Screening for the Human Immunodeficiency Virus (HIV) Infection: Posted final decision memo

Decision Summary

CMS has determined that the evidence is adequate to conclude that screening for HIV infection, which is recommended with a grade of A by the U.S. Preventive Services Task Force (USPSTF) for certain individuals, is reasonable and necessary for early detection of HIV and is appropriate for individuals entitled to benefits under Part A or enrolled under Part B.

Therefore CMS will cover both standard and U.S. Food and Drug Administration (FDA)-approved HIV rapid screening tests for:

1. Annual voluntary HIV screening of Medicare beneficiaries at increased risk for HIV infection per USPSTF guidelines:

• Men who have had sex with men after 1975;
• Men and women having unprotected sex with multiple [more than one] partners;
• Past or present injection drug users;
• Men and women who exchange sex for money or drugs, or have sex partners who do;
• Individuals whose past or present sex partners were HIV-infected, bisexual or injection drug users;
• Persons being treated for sexually transmitted diseases;
• Persons with a history of blood transfusion between 1978 and 1985;
• Persons who request an HIV test despite reporting no individual risk factors, since this group is likely to include individuals not willing to disclose high-risk behaviors; and

2. Voluntary HIV screening of pregnant Medicare beneficiaries when the diagnosis of pregnancy is known, during the third trimester, and at labor.

We are deleting the following reference to non-coverage of HIV screening from the coverage manual, Section 190.14: “However, in the absence of a documented AIDS defining or HIV-associated disease, an HIV-associated sign or symptom, or documented exposure to a known HIV-infected source, the testing is considered by Medicare to be screening and thus is not covered by Medicare (for example, history of multiple blood component transfusions, exposure to blood or body fluids not resulting in consideration of therapy, history of transplant, history of illicit drug use, multiple sexual partners, same-sex encounters, prostitution, or contact with prostitutes).”