CurrentAetnaPolicy 0433

Chlamydia Trachomatis - Screening and Diagnosis

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.

Policy Summary

PayerAetna

PolicyChlamydia Trachomatis - Screening and Diagnosis

Policy CodePolicy 0433

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument indication consistent with medical necessity (pregnancy status and trimester, age and sexual activity, risk factors, symptoms, or testing prior to uterine instrumentation).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Mpeople affected (est)

First trimesterrecommended: pregnant

≤24 yrsrecommended: young women

5.1%median positivity (men)

08/22/2023last review

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:

Screening recommendations: Screening is medically necessary per USPSTF/CDC/NICE recommendations for: (1) All pregnant women in the first trimester; and (2) All sexually active women aged 24 years and younger; and (3) Women 25 years and older with any of the following risk factors: prior C. trachomatis or other STI; new or multiple sexual partners; inconsistent or incorrect condom use; or prior to uterine instrumentation for assessment/treatment of infertility.

From policy medical necessity section.

Diagnostic testing is medically necessary for members with signs or symptoms of C. trachomatis infection.

Symptomatic individuals.

Re-testing in pregnancy: Re-testing is medically necessary in pregnant women who tested positive in the first trimester.

Policy Summary

PayerAetna

PolicyChlamydia Trachomatis - Screening and Diagnosis

Policy CodePolicy 0433

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument indication consistent with medical necessity (pregnancy status and trimester, age and sexual activity, risk factors, symptoms, or testing prior to uterine instrumentation).

SourceLink

On This Page

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Medically necessary diagnostic methods

Covered when performed for screening or diagnosis of C. trachomatis infection using the listed methods

Medically necessary diagnostic methods: Cell culture; Enzyme immunoassay (EIA); Direct fluorescent antibody (DFA); DNA hybridization (DNA probe); and DNA amplified hybridization (nucleic acid amplification) methods including ligase chain reaction (LCR), polymerase chain reaction (PCR), self-sustaining sequence replication (SSR), and strand displacement amplification (SDA).

Listed in appendix as medically necessary diagnostic methods.

Coding — CPT, HCPCS, and ICD-10

Covered CPT/HCPCS Codes (if selection criteria are met)CPTCovered

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.

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Covered ICD-10 Codes (if selection criteria are met)ICD-10Covered

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.

Medically necessary tests (no billing codes listed)mixed

No codes listed

Tests considered medically necessary (no codes listed)mixed

No codes listed

Provider Actions, Documentation, and Billing Guidance

Denial Risk

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).

Note

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.

Billing Rule

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).

Documentation Required

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

High-risk sexual behavior / risk factors

Prior STI historyHaving had C. trachomatis or other sexually transmitted diseases in the past.

New or multiple partnersNew or multiple sexual partners.

Inconsistent condom useNot using condoms consistently or correctly.

Uterine instrumentationPrior to undergoing uterine instrumentation for assessment and treatment of infertility.

Pregnancy (re-testing context)Pregnant women who tested positive in the first trimester should be re-tested (guidance supports re-testing in ~3–6 months, preferably in third trimester).

NAAT — definition and examples of nucleic acid amplification tests

DefinitionNucleic acid amplification tests (NAATs) used for detection of Chlamydia trachomatis with high sensitivity and specificity; applicable to urine and genital specimens.

Examples (document)PCR, LCR, TMA, NASBA and other DNA amplified hybridization techniques.

Specimen typesCan be performed on urine specimens and lower genital tract samples (per policy background).

Nucleic acid amplification (NAAT) — included methods

Included methodsLigase chain reaction (LCR).

Included methodsPolymerase chain reaction (PCR).

Included methodsSelf-sustaining sequence replication (SSR).

Included methodsStrand displacement amplification (SDA).

Nucleic acid amplification (DNA amplified hybridization) — included methods

Included methodsLigase chain reaction (LCR).

Included methodsPolymerase chain reaction (PCR).

Included methodsSelf-sustaining sequence replication (SSR).

Included methodsStrand displacement amplification (SDA).