequency of the prescribed medication, and laboratory tests that support all of the following:
HIV drug-resistance testing is not recommended when one of the following criteria is met:
Refer to:
Subsection C.1.1, “Routine HIV Testing Procedure Codes” in Appendix C, “HIV/AIDS” (Vol. 1, General Information) for additional information about HIV testing laboratory procedures.

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