Chlamydia Trachomatis - Screening and Diagnosis
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Clinical policy bulletin defining medical necessity, recommended screening groups, and diagnostic testing for Chlamydia trachomatis; applies to Aetna members and providers performing screening and diagnostic testing.
No material clinical or coverage changes in this revision.
Coverage Criteria for Chlamydia trachomatis Screening and Diagnosis
Medically Necessary Indications
Aetna considers the following indications as medically necessary for screening and diagnosis of C. trachomatis:
From policy medical necessity section.
Symptomatic individuals.
Policy recommends re-testing in pregnancy (timing per clinical guidance).
Experimental and Investigational
Tests and uses considered experimental and investigational (not covered):
Listed as experimental/investigational in the policy because effectiveness has not been established.
Medically necessary diagnostic methods
Covered when performed for screening or diagnosis of C. trachomatis infection using the listed methods
Listed in appendix as medically necessary diagnostic methods.
Medically necessary tests
The following tests are considered medically necessary for screening or diagnosis of C. trachomatis infection:
No additional clinical eligibility criteria provided in this appendix list.
Aetna considers screening of asymptomatic men for Chlamydia trachomatis to be experimental and investigational. As stated in the policy, CPT/HCPCS codes for chlamydia testing are not covered for screening of asymptomatic men unless the member meets the policy's specified selection criteria for medically necessary testing.
Systematic reviews summarized by Kelly and colleagues (2017) found that commercially available antigen-detection point-of-care tests (POCTs) for C. trachomatis have low pooled sensitivities (for antigen tests: ~53% for cervical swabs, 37% for vaginal swabs, and 63% for male urine in one review; 22.7%–37.7% in another), despite high specificities. The authors concluded that antigen-detection POCTs "lacked sufficient sensitivity to be recommended as a screening test," although near-patient NAATs showed acceptable performance but have operational constraints.
There are no additional explicit exclusions listed in the appendix section of the policy beyond those already stated under Experimental and Investigational; the appendix instead lists tests considered medically necessary for screening or diagnosis.
Examples of testing and uses that are considered not covered / experimental and investigational include: antigen-detection point-of-care tests for screening asymptomatic persons; home testing for C. trachomatis; and routine screening of asymptomatic men (CPT/HCPCS codes are not covered for that use). These examples are explicitly listed in the policy's Experimental and Investigational section.
Within the excerpt provided there are no statements labeled ‘not medically necessary’; the policy uses an Experimental and Investigational designation for the items described rather than a formal not medically necessary statement in this section.
Coding — CPT, HCPCS, and ICD-10
| 0353U | Infectious agent detection by nucleic acid (DNA), Chlamydia trachomatis and Neisseria gonorrhoeae, multiplex amplified probe technique, urine, vaginal, pharyngeal, or rectal, each pathogen reported as detected or not detected. |
| 86631 | Antibody; Chlamydia. |
| 86632 | Chlamydia, IgM. |
| 87110 | Culture, Chlamydia, any source. |
| 87270 | Infectious agent antigen detection by immunofluorescent technique; Chlamydia trachomatis. |
| 87320 | Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; Chlamydia trachomatis. |
| 87490 | Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique. |
| 87491 | Chlamydia trachomatis, amplified probe technique. |
| 87492 | Chlamydia trachomatis, quantification. |
| 87798 | Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism. |
| N97.0-N97.9 | Female infertility. |
| Z11.3 | Encounter for screening for infections with a predominantly sexual mode of transmission. |
| Z11.8 | Encounter for screening for other infectious and parasitic diseases [chlamydia]. |
| Z22.4 | Carrier of infections with a predominantly sexual mode of transmission. |
| Z31.41 | Encounter for fertility testing. |
| Z72.51-Z72.53 | High-risk sexual behavior. |
| No codes listed |
| No codes listed |
Provider Actions, Documentation, and Billing Guidance
Coverage limitation for asymptomatic men
CPT/HCPCS codes are covered only when the policy's selection criteria are met. Testing billed for screening of asymptomatic men is not covered.
- Affected codes: see CPT/HCPCS code list in policy (Chunk 5).
No provider action specified here
No additional provider actions (such as prior authorization or step therapy) are specified in this portion of the policy; follow the main policy text or payer portal for any administrative requirements.
Use listed medically necessary tests
Use only the medically necessary tests listed in the Appendix when submitting claims for screening or diagnostic evaluation. Use of tests not listed (for example, unlisted methods or point-of-care antigen tests for screening asymptomatic persons) may result in claim denial if billed as the primary diagnostic/screening method.
- Medically necessary tests: Cell culture; Enzyme immunoassay (EIA); Direct fluorescent antibody (DFA); DNA hybridization (DNA probe); Nucleic acid amplification tests (LCR, PCR, SSR, SDA).
- Do not rely on antigen point-of-care tests for screening asymptomatic persons (considered experimental/investigational).
Required documentation to support medical necessity and test method
Document clinical indication and supporting test method on the medical record and claim. Required documentation should demonstrate that testing meets one of the policy's medically necessary indications (e.g., pregnancy status/trimester, age, sexual activity, risk factors, signs or symptoms, or positive first‑trimester result in pregnancy) and identify which medically necessary test listed in the Appendix was used.
- Documentation must support one of the listed indications (pregnant and trimester, sexually active age ≤24, women ≥25 with risk factors, symptomatic members, or re‑testing in pregnancy).
- Claims should indicate the specific test performed (eg, NAAT/PCR, EIA, culture) to align with Appendix-listed methods.
Background and Epidemiology
Chlamydia trachomatis is the most commonly reported sexually transmitted infection in the United States. Most infections are asymptomatic but can lead to complications including pelvic inflammatory disease, tubal infertility, ectopic pregnancy, and neonatal infection. Screening is recommended for all pregnant women in the first trimester, sexually active women aged 24 years and younger, and women 25 years and older with risk factors (prior STI, new or multiple partners, inconsistent condom use, or prior to uterine instrumentation). Nucleic acid amplification tests (NAATs) such as LCR, PCR, SSR, and SDA are listed in the appendix as medically necessary diagnostic methods due to their high sensitivity and specificity.
Definitions and Key Terms
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