CurrentAetnaPolicy 0650

Polymerase Chain Reaction (PCR) Testing: Selected Indications

Clinical policy governing medical necessity, covered indications, and experimental/investigational determinations for qualitative, multiplex, and quantitative PCR tests for Aetna members.

Policy Summary

PayerAetna

PolicyPolymerase Chain Reaction (PCR) Testing: Selected Indications

Policy CodePolicy 0650

Change TypeNo material change

Effective DateSep 24, 2002

Next Review DateJul 11, 2024

Key ActionOrder multiplex and quantitative PCR tests only when documented clinical selection criteria are met and appropriate ICD-10 codes are submitted.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+individual qualitative PCR indications listed

Multiplequalitative multiplex PCR panels with specified criteria

Manylisted qualitative PCR tests considered experimental

15+quantitative PCR tests listed as experimental

Coverage Criteria

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Qualitative PCR: selected individual indications (partial list)

Aetna considers the following qualitative PCR tests medically necessary (not an all‑inclusive list):

examples: Includes but not limited to: Acanthamoeba (corneal ulceration); Actinomyces species identification in tissue; Adenovirus (diagnosis of myocarditis and infection in immunocompromised hosts); Anaplastic lymphoma kinase (ALK) testing as an alternative to FISH for selecting individuals for ALK inhibitor therapy; Avian influenza A (H5N1) in symptomatic persons with relevant travel/contact history; Babesiosis (Babesia spp.) diagnosis; Bacterial vaginosis pathogens (Gardnerella vaginalis, Atopobium vaginae, Mobiluncus spp., Megasphaera spp.) for diagnosis in symptomatic vaginitis.

See full policy list for additional qualitative PCR indications.

Qualitative multiple PCR (multiplex) panels — coverage criteria

Multiplex PCR panels are covered when the documented clinical selection criteria below are met:

CSF pathogen panel (e.g., FilmArray ME): Member has clinical findings consistent with CNS infection (eg, meningitis or encephalitis) AND a viral etiology is suspected OR CSF culture is inconclusive.

Use alongside standard CSF and blood cultures; PCR does not provide susceptibility data.

COVID-19 respiratory panel (up to 5 targets): Member has signs and symptoms consistent with COVID-19 AND the test result will be used to guide therapy.

Applies to panels up to 5 respiratory pathogens when selection criteria met.

Gastrointestinal pathogen panel: Covered when ANY of: community-acquired diarrhea ≥7 days; travel-related diarrhea; or diarrhea with signs/risk factors for severe disease (eg, fever, bloody diarrhea, dehydration, hospitalization, immunocompromised state). Panels up to 11 targets for immunocompetent meeting criteria; >11 targets for critically ill or immunocompromised persons.

Map to CPT codes 87505/87506/87507/0369U as applicable and include ICD-10 linkage (eg, R19.7).

Respiratory virus/bacteria panel: Member has signs/symptoms of respiratory infection AND is immunocompromised or high-risk (eg, receiving cancer therapy, transplant recipient) AND the test will be used to guide therapy.

Respiratory panel CPT/HCPCS map to panel size (eg, 87631/87632/87633, 0202U/0223U/0225U).

Sepsis pathogen panel (eg, BCID panels): Member has signs/symptoms consistent with sepsis AND molecular testing is performed directly on a positive culture obtained from body fluid (eg, blood) AND the test will be used to guide therapy.

Use only on positive culture material per policy.

Quantitative PCR testing — covered indications (examples)

Aetna considers the following quantitative PCR tests medically necessary for diagnosis, monitoring disease progression, or to assess response to therapy:

AML fusion transcripts: Quantitative RT‑PCR assays for AML-associated fusion transcripts (eg, AML1/ETO t(8;21), CBFβ/MYH11 inv(16), PML/RARA t(15;17)) for diagnosis and serial monitoring of minimal residual disease and treatment response.

PML/RARA RT‑PCR is diagnostic for APL.

Leukemia/lymphoma rearrangements: Quantitative PCR for bcr/abl fusion (CML/ALL), bcl‑2 translocation in B‑cell lymphomas, mantle cell bcl‑1 (t(11;14)) and T‑cell receptor/IG gene rearrangements when used for monitoring disease or clarifying diagnosis.

Use per guideline‑based indications to guide therapy/monitoring.

Viral load monitoring: Quantitative viral load PCR for CMV, EBV (with screening schedules for high‑risk allogeneic stem cell transplant recipients), adenovirus, BK polyomavirus, hepatitis B, hepatitis C, and HIV RNA when used to monitor antiviral therapy or detect clinically significant replication.

EBV screening: begin day of transplant and at least weekly for first 3 months in high‑risk allogeneic recipients; BK viremia/viruria thresholds referenced in policy.

Experimental and Investigational — qualitative and quantitative PCR tests

Aetna considers the following PCR tests experimental and investigational (not medically necessary) because their clinical role or impact on patient management has not been established:

Qualitative tests considered experimental: Extensive list including—among others—Aspergillus commercial panels with unvalidated performance, human bocavirus, HHV‑7, HHV‑8, Creutzfeldt‑Jakob disease assays, many organism‑specific PCRs listed in policy (see detailed policy list).

See policy enumerated lists (chunks 16–19) for full items.

Quantitative tests considered experimental: Examples include quantitative PCR for Bartonella species, Candida species quantification, EoGenius 96‑gene qPCR array for eosinophilic esophagitis, Karius cfDNA NGS (microbial cfDNA) and other listed assays where evidence of clinical utility is insufficient.

See policy enumerated lists (chunks 18–20) for complete items.

Selected Indications (enumerated list)

Aetna provides an enumerated list of selected indications and agents; coverage depends on whether the indication is listed and applicable selection criteria are met.

Enumerated selected indications: Numerous specific indications are enumerated (examples include melanoma micrometastases, MTHFR testing in hyper‑homocysteinemia, Mycobacterium species, onychomycosis, parainfluenza, pneumocystis, stool H. pylori panels, UTI and wound infection panels, and many others listed in the policy).

Refer to the policy enumerated list items 50–101 and related entries for full detail.

Quantitative PCR tests considered experimental/investigational

Aetna considers the following quantitative PCR tests experimental/investigational (not medically necessary) because their role in clinical management has not been established:

Experimental quantitative PCR list: Includes but not limited to: Bartonella spp.; candidiasis species quantification; Chlamydia spp. quantitative assays for non‑established uses; EoGenius 96‑gene qPCR for eosinophilic esophagitis; hantavirus RT‑PCR as routine; hepatitis G virus; Karius microbial cfDNA NGS pending validation; Kawasaki disease RT‑qPCR (KawasakiDx); Legionella PCR for routine diagnosis; Lyme disease PCR; Mycobacterium species quantitative assays; Mycoplasma species; Neisseria gonorrhoeae quantification for non‑established uses; pharyngitis and community shotgun panels; uBiome commercial services.

See chunks 19–20 for complete enumerated items.

Coverage conditional on selection criteria

Coverage of many PCR tests is conditional on meeting the clinical selection criteria and submitting appropriate procedure and diagnosis code linkage:

Coverage conditional on selection criteria: Coverage applies to specific PCR CPT/HCPCS codes for panels or pathogen‑specific tests only when the documented ICD‑10 diagnosis corresponds to indications listed in the policy AND selection criteria are met.

Examples: CPT 87483 (CSF panel), respiratory panel U‑codes/8763x series, GI panel codes 87505/87506/87507/0369U, orthopoxvirus 87593 when selection criteria/ICD‑10 mapping met.

General coverage contingent on selection criteria

The policy states tests are covered when ALL of the following are met:

General coverage contingent on selection criteria: The listed CPT/HCPCS codes are covered only when the CPB selection criteria are satisfied AND the required ICD‑10 diagnosis codes are submitted with the claim (eg, R19.7 required for GI panel claims).

Providers must map the ordered CPT/HCPCS to the covered indications and ICD‑10 codes per the policy code tables.

Clinical use and investigational contexts

Contextual clinical-use statements and limitations where PCR may be recommended, adjunctive, or investigational:

AML fusion transcript monitoring: RT‑PCR quantitative assays (AML1/ETO, CBFβ/MYH11, PML/RARA) are useful for diagnosis, MRD monitoring, assessing treatment response, and predicting relapse; PML/RARA detection is diagnostic for APL.

Use in conjunction with clinical and cytogenetic data.

Adenovirus in transplant patients: Quantitative adenovirus PCR can detect viremia and rising viral loads that correlate with invasive disease in hematopoietic stem cell transplant recipients and can be used to monitor response to therapy.

Culture/antigen remain preferred in many settings; use per AAP guidance.

Aspergillus PCR adjunctive use: Aspergillus PCR assays show variable performance and are recommended as adjunctive tests to antigen assays and clinical data; reproducibility/validation issues limit routine use and two positive PCRs increase specificity.

Interpret results in clinical context; repeat testing may improve specificity.

Babesiosis PCR role: PCR has a limited role; microscopy of blood smears is primary diagnostic; PCR useful when morphology cannot distinguish Babesia from Plasmodium or in research/variant identification.

Follow CDC guidance for use.

BV molecular testing considerations: Molecular NAAT/PCR for bacterial vaginosis may have higher sensitivity in symptomatic women and can influence management when symptomatic; PCR/NAATs are not recommended for routine asymptomatic screening and require symptomatic indication.

Study‑derived G. vaginalis qPCR threshold ≥10^7 copies/mL associated with Nugent‑defined BV in some studies.

BV NAATs — Appropriate Use

Appropriate use of BV NAATs / molecular tests for bacterial vaginosis:

BV NAATs — symptomatic use: Molecular NAAT/PCR testing for BV is appropriate when the patient is symptomatic (eg, vaginal discharge, odor, itch) AND the result will affect management; BV NAATs are not well defined for asymptomatic screening.

Traditional methods (Amsel, Nugent, wet mount) remain useful initial tests; internal validation required for laboratory‑developed tests.

Clonality and bcl-2 PCR — Appropriate Use

Appropriate use of clonality and bcl-2 PCR testing in suspected lymphoproliferative disease:

Clonality/bcl-2 testing contexts: PCR‑based clonality assays (BIOMED‑2 IG/TCR) and bcl‑2 (t(14;18)) translocation testing are appropriate adjunctive tests when morphology and immunophenotyping/flow cytometry are inconclusive, to assist diagnosis, staging (eg, bone marrow involvement), or to reduce need for re‑biopsy in select cases.

Interpret results with morphologic and clinical correlation; results may be non‑diagnostic in polyclonal/reactive processes.

BK/JCV PCR — Appropriate Use

Appropriate use of BK and JC viral PCR testing:

BK/JCV testing contexts: Quantitative PCR testing for BK and JC viruses is appropriate in immunocompromised patients (eg, organ transplant recipients) to evaluate suspected active infection, allograft dysfunction, or neurologic disease (eg, PML) AND to guide antiviral therapy or immunosuppression adjustments.BK viremia >5,000 copies/mL (plasma) and BK viruria >10^7 copies/mL associated with BK nephropathy

Provide specimen type and clinical context (plasma vs urine); monitoring frequency guided by clinical protocol.

Selected clinical indications and considerations

Selected clinical indications and operational considerations where PCR testing is supported or should be used adjunctively:

Clonality testing for lymphoma: Determine B‑ or T‑cell clonality when lymphoid malignancy is suspected and morphology/flow cytometry are inconclusive; clonality PCR can reduce re‑biopsy rates in select CNS lymphoma cases.

Follow NCCN guidance; interpret with clinical and morphologic data.

BK/JC in transplant context: Quantitative BK and JC PCR in blood/urine support diagnosis of viral nephropathy or PML; thresholds correlate with disease risk and can prompt immunosuppression modulation.BK plasma >5,000 copies/mL; urine >10^7 copies/mL

Document transplant status and suspected graft dysfunction.

JC virus in natalizumab patients: For suspected PML in patients on natalizumab, document baseline MRI and consider CSF JC PCR; stop natalizumab when PML suspected per TOUCH program guidance.

Provide supporting neurologic and imaging documentation.

CSF multiplex panel use: Multiplex CSF panels (eg, FilmArray ME) provide rapid detection of multiple CNS pathogens but should be used alongside standard CSF and blood cultures because panels do not give susceptibility data and specificity issues have been reported.

Useful when prior antimicrobials may reduce culture yield; reported sensitivity/specificity high for panel.

Pathogen-specific PCR coverage statements

Pathogen‑specific PCR coverage statements — summaries of when PCR is appropriate, adjunctive, limited, or investigational by organism:

Neisseria gonorrhoeae: NAATs/PCR/TMA/LCR are recommended for urethral swabs (males), endocervical swabs (females), and first‑void urine when appropriate; PCR not recommended for vaginal, rectal, conjunctival, or pharyngeal swabs per CDC guidance.

Be aware of cross‑reactivity concerns with some assays; follow CDC specimen recommendations.

Haemophilus influenzae: Culture and serotyping of sterile site specimens remain standard; PCR may be adjunctive but is not the routine primary diagnostic method for invasive disease.

Use culture/antigen testing per guidelines.

Hantavirus: RT‑PCR can detect viral RNA early but is prone to cross‑contamination and is considered experimental for routine diagnosis; use with caution in specialized labs.

Refer to CDC containment lab guidance.

HBV/HCV: PCR (HBV DNA, HCV RNA) is useful to select candidates for antiviral therapy and to monitor response; quantitative assays provide therapy guidance or prognosis per guidelines.

Document clinical indication (diagnosis, monitoring, neonatal testing) when ordering.

HSV: Real‑time PCR is the preferred diagnostic method for genital herpes and is diagnostic for HSV CNS infection (CSF PCR); there is no role for serial blood PCR for monitoring therapy.

Follow AAP/CDC guidance for specimen selection.

HHV‑6/HHV‑7: Testing generally limited to immunocompromised patients or specific clinical scenarios (eg, febrile infants, mononucleosis‑like illness when EBV/CMV negative); exclude chromosomal integration for HHV‑6 by comparing serum/CSF and whole blood viral loads.

Chromosomal integration may confound interpretation; testing limited to reference labs.

Pathogen-specific coverage guidance

Additional pathogen‑ and condition‑level coverage guidance and limitations:

HHV‑6/HHV‑7/HHV‑8 guidance: HHV‑6 testing may be appropriate in immunocompromised patients or selected clinical contexts; HHV‑7 and HHV‑8 testing are limited to research/reference labs and generally will not alter management in immunocompetent hosts.

Exclude chromosomal integration for HHV‑6 when interpreting results.

HIV in infants: For infants up to 18 months, HIV nucleic acid detection by PCR of DNA from peripheral blood mononuclear cells is the preferred diagnostic test because maternal antibodies confound serology.

Document infant age and clinical indication when ordering.

Influenza (including H5N1): RT‑PCR of respiratory specimens offers high sensitivity/specificity; testing for H5N1 PCR indicated only for hospitalized patients with severe respiratory illness AND recent travel to an H5N1‑affected country within 10 days of symptom onset (or per public health consultation).

Coordinate with public health authorities for H5N1 testing.

Measles: Diagnosis may be established by measles IgM serology, rise in IgG in paired sera, or RT‑PCR detection of measles RNA from appropriate specimens; document specimen type and timing relative to symptom onset.

Follow CDC guidance for specimen choice and timing.

Kawasaki disease assay note: Kawasaki disease diagnosis is clinical; commercial RT‑qPCR assays (eg, KawasakiDx) exist but have limitations and unclear clinical utility and do not replace clinical diagnosis.

Positive respiratory viral PCR does not exclude Kawasaki disease.

Condition-level coverage assessments (selected indications)

Condition‑level assessments — statements on clinical utility or investigational status for selected conditions:

Joint effusion/synovial fluid PCR: UpToDate reviews do not cite PCR testing as a routine management tool for synovial fluid analysis or monoarthritis; PCR not established for routine use in this context.

Use conventional diagnostics per clinical context.

Leishmaniasis: PCR assays can distinguish Leishmania species and are increasingly available to aid management decisions, supplementing microscopy/culture when species identification is needed.

Specimen choice and species identification informs therapy.

Lyme disease: PCR has not been validated for routine diagnosis or monitoring of Lyme disease and is considered investigational/unsupported for routine clinical use due to low organism burden in accessible fluids and contamination risk.

Follow guideline‑based serologic testing algorithms.

Malaria: PCR may be slightly more sensitive than smear microscopy but is of limited utility in acute care because of turnaround time; PCR is most useful to confirm species after diagnosis by smear or rapid test.

Use smear/rapid test for acute management; PCR for species confirmation when needed.

MRSA detection: PCR detection of the mecA gene is an accurate method to identify MRSA and is supported for detection and infection control purposes.

Molecular methods are among the most accurate techniques for MRSA identification.

Agent-specific PCR utility and limitations

Agent‑specific utility and limitations — guidance to inform ordering, interpretation, and sample selection:

MALT lymphoma t(11;18): PCR detection of t(11;18) translocation is useful when atypical lymphoid infiltrates are non‑diagnostic and H. pylori is present; presence predicts lack of response to H. pylori eradication and guides alternative therapy selection.

NCCN referenced; provide clinical context when ordering.

Mycobacterium species PCR limitations: FDA‑licensed PCR for M. tuberculosis is limited to certain respiratory specimen types; sensitivity is decreased for gastric aspirate, CSF, and tissue — culture remains definitive.

Avoid overreliance on PCR for non‑validated specimen types.

Molluscum contagiosum: Diagnosis is usually clinical; PCR lacks reliable evidence for routine diagnosis/management and is therefore generally not indicated.

Wright/Giemsa staining of lesion core can demonstrate characteristic inclusions.

Orthopoxvirus/monkeypox testing: PCR testing should be performed on lesion swabs for suspected monkeypox; positive orthopoxvirus PCR constitutes a probable monkeypox case and confirmatory testing may include monkeypox‑specific PCR/NGS or culture. Avoid non‑lesion samples (blood, saliva) due to lack of supporting data and risk of false results.lesion swab sample

Testing available at LRN and select commercial labs; follow CDC/FDA specimen guidance.

Selected pathogen-specific PCR coverage guidance

Selected pathogen‑specific guidance emphasizing sample type, interpretation caveats, and investigational status:

Monkeypox/orthopoxvirus testing: Order PCR on lesion swab for suspected monkeypox; positive orthopoxvirus PCR is a probable case and monkeypox virus DNA by PCR/NGS or culture confirms disease. Do not use non‑lesion sample types for routine diagnosis due to false result risk.lesion swab specimen

Follow CDC case definitions and FDA guidance regarding specimen types.

Parvovirus B19 testing: In immunocompetent patients, serum IgM is preferred for acute infection; PCR/nucleic acid testing is useful for diagnosing chronic infection in immunocompromised patients but detection may persist for months and does not necessarily indicate acute infection.PCR interpretation requires clinical context

PCR positivity may reflect prolonged DNAemia up to 9 months.

Pneumococcal blood PCR: Blood PCR methods for invasive pneumococcal disease currently lack sufficient sensitivity and/or specificity for routine standalone clinical use; correlate with culture and clinical context.sensitivity approx 57–66%

Heterogeneous study results; interpret cautiously.

Pneumocystis jiroveci PCR: PCR assays for Pneumocystis jiroveci are considered experimental/unapproved by some guideline bodies and are not endorsed as standard diagnostic tests in this policy excerpt.investigational

Definitive diagnosis relies on demonstration in respiratory specimens (BAL, induced sputum).

cfDNA/NGS (Karius) testing: Microbial cfDNA NGS may detect pathogens when conventional methods are negative and shows preliminary concordance in small immunocompromised cohorts, but clinical utility requires further validation and results must be interpreted in clinical context.use with clinical correlation

Larger studies are needed to establish clinical utility.

Testing required solely to meet non-medical requirements (for example, clearance for work, school, or recreational activities) is excluded under standard benefit plans. Providers and facilities should verify benefit plan descriptions and not bill such testing as medically necessary clinical care.

Testing with the C. difficile toxin gene PCR (CPT 87493) is not covered when performed in asymptomatic persons or for a routine "test of cure". Repeat or surveillance testing outside stated diagnostic indications may be denied.

The policy lists examples of ICD-10 codes not covered for indications in this CPB (not exhaustive). Examples include certain bacterial intestinal infections, Lyme disease, Creutzfeldt-Jakob disease, selected fungal/mycotic diseases, and other codes shown in the CPB ICD-10 lists. Claims using these ICD-10 codes for CPB-listed PCR indications may not meet coverage criteria.

CPT code 87913 (SARS‑CoV‑2 genotype/mutation identification) is listed as not covered for the indications described in this clinical policy bulletin.

Specific named commercial consumer/self-directed assays (for example, EoGenius, uBiome SmartGut, SmartJane, SmartFlu, Explorer) and similar consumer/genetic-type panels are explicitly listed as not covered. These assays and related organism‑quantification codes are excluded when submitted for CPB-listed indications unless otherwise specified.

Multiple guideline bodies currently do not recommend routine PCR testing for bacterial vaginosis (BV). Molecular assays have been used in research and investigational settings and their clinical utility remains uncertain; PCR/NAATs for BV should be considered only when symptomatic and when results will influence management.

NAATs/quantitative PCRs for BV are appropriate for symptomatic women when results will guide therapy, but are not recommended for routine testing of asymptomatic women because accuracy and clinical-value thresholds are not well defined for screening populations.

PCR assays for candidiasis (Candida spp.) have not been validated for routine clinical use in many settings and are described in guidelines as largely research tools. Real‑time PCR for candidemia remains investigational pending further assay validation and demonstration of clinical benefit compared with standard methods (culture, microscopy, antigen tests).

Current evidence-based guidelines from NCCN and NCI indicate no role for PCR testing to detect metastases from cervical cancer; PCR is not supported for this purpose in the cited guidance.

Per cited NCCN/NCI sources, PCR does not have an established role for detection of metastases from cervical intraepithelial neoplasia or cervical cancer and is not recommended for that indication.

The American Academy of Pediatrics characterizes PCR tests for cryptococcus as investigational. Antigen detection in CSF or serum remains the recommended rapid diagnostic approach for cryptococcal disease.

Molecular diagnostic assays for Cyclospora are described as investigational and are primarily available at CDC and selected reference laboratories; stool microscopy and specialized staining remain standard diagnostic methods.

PCR-based species or genotype identification for Cryptosporidium in immunocompetent patients is unlikely to change clinical management and therefore is of limited clinical utility; such testing is generally not indicated for routine care.

Testing for Cyclospora and Donovanosis (Klebsiella granulomatis) by PCR or serology is described as investigational/research in the CPB and is mainly available through reference or public health laboratories rather than routine clinical labs.

Covered Indications

CSF pathogen panel

Covered CSF multiplex panel indication (example):

CSF pathogen panel for meningitis/encephalitis: Member has clinical findings consistent with CNS infection (eg, meningitis, encephalitis) AND viral etiology is suspected OR CSF culture is inconclusive.

CPT 87483 covered if selection criteria met; order alongside standard microbiologic testing.

Gastrointestinal pathogen panel

Covered gastrointestinal panel indications and coding guidance:

GI pathogen panel — indications: Covered when member has community‑acquired diarrhea ≥7 days OR travel‑related diarrhea OR diarrhea with signs/risk factors for severe disease (eg, fever, bloody diarrhea, dehydration, hospitalization, immunocompromised state).

CPT 87505 (3–5 targets) and 87506 (6–11 targets) covered if selection criteria met; >11 targets (eg, 0369U/87507) allowed for critically ill or immunocompromised persons; R19.7 required for claims.

Respiratory virus/bacteria panel

Covered respiratory panel indications (including SARS‑CoV‑2‑containing panels):

Multiplex respiratory pathogen panels: Member has signs/symptoms of respiratory infection AND is immunocompromised or high‑risk (eg, cancer therapy, transplant recipient) AND the test will be used to guide therapy.

Different CPT/HCPCS map to panel size (eg, 0240U/0241U for 3–4 targets; 0202U/0223U/0225U/87631/87632/87633 for larger panels); include appropriate ICD‑10 mapping per policy.

Sepsis pathogen panel

Covered sepsis panel use when specific criteria are met:

Sepsis pathogen panel: Member has signs and symptoms consistent with sepsis AND molecular testing is performed directly on a positive culture obtained from a body fluid (eg, blood) AND the test result will be used to guide therapy.

Examples include BioFire BCID and ePlex BCID panels; use only on culture‑positive material per policy.

Wide range of infectious and some genetic indications enumerated

Broad coverage note — multiple infectious and selected genetic indications are enumerated in the policy; coverage contingent on meeting selection criteria and code mapping:

Wide range of indications (see policy): Numerous infectious agents, genetic translocations, and other indications are listed in the policy (see enumerated items 50–101 and related entries); coverage depends on meeting the listed selection criteria and correct CPT/HCPCS/ICD‑10 mapping.

Refer to policy lists for full enumeration and code mapping.

CSF pathogen panel for meningitis/encephalitis signs and symptoms

CSF pathogen panel coverage for meningitis/encephalitis signs and symptoms (coding examples):

CSF panel — clinical + coding: Member has clinical findings consistent with meningitis/encephalitis AND viral etiology suspected OR CSF culture inconclusive; include appropriate ICD‑10 (eg, G00.0–G03.9, G04.00–G05.4) and CPT 87483 when selection criteria met.

Panel should be ordered with concurrent CSF/blood cultures per guidance.

Multiplex respiratory pathogen panels including SARS-CoV-2 for acute respiratory illness

Multiplex respiratory panels (including SARS‑CoV‑2) covered when criteria met and appropriate ICD‑10 linkage provided:

Respiratory multiplex panels — coverage logic: Member has acute respiratory illness AND is immunocompromised/high‑risk AND test will guide therapy; select CPT/HCPCS that maps to panel target count (eg, 87631/87632/87633; 0202U/0223U/0225U) and submit corresponding acute respiratory ICD‑10 code(s).

Panel size determines CPT/HCPCS selection per policy tables.

Gastrointestinal pathogen panel for infectious diarrhea/Clostridium difficile

Gastrointestinal pathogen panel coverage specifics (coding and selection criteria):

GI panel coding and coverage: CPT 87505 (3–5 targets) and 87506 (6–11 targets) are covered when selection criteria for infectious diarrhea are met; panels >11 targets (eg, 0369U/87507) may be covered for critically ill or immunocompromised persons meeting criteria. Include ICD‑10 linkage (eg, R19.7) as required.

Claims must include required diagnosis codes per policy.

Orthopoxvirus testing (eg, monkeypox) when selection criteria met

Orthopoxvirus (including monkeypox) PCR testing indication and coding guidance:

Orthopoxvirus/monkeypox PCR: PCR testing for orthopoxvirus (eg, monkeypox) on lesion specimens is covered when selection criteria and appropriate ICD‑10 mapping are met; CPT 87593 is listed for orthopoxvirus testing when criteria satisfied.lesion swab specimen

Follow CDC/FDA specimen guidance; avoid non‑lesion samples for routine testing.

Respiratory, gastrointestinal, vaginal, sepsis, and other infection-related indications when specific ICD-10 diagnoses and selection criteria are met

Other infection‑related indications (respiratory, GI, vaginal, sepsis) are covered when specific ICD‑10 diagnoses and selection criteria are met:

Respiratory/GI/vaginal/sepsis coverage: Multiple ICD‑10 code ranges are listed as covered when selection criteria are met (examples include respiratory failure, transplant status, immunosuppressed states, diarrhea); order appropriate panel and submit required diagnosis codes per policy mapping.

See CPT/ICD‑10 code tables in the policy for mapping and R19.7 requirement for GI panels.

Detection and monitoring of AML-associated fusion transcripts (AML1/ETO, CBFß/MYH11, PML/RARA).

Molecular testing for AML‑associated fusion transcripts — diagnostic and monitoring use:

AML fusion transcript detection/monitoring: RT‑PCR assays for AML1/ETO (t(8;21)), CBFβ/MYH11 (inv(16)), and PML/RARA (t(15;17)) are useful for diagnosis, minimal residual disease monitoring, and predicting relapse; PML/RARA detection is diagnostic for APL.

Use RT‑PCR for serial monitoring per hematology protocols.

Quantitative adenovirus PCR to detect viremia and monitor response in hematopoietic stem cell transplant recipients.

Quantitative adenovirus PCR use in transplant recipients:

Adenovirus viral load monitoring: Quantitative adenovirus PCR to detect viremia and monitor response to therapy in hematopoietic stem cell transplant recipients when rising blood viral loads correlate with invasive disease.

Serial monitoring frequency as clinically indicated.

Aspergillus PCR as adjunctive test

Aspergillus PCR role as adjunctive testing:

Aspergillus PCR adjunctive use: Aspergillus PCR may be used adjunctively in suspected invasive aspergillosis alongside antigen detection assays and clinical data; variable performance and need for validation limit routine standalone use.

Consider repeat testing and combined assays to improve specificity.

Diagnosis of symptomatic vaginitis/BV using NAAT/PCR when results will influence management

Molecular testing for symptomatic vaginitis/BV when results will influence management:

Symptomatic vaginitis/BV molecular testing: Use NAAT/PCR panels for BV, Candida spp., and Trichomonas when the patient is symptomatic AND the result will influence management; BV NAATs are not recommended for routine testing of asymptomatic women.

Investigational tests require validation; some qPCR thresholds (eg, G. vaginalis ≥10^7 copies/mL) have been proposed in studies.

Monitoring or diagnosing BK/JC infection in immunocompromised/transplant patients

BK/JC PCR testing for transplant recipients — monitoring and diagnostic role:

BK/JC monitoring/diagnosis: Quantitative PCR detection of BK and JC viral DNA in plasma, urine, or CSF is appropriate in immunocompromised/transplant patients to diagnose active infection and to guide reduction of immunosuppression or antiviral therapy.BK viremia >5,000 copies/mL (plasma); BK viruria >10^7 copies/mL (urine)

Provide transplant status and clinical context for interpretation; monitoring frequency per clinical protocol.

Adjunctive clonality PCR testing and bcl-2 translocation assays

Clonality and bcl‑2 translocation testing as adjuncts in lymphoproliferative disorders:

Clonality/bcl‑2 adjunct testing: Adjunctive multiplex clonality PCR (BIOMED‑2 IG/TCR) and bcl‑2 translocation assays are appropriate when morphology/flow cytometry are inconclusive to assist diagnosis or staging and may reduce need for re‑biopsy in selected cases.

Interpret clonality results in the context of morphology and immunophenotyping.

PCR or serology for suspected Bartonella infection when clinically warranted

Bartonella testing considerations:

Bartonella PCR/serology: When clinical presentation (eg, regional lymphadenopathy, systemic disease) warrants confirmatory testing, order IFA serology and consider PCR from tissue or blood through reference/CDC labs to differentiate species; IFA is sensitive and specific.

PCR availability may be limited to reference laboratories; interpret with clinical features.

Monitoring and diagnosis of BK virus infection in transplant recipients (blood and urine PCR)

BK virus monitoring and interpretation guidance for transplant recipients:

BK virus monitoring guidance: Use blood and urine quantitative PCR to detect BK viral DNA and quantify viral load to support diagnosis of BKV nephropathy and to guide reduction of immunosuppression or antiviral therapy in transplant recipients.BK plasma >5,000 copies/mL; urine >10^7 copies/mL

Document transplant type, clinical signs of nephropathy, and specimen type with orders/claims.

Rapid detection of multiple CSF pathogens in suspected meningitis/encephalitis

Rapid CSF pathogen detection using multiplex PCR panels — recommended adjunctive use:

Rapid CSF multiplex testing: Multiplex CSF PCR panels can rapidly detect multiple CNS pathogens and are useful when CSF findings suggest infection but Gram stain/culture are negative or when prior antibiotics may reduce culture yield; panels should be used alongside standard microbiologic tests.

FilmArray ME panel has reported high sensitivity/specificity but does not replace culture or susceptibility testing.

B-cell and T-cell clonality testing to support lymphoma diagnosis

Clonality testing to support lymphoma diagnosis per guideline recommendations:

B‑ and T‑cell clonality testing: NCCN recommends determination of clonality in appropriate lymphomas; order clonality PCR to support diagnosis when indicated.

Integrate results with morphology and immunophenotyping.

CSF PCR for bacterial and viral meningitis

CSF PCR for bacterial and viral meningitis — diagnostic role when culture/Gram stain negative or after prior antimicrobials:

CSF PCR for meningitis: CSF PCR is useful for definitive diagnosis of viral meningitis and for bacterial etiologies when CSF findings are consistent with meningitis but Gram stain/culture are negative or when prior antimicrobials may have reduced culture yield.

Order cultures concurrently; PCR does not provide susceptibility data.

Chlamydia trachomatis NAAT

Chlamydia trachomatis NAAT/ PCR screening and diagnostic guidance:

Chlamydia NAAT indications: Routine screening recommended for sexually active women ≤25 years and other at‑risk women; NAATs are more sensitive than culture and suitable for urine and genital specimens. Use PCR/TMA/SDA methods per guidelines.

Follow USPSTF and AAP guidance for screening intervals and specimen types.

Clostridioides difficile molecular testing

Clostridioides difficile molecular testing coverage and frequency considerations:

C. difficile molecular testing: PCR/molecular assays for C. difficile are indicated per IDSA guidelines for diagnosis of C. difficile infection; repeat enzyme immunoassay or PCR within 7 days has minimal diagnostic yield and is generally discouraged.Repeat testing within 7 days discouraged

87493 not covered for asymptomatic persons or test‑of‑cure scenarios.

Chikungunya RT-PCR on serum

Chikungunya RT‑PCR — timing and specimen guidance:

Chikungunya RT‑PCR indication: RT‑PCR on acute‑phase serum is useful during the first week of illness to diagnose chikungunya; serology (IgM/neutralizing) is used later and confirmatory testing may be available at CDC/state labs.

Document travel/epidemiologic history and specimen timing when ordering.

BCR-ABL (bcr/abl) testing by PCR/RT-PCR

BCR‑ABL testing by PCR/RT‑PCR for CML and subset of ALL — diagnostic and monitoring role:

BCR‑ABL RT‑PCR: RT‑PCR detection and quantification of bcr/abl transcripts is used for diagnosis and monitoring of CML and a subset of ALL; serial quantitative assays inform disease progression and therapeutic response.

RT‑PCR is the most sensitive technique for low‑level detection.

Diagnosis and monitoring of CMV infection (including quantitative PCR viral load testing)

CMV PCR (quantitative viral load) — diagnostic and monitoring contexts:

CMV viral load PCR: Quantitative PCR for CMV is used to monitor response to therapy and to evaluate suspected invasive disease in immunocompromised patients or to assess congenital infection; specimen source and clinical context must be specified.

DBS PCR for newborn CMV screening has shown low sensitivity in studies and is not established as a primary screening method.

Detection of enterovirus RNA, especially in CSF for suspected viral meningitis.

Enterovirus RNA detection — CSF testing preferred for suspected viral meningitis:

Enterovirus PCR (CSF): PCR detection of enterovirus RNA in CSF is more rapid and sensitive than culture and is the preferred method for suspected enteroviral meningitis.

Order CSF PCR when clinical features suggest viral meningitis.

Acute-phase diagnosis of ehrlichiosis/anaplasmosis via PCR

Ehrlichiosis/anaplasmosis — acute‑phase PCR use and ordering considerations:

Ehrlichiosis/anaplasmosis PCR: PCR of peripheral blood is useful in the acute phase before serologic conversion and is often available only at reference/CDC laboratories; verify test availability and specimen handling prior to ordering.

Document travel/exposure history and timing relative to symptom onset.

Consider EBV PCR in immunocompromised patients or when CNS lymphoma suspected

EBV PCR consideration — limited to immunocompromised contexts or suspected EBV‑related lymphoma:

EBV PCR — selective use: Consider EBV PCR in immunocompromised patients or when CNS lymphoma/lymphoproliferative disease involving EBV is suspected; routine PCR is not indicated in immunocompetent hosts.

Order with appropriate clinical documentation when used for monitoring/diagnosis in transplant recipients.

N. gonorrhoeae testing on recommended specimen types

Neisseria gonorrhoeae testing — specimen and screening guidance:

N. gonorrhoeae specimen guidance: NAATs/PCR recommended for urethral swabs (males) and endocervical swabs (females) when culture viability is compromised; urine PCR may be used for screening when pelvic exam is not performed; PCR not recommended for vaginal, rectal, conjunctival, or pharyngeal swabs per CDC guidance.

Use approved NAAT platforms and follow specimen guidance to avoid cross‑reactivity and false positives.

HCV RNA testing for early diagnosis, neonatal/perinatal infection detection, and monitoring

HCV RNA testing — indications for early diagnosis, neonatal detection, and monitoring therapy:

HCV RNA testing: Qualitative and quantitative HCV RNA PCR assays are used for early diagnosis after exposure, for neonatal/perinatal infection detection when maternal antibody may confound serology, and for monitoring antiviral therapy; order and interpret per guideline recommendations.

Quantitative assays are used for prognosis/therapy decisions; document clinical indication.

HBV DNA and HBeAg testing to select candidates for antiviral therapy and to monitor response

HBV DNA / HBeAg testing — role to select candidates for antiviral therapy and to monitor response:

HBV molecular testing: HBV DNA quantification and HBeAg testing are appropriate to select candidates for antiviral therapy and to monitor response to therapy; document indication when ordering.

Use guideline‑based thresholds to guide therapy initiation and monitoring.

HSV PCR (CSF) for suspected CNS infection; PCR preferred for genital herpes diagnosis

HSV PCR (CSF) — preferred diagnostic method for CNS infection and genital herpes:

HSV PCR indications: Real‑time PCR of CSF is the diagnostic method of choice for suspected HSV CNS infection; PCR is preferred over culture for genital herpes diagnosis; no role for routine viral load quantification or serial blood PCR to monitor therapy.

Order CSF PCR in patients with neurologic features suggestive of HSV encephalitis.

HHV-6 PCR testing indications and chromosomal integration consideration

HHV‑6 PCR — indicated in selected clinical scenarios with integration caveat:

HHV‑6 PCR indications: Consider HHV‑6 PCR in febrile infants (<3 years) with compatible illness, in immunocompromised patients, or in mononucleosis‑like illness when EBV/CMV are negative; exclude chromosomal integration by comparing serum/CSF and whole blood viral loads before diagnosing active infection.

Chromosomal integration may lead to persistently high DNA loads and confound interpretation.

HIV diagnosis in infants up to 18 months

HIV PCR for infant diagnosis — preferred testing approach:

HIV infant PCR: For diagnosis of HIV infection in infants up to 18 months, nucleic acid detection by PCR of DNA extracted from peripheral blood mononuclear cells is the preferred diagnostic test due to interference from maternal antibodies.

Document infant age and exposure history when ordering.

Suspected H5N1 influenza in hospitalized severe respiratory illness with recent travel to affected country

Criteria for H5N1 influenza PCR testing (per CDC):

H5N1 testing criteria: PCR testing for highly pathogenic avian influenza A (H5N1) is indicated when BOTH: (1) radiographically confirmed pneumonia, ARDS, or other severe respiratory illness without alternative diagnosis; AND (2) history of travel to an H5N1‑affected country within 10 days of symptom onset — consider testing with public health consultation.

Follow CDC guidance and coordinate with state/local health departments.

HPV testing as adjunct to cervical cancer screening

HPV testing — limited adjunctive screening role and restrictions:

HPV testing indications: HPV nucleic acid testing is primarily indicated as an adjunct to cervical cancer screening (eg, women >30 years or ASCUS triage); not recommended for men, women <20 years, or as general STI screening.

Use FDA‑approved assays and follow screening guidelines.

MRSA detection

MRSA molecular detection — role of mecA PCR:

MRSA mecA PCR: PCR detection of the mecA gene is an accurate and supported method to identify MRSA for diagnostic and infection control purposes.

Use validated molecular assays for mecA detection.

Leishmaniasis species identification

Leishmaniasis — species identification utility:

Leishmania species PCR: PCR assays can distinguish Leishmania species and are increasingly available to aid management decisions, supplementing microscopy or culture when species identification affects therapy.

Order species‑level testing when clinical management depends on species identification.

Microsporidia diagnosis by PCR

Microsporidia diagnosis — PCR utility:

Microsporidia PCR: PCR assays may be used to document Microsporidia infection in appropriate specimens (eg, stool, duodenal aspirate, biopsy) in immunocompromised patients.

Interpret results in clinical context and confirm with microscopy/culture as appropriate.

Detection of t(11;18) translocation in gastric MALT lymphoma

t(11;18) translocation testing in gastric MALT lymphoma — clinical utility:

t(11;18) PCR in MALT lymphoma: PCR detection of t(11;18) translocation is appropriate in patients with gastric MALT or extra‑nodal marginal zone lymphoma when H. pylori infection is present and atypical lymphoid infiltrates are non‑diagnostic; presence predicts lack of response to H. pylori eradication and guides alternative therapy.

Document H. pylori status and histologic context when ordering.

PCR testing for orthopoxvirus (including monkeypox) on lesion specimens

Orthopoxvirus/monkeypox PCR testing guidance and specimen recommendations:

Orthopoxvirus/monkeypox PCR: PCR testing for orthopoxvirus (including monkeypox) should be performed on lesion swabs in patients with compatible clinical presentation and epidemiologic risk factors; a positive orthopoxvirus PCR is a probable monkeypox case and confirmatory testing (monkeypox‑specific PCR/NGS or culture) can follow.lesion swab specimen

Avoid non‑lesion specimens (blood, saliva) for routine clinical diagnosis per FDA guidance.

Coding

Covered CPT Codes (selected examples)mixedCovered

0017U	Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis
0040U	BCR/ABL1 (t(9;22)) translocation analysis, major breakpoint, quantitative
0353U	Infectious agent detection by nucleic acid (DNA), Chlamydia trachomatis and Neisseria gonorrhoeae, multiplex amplified probe technique
81206	BCR/ABL1 (t(9;22)) translocation analysis
81210	BRAF gene analysis, V600 variant(s)
81220-81224	CFTR gene analysis
81225	CYP2C19 gene analysis
81226	CYP2D6 gene analysis
81227	CYP2C9 gene analysis
81240	F2 (prothrombin) gene analysis, 20210G>A variant

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CPT/HCPCS codes not covered for certain CPB indications or requiring specific criteriamixedNot Covered

81291	MTHFR gene analysis (listed as CPT code not covered for indications in this CPB)
0301U	Infectious agent detection by nucleic acid (DNA or RNA), Bartonella henselae and B. quintana, ddPCR
0068U	Candida species panel, amplified probe technique (CPT not covered for CPB indications)
0109U	Infectious disease (Aspergillus species), real-time PCR for detection of DNA from 4 species
0140U	Fungal pathogen identification DNA (15 fungal targets), blood culture, amplified probe technique
0141U	Bacterial and fungal gram-positive identification and resistance gene detection, blood culture
0142U	Gram-negative bacterial identification and resistance gene detection, blood culture
0152U	Bacteria, fungi, parasites, and DNA viruses; PCR and NGS, plasma; detection of >1,000 potential organisms
0321U	Genitourinary pathogens identification and antibiotic-resistance genes, multiplex amplified probe technique
0370U-0374U	Multiplex panels for wound and genitourinary pathogens with resistance gene ID (various U-codes)

Additional infectious agent CPT codes (selected)CPTCovered

87468-87471	Amplified probe techniques for tickborne and Bartonella agents
87476	Borrelia burgdorferi nucleic acid detection
87500	Vancomycin resistance detection (e.g., vanA, vanB)
87526	Hepatitis G virus, amplified probe technique
87541	Legionella pneumophila, amplified probe technique
87551	Mycobacteria species, amplified probe technique
87561	Mycobacterium avium-intracellulare, amplified probe technique
87913	SARS-CoV-2 genotype analysis, mutation identification

COVID-19 specific HCPCS U-codesHCPCSCovered

U0001	CDC 2019 Novel Coronavirus Real-Time RT-PCR Diagnostic Panel
U0002	2019-nCoV Coronavirus, any technique, multiple types or subtypes, non-CDC
U0003	SARS-CoV-2, amplified probe technique, high throughput technologies
U0004	2019-nCoV, any technique, high throughput technologies, non-CDC
U0005	SARS-CoV-2 amplified probe technique, high throughput, completed within 2 calendar days (add-on)

ICD-10 codes covered if selection criteria are met (selected ranges)ICD-10Covered

C18.0-C20	Malignant neoplasm of colon, rectosigmoid junction, and rectum
C43.0-C43.9	Malignant melanoma of skin
C81.00-C91.42	Various lymphoid and leukemic malignancies enumerated for coverage alignment
D57.00-D57.819	Sickle-cell disorders
E84.0-E84.9	Cystic fibrosis
B20	Human immunodeficiency virus [HIV] disease
B25.0-B25.9	Cytomegaloviral disease

ICD-10 codes not covered for certain CPB-listed indicationsICD-10Not Covered

C94.80-C94.82	Other specified leukemia [Xenotrophic murine leukemia] — listed as ICD-10 not covered for CPB indications
G60.0-G60.9	Hereditary and idiopathic neuropathy — listed as ICD-10 not covered for CPB indications
C61	Malignant neoplasm of prostate — listed as ICD-10 not covered for CPB indications

Selected ICD-10 codes (partial list shown)ICD-10

A75.2	Typhus fever due to rickettsia typhi.
A77.0 - A77.3, A77.9	Spotted fever [tick-borne rickettsioses].
A77.40 - A77.49	Ehrlichiosis.
A78	Q Fever.
A80.0 - A80.9	Acute poliomyelitis.
A81.2	Progressive multifocal leukoencephalopathy.
A87.0	Enteroviral meningitis.
A90	Dengue fever [classical dengue].
A91	Dengue hemorrhagic fever.
A92.30 - A92.39	West Nile virus infection.

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Covered CPT/HCPCS codes for multiplex PCR panels and related specimen collectionmixedCovered

87593	Infectious agent detection by nucleic acid (DNA or RNA); orthopoxvirus, amplified probe technique, each.
87483	Infectious agent detection by nucleic acid (DNA or RNA); central nervous system pathogen, includes multiplex RT, 12-25 targets.
0202U	Infectious disease pathogen-specific nucleic acid, 22 targets including SARS-CoV-2, qualitative RT-PCR, each pathogen reported.
0223U	Infectious disease pathogen-specific nucleic acid, 22 targets including SARS-CoV-2, qualitative RT-PCR, nasopharyngeal swab.
0225U	Infectious disease pathogen-specific DNA and RNA, 21 targets including SARS-CoV-2, amplified probe technique.
87632	Respiratory virus nucleic acid detection, multiplex RT, 6-11 targets.
87633	Respiratory virus nucleic acid detection, multiplex RT, 12-25 targets.
0240U	Infectious disease pathogen-specific RNA, 3 targets (SARS-CoV-2, influenza A/B).
0241U	Infectious disease pathogen-specific RNA, 4 targets (SARS-CoV-2, influenza A/B, RSV).
87631	Respiratory virus nucleic acid detection, multiplex RT, 3-5 targets.

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CPT codes not covered for indications listed in the CPBCPTNot Covered

87913

Infectious agent genotype analysis by nucleic acid; SARS-CoV-2 mutation identification in targeted region(s).

Gastrointestinal pathogen panel (3-5 targets)CPTCovered

87505

Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen, 3-5 targets

Gastrointestinal pathogen panel (6-11 targets)CPTCovered

87506

Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen, 6-11 targets

Gastrointestinal pathogen panel (>11 targets)HCPCS | CPTCovered

0369U	Infectious agent detection by nucleic acid (DNA and RNA), gastrointestinal pathogens, 31 organisms and 21 resistance genes
87507	Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen, 12-25 targets

Respiratory viral panels — amplified probeHCPCSCovered

0115U	Respiratory infectious agent detection by nucleic acid (DNA and RNA), 18 viral types/subtypes and 2 bacterial targets
0373U	Infectious agent detection by nucleic acid; respiratory tract infection, multiple bacteria, fungi, viruses, and resistance genes

Symptomatic vaginitis panels and related codesHCPCS | CPTCovered

0330U	Infectious agent detection by nucleic acid; vaginal pathogen panel, 27 organisms
0352U	Multiplex amplified probe technique for bacterial vaginosis and vaginitis organisms
81513	Infectious disease, bacterial vaginosis, quantitative real-time amplification of RNA markers
81514	Infectious disease, bacterial vaginosis and vaginitis, quantitative DNA markers, algorithm
87481	Infectious agent detection by nucleic acid; Candida species, amplified probe
87511	Gardnerella vaginalis, amplified probe technique
87512	Gardnerella vaginalis, quantification
87799	Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; quantification, each organism

Sepsis / culture-related and quantification codesCPT

87040

Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates

Quantification assays (covered if criteria met)CPTCovered

87497	Cytomegalovirus, quantification
87517	Hepatitis B virus, quantification
87522	Hepatitis C virus, quantification
87533	Herpes virus-6 quantification
87536	HIV-1, quantification
87539	HIV-2, quantification
87799	Infectious agent detection by nucleic acid, not otherwise specified; quantification

Specific organism quantification codes listed as not covered for CPB indicationsCPTNot Covered

87472	Bartonella quantification
87477	Borrelia burgdorferi, quantification
87482	Candida species, quantification
87487	Chlamydia pneumoniae, quantification
87527	Hepatitis G, quantification
87530	Herpes simplex virus, quantification
87533	Herpes virus-6, quantification
87542	Legionella pneumophilia, quantification
87562	Mycobacteria avium-intracellulare, quantification
87582	Mycoplasma pneumoniae, quantification

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inv-72: Turnaround time-based add-on — completed within 2 calendar days

Add-on codeHCPCS U0005 applicable when high-throughput SARS-CoV-2 testing is completed within 2 calendar days

Completion windowCompleted within 2 calendar days to qualify for U0005 add-on

Applicable testsHigh-throughput SARS-CoV-2 amplified probe techniques (U0003/U0004) where site/lab uses U0005 billing convention

inv-73: Panel target counts

Panel size groupings3–5 targets; 6–11 targets; 12–25 targets; larger panels (e.g., 21–22 or 22-target listings)

Respiratory panels mappingCPT 87631 = 3–5 targets; 87632 = 6–11 targets; 87633 = 12–25 targets; 0202U/0223U/0225U map to 21–22 or 22-target respiratory panels

Gastrointestinal panels mappingCPT 87505 = 3–5 targets; 87506 = 6–11 targets; 0369U/87507 referenced for >11 targets

inv-74: Gastrointestinal panel target count thresholds

Small GI panel3–5 targets — CPT 87505

Medium GI panel6–11 targets — CPT 87506

Large GI panel12–25 targets or >11 targets — CPT 87507 or 0369U for panels >11 targets

inv-75: G. vaginalis qPCR threshold

Proposed qPCR threshold>= 10^7 copies/mL (G. vaginalis) associated with Nugent-defined BV in study cohorts

Analytical sensitivity exampleSingleplex G. vaginalis qPCR analytical sensitivity reported to 3.1 x 10^4 copies/mL in study

Combined-target approachStudies suggest combined G. vaginalis + A. vaginae + Lactobacillus genus qPCR panels improve diagnostic sensitivity/specificity for BV

inv-76: BK viremia threshold

BK viremia threshold> 5,000 copies/mL (plasma) — associated with BK nephropathy

BK viruria threshold> 10^7 copies/mL (urine) — associated with BK nephropathy

Clinical implicationDetection/quantification may prompt reduction of immunosuppression or antiviral interventions in transplant recipients

inv-77: BK viruria threshold

BK viruria threshold> 10^7 copies/mL (urine) associated with BK nephropathy

ContextViruria commonly seen in transplant patients; quantification used with plasma viral load to assess nephropathy risk

Associated incidenceBKV nephropathy seen in ≈8% of kidney transplant recipients when thresholds exceeded

inv-78: G. vaginalis qPCR threshold (duplicate)

G. vaginalis qPCR threshold (study)>= 10^7 copies/mL correlated with Nugent-defined BV (positive predictive value 57.1%, negative predictive value 100%)

Multi-target qPCR benefitCombination of G. vaginalis, A. vaginae, and Lactobacillus genus qPCR showed higher sensitivity (93.4%) in one study

Use limitationBV NAATs/PCR recommended for symptomatic women only; accuracy in asymptomatic women not well defined

inv-79: BK viral load thresholds summary

BK viremia> 5,000 copies/mL (plasma) — associated with BK nephropathy

BK viruria> 10^7 copies/mL (urine) — associated with BK nephropathy

Peak viral load riskPeak BK viral load ≥ 10,000 copies/mL associated with higher risk of end-stage kidney disease in single-center lung transplant series

inv-80: Q fever chronic serology threshold (IgG IFA >= 800)

Chronic Q fever serology thresholdIgG IFA titer >= 800 — diagnostic criterion for chronic Q fever

Acute Q fever confirmation optionsFourfold rise in IgG between acute and convalescent sera OR detection of C. burnetii DNA by PCR in clinical sample

Other confirmation methodsCulture of C. burnetii or positive immunohistochemistry on tissue can confirm acute infection

Provider Actions / Documentation

Prior Authorization

Coverage tied to selection criteria and coding

Criteria-based coverage: Multiplex PCR panels (eg, CSF, respiratory, gastrointestinal, sepsis panels) are covered only when the specific selection criteria in the policy are met (signs/symptoms, immunocompromised/high-risk status, duration, specimen/source and that results will be used to guide therapy). Coding for claims must match the covered indication and required ICD-10 documentation (eg, R19.7 for GI panels when required).

Multiplex CSF pathogen panel (eg, 87483) — covered when CSF findings are consistent with CNS infection (meningitis/encephalitis), viral etiology suspected or culture inconclusive; culture and Gram stain should still be ordered as appropriate.
Respiratory panels — covered when member has signs/symptoms of respiratory infection and is immunocompromised/high-risk AND test will guide therapy (COVID-19 panels: up to 5 targets covered with criteria; >5 targets require criteria for broader panels).
Gastrointestinal pathogen panels — up to 11 targets covered for immune-competent persons meeting diarrhea/travel/severe disease criteria; >11 targets covered for critically ill or immunocompromised when criteria and ICD-10 coding (eg, R19.7) are documented.
Sepsis pathogen panels (eg, blood culture–based BCID panels) — covered when testing is performed on a positive culture and will guide therapy.

Denial Risk

COVID-19 testing: clinical indication required; non-clinical testing not covered

COVID-19 testing: Molecular/genotyping testing related to SARS-CoV-2 has limited coverage pathways and must follow indication-specific rules. Testing performed solely for non-clinical reasons (eg, travel, employment, surveillance) is not supported by clinical-necessity criteria and is not covered under the clinical indications in this policy.

Multiplex SARS-CoV-2/flu/RSV panels (eg, 87636, 87637) and upper respiratory multiplex assays (0240U/0241U/0202U etc.) — covered only when respiratory signs/symptoms and selection criteria met.
Genotype/mutation analysis (CPT 87913) — coverage limited; must be ordered for clinical management when mutation identification will change care decisions and meet documented indication.
Tests for non-clinical purposes (eg, screening for travel or workplace clearance) — not covered; such use may lead to claim denial.

Documentation Required

Documentation requirements and ICD-10 coding

Document required clinical context and specimen information: Claims for PCR/NAAT testing must include diagnosis codes that match covered indications and required documentation (clinical signs/symptoms, immunocompromised/high-risk status, specimen type, timing relative to symptoms or therapy, and how results will guide management). Missing or non-supported ICD-10 codes or lack of clinical documentation risks denial.

ICD-10 codes not covered for CPB indications: listed excluded codes (examples include A07.2 Cryptosporidiosis, A04.6 Yersinia enterocolitica enteritis, A07.1 Giardiasis, etc.).
Required ICD-10 note: R19.7 (Diarrhea, unspecified) is required for many GI panel claims; transplant/status and immunocompromised codes (eg, Z94.x, T86.x) are referenced where applicable.
Specimen/timing documentation: For many assays (eg, CSF panel, BK/JC, CMV, measles, monkeypox) the specific specimen type and timing relative to symptom onset or therapy must be documented in the medical record.

Billing Rule

Specimen, sample-type and initial testing guidance

Provider actions for specific tests and sample-type cautions: Use recommended specimen types only, avoid non-lesion or non-recommended samples that increase false results, and prefer initial lower-cost or traditional tests when appropriate before reflexing to molecular assays.

BV NAATs: Use among symptomatic women only (vaginal discharge, odor, itch); PCR/NAAT for BV is not recommended for asymptomatic screening — traditional Amsel/Nugent methods remain useful and lower cost.
Gonorrhea NAATs: Certain specimen types (eg, blood, urine for extragenital disease) are not recommended for NAAT — follow test-specific specimen guidance to avoid false negatives/positives.
Monkeypox PCR: Use lesion swab specimens; non-lesion sample types (eg, blood) carry higher risk of false or indeterminate results — document lesion type and timing per CDC guidance.
Hantavirus RT-PCR: Limited sensitivity; negative RT-PCR does not rule out infection; interpret in clinical context and consider serology for confirmation.
Highly pathogenic avian influenza and other high-risk pathogens: Follow public health/lab reporting pathways; some assays may be reserved for public health laboratories.
Avoid shotgun or broad 'shotgun' PCR panels for nonspecific indications without clinical justification — broad panels without matching clinical need may be deemed not medically necessary.
Mycobacterium tuberculosis PCR assays: Use according to established diagnostic algorithms; molecular assays are adjuncts and specimen selection matters (sputum, BAL, tissue) for sensitivity.

Note

Adjunct testing and repeat-testing risk

Adjunctive use and repeat testing considerations: Multiplex panels and advanced molecular tests are often adjunctive to traditional methods and should be used when results will impact management. Routine repeat testing within short intervals is generally of low yield and may not be necessary.

CSF multiplex panels: Consider as adjunct when CSF findings are consistent with CNS infection and Gram stain/culture are negative or prior antimicrobials received; culture and directed testing should not be omitted.
Repeat C. difficile testing: Little value in repeat PCR or EIA within 7 days; repeat testing yields small diagnostic gain and is discouraged unless clinically indicated.
Repeat PCR testing risk: Many assays (eg, C. difficile, HBV/HCV, BK/JC) can show intermittent detection; repeat testing without new clinical indication may not change management and can risk denial.
Cryptosporidium species-level PCR: Species-level identification has limited clinical impact in many cases and may not be necessary for routine management.

Documentation Required

Transplant and viral load testing — document clinical context

High-risk and transplant-related testing: Viral load and quantitative PCR tests (eg, BK, JC, CMV, EBV, HBV, HCV) are clinically indicated to guide therapy and monitoring in transplant and immunocompromised patients; document transplant status, immunosuppression, and monitoring plan.

BK/JC testing: Require clinical context (eg, renal allograft dysfunction, neurologic signs for JC/PML) and appropriate specimen (plasma for BK viremia; CSF for JC in suspected PML) with timing and correlation to imaging and clinical findings.
EBV viral load: Document transplant type and surveillance plan; high-risk allogeneic stem cell transplant recipients may require weekly monitoring for the first 3 months or longer per note in policy.
CMV: Specify specimen (plasma/whole blood) and clinical reason (diagnosis vs. monitoring); quantitative CMV assays are used to monitor response to therapy.
HBV/HCV molecular testing: Use quantitative assays to guide antiviral therapy selection and monitor response; document treatment intent and baseline viral load/genotype where relevant.

Denial Risk

Limited/Investigational PCR uses

Tests with limited or investigational roles: Some PCR assays are investigational or not routinely recommended (eg, Pneumocystis jirovecii PCR, certain broad microbiome or ‘shotgun’ panels, some quantitation assays) and may be denied when ordered outside defined clinical indications.

Pneumocystis jirovecii PCR: Considered experimental/investigational for routine diagnosis per some guidelines — use established invasive sampling methods (BAL, tissue) and follow institutional guidance.
Shotgun cfDNA/NGS panels (eg, plasma microbial cfDNA) — interpret cautiously; results require clinical correlation and may be limited in immunocompromised hosts; use only when results will change management.
Quantitative/novel arrays and consumer microbiome tests (eg, EoGenius, SmartGut, uBiome, SmartJane) — not covered for routine indications and may be considered investigational.

Documentation Required

Measles and monkeypox — specimen and documentation

Measles and orthopoxvirus (monkeypox) testing documentation: For measles, serologic IgM testing or RT‑PCR from appropriate specimens are acceptable diagnostic options; for suspected monkeypox, document clinical case criteria and epidemiologic risk per CDC case definitions when submitting PCR testing.

Measles: Acceptable diagnostic documentation includes positive measles IgM or RT‑PCR from urine, blood, throat, or nasopharyngeal secretions; single IgM during first encounter often sufficient.
Monkeypox: Document characteristic lesion description and epidemiologic criteria (contact/exposure/travel or high clinical suspicion). Follow CDC specimen guidance (lesion swabs) and case reporting requirements.

Note

Herpesvirus PCR — limited to specified clinical scenarios

Herpesviruses and related guidance: PCR testing for HHV-6/HHV-7/HHV-8 and other herpesviruses is generally limited to specific clinical scenarios (eg, immunocompromised hosts, encephalitis) — routine testing in immunocompetent persons is not indicated and may be denied.

HHV-6/HHV-7: Testing reserved for immunocompromised patients or when differential diagnosis requires exclusion (eg, encephalitis, febrile mononucleosis-like illness) — document why testing will affect management.
HHV-8: Tests largely limited to research settings; diagnosis typically will not alter management and routine screening is not supported.

Note

H. pylori / MALT lymphoma — t(11;18) testing implications

H. pylori–associated MALT lymphoma: Detection of the t(11;18) rearrangement by PCR predicts lack of response to H. pylori eradication; document H. pylori–associated MALT lymphoma when ordering t(11;18) testing and use results to guide alternative therapy.

Ordering note: Document diagnosis of MALT lymphoma and intent to use t(11;18) result to direct therapy; positive t(11;18) suggests antibiotic therapy for H. pylori is unlikely to be effective.

Ordering Requirements

Documentation Required

Document clinical indication and intended impact on management

Clinical indication and documentation that test results will guide therapy are required for covered multiplex panels and quantitative viral load tests; ordering clinicians should record how results will affect management when placing the order.

State intended clinical use (diagnosis, therapy selection, monitoring) on requisition
Provide supporting clinical notes or prior test results when applicable

Billing Rule

Order tests with appropriate diagnosis codes

Tests must be ordered with appropriate diagnosis codes corresponding to the covered indications; include the CPT/HCPCS code and the supporting ICD‑10 code that meets the CPB selection criteria to avoid claim denials.

Include both procedure code and matching ICD‑10 on claim
Ensure ICD‑10 maps to CPB selection criteria

Billing Rule

Link orders to ICD‑10 diagnoses that meet CPB criteria

Orders must be linked to ICD‑10 diagnoses that meet the CPB selection criteria for the specific PCR panel or pathogen test being requested; unsupported ICD‑10 diagnoses or missing codes (eg, R19.7 for GI panels) may result in noncoverage.

Link panel CPT to ICD‑10 that meets selection criteria
R19.7 required for many GI panel claims

Billing Rule

Submit required ICD‑10 codes with claims (eg, R19.7)

Submit the appropriate ICD‑10 diagnosis codes with claims (for example, R19.7 for gastrointestinal pathogen panels) as required by the CPB; failure to include required ICD‑10 codes can lead to denial.

R19.7 required for GI panel claims

Note

Follow specialty guidelines for molecular testing in oncology/infectious disease

Follow specialty and guideline recommendations (eg, CAP/IASLC/AMP, ASCO, IDSA) for molecular testing in oncology and infectious disease contexts when ordering molecular assays; document adherence to guideline‑based indications when applicable.

Documentation Required

Document symptoms (BV) and transplant status (BK/JC)

Document symptomatic status for BV testing (symptoms such as vaginal discharge, odor, itch) and transplant/immunocompromised status for BK/JC testing to justify molecular assays per CPB selection criteria.

Record vaginal symptoms when ordering BV NAATs
Document transplant or immunocompromised status for BK/JC PCR orders

Note

Order CSF multiplex panels only with CNS signs/symptoms and concurrent cultures

CSF multiplex panels should be ordered for patients with signs or symptoms of meningitis/encephalitis and when pretest probability supports testing; document CNS signs/symptoms and consider concurrent CSF and blood cultures as recommended.

Document meningitis/encephalitis clinical signs
Order CSF/blood cultures alongside multiplex PCR

Documentation Required

Document specimen type and timing on orders

Pay attention to specimen type and timing when ordering PCR tests (eg, acute‑phase serum for chikungunya RT‑PCR within first week of illness; upper respiratory tract specimens for SARS‑CoV‑2 NAAT); document specimen source and timing on the requisition.

Specify specimen and time since symptom onset
Use acute‑phase serum for arboviral RT‑PCR when within first week

Note

Confirm test availability at reference/CDC labs before ordering

Some PCR tests (eg, Cyclospora, ehrlichiosis) are primarily available at reference or CDC laboratories; confirm test availability and routing before ordering and document if testing will be sent to a reference lab.

Verify laboratory capability prior to ordering
Document reference/CDC lab referral on requisition if applicable

Documentation Required

Document clinical indication and select appropriate ICD‑10 codes

Document the clinical indication clearly and select ICD‑10 codes that correspond to the CPB-covered indications; incomplete or non‑matching documentation may result in denial.

Provide concise clinical rationale on requisition
Ensure ICD‑10 matches CPB selection criteria

Documentation Required

Document infant age and indication for HIV PCR

When ordering HIV PCR for infant diagnosis, document the infant’s age and the clinical indication (eg, perinatal exposure) to support use of nucleic acid testing (PCR of PBMC DNA) rather than serology.

Record infant age and exposure history
Indicate why PCR is required vs serology

Note

Suspected H5N1 testing — consult public health and document criteria

Testing for suspected highly pathogenic avian influenza (H5N1) should be done in consultation with public health authorities and is indicated only when severe respiratory illness plus recent travel to an affected country are present; document severity and travel history when ordering.

Consult state/local health departments for H5N1 testing
Document radiographic pneumonia/ARDS and travel within 10 days

Note

Align ordering with clinical presentation for Kawasaki disease/measles

Order testing for Kawasaki disease and measles in alignment with clinical presentation; document timing for measles serology or PCR and note that positive respiratory viral PCR does not exclude Kawasaki disease.

Document clinical diagnostic criteria for Kawasaki disease
Time measles serology/PCR appropriately relative to symptom onset

Note

Order arbovirus/orthopoxvirus testing based on clinical & epidemiologic context

Arbovirus and orthopoxvirus (monkeypox) testing should be guided by clinical and epidemiologic context; consult public health or reference labs as needed and document exposure/travel and characteristic findings when ordering.

Document epidemiologic risk factors and lesion characteristics for monkeypox
Use public health/reference labs for specialized arbovirus testing

Note

Order lesion swab PCR for monkeypox; respiratory panels for symptomatic patients

For monkeypox, order lesion swab PCR; multiplex respiratory PCR panels are generally ordered for symptomatic patients, especially those who are immunocompromised or high‑risk — document symptoms and risk status when placing the order.

Order lesion swab for monkeypox PCR
Reserve respiratory multiplex panels for symptomatic, high‑risk or immunocompromised patients

Not Covered / Experimental & Investigational

COVID‑19 testing performed solely for non‑clinical reasons (for example, testing required for work, school, or recreational activities) is excluded under standard benefit plans and may be denied if billed as medically necessary clinical testing.

The CPB enumerates numerous qualitative and quantitative PCR assays and multiplex panels that are considered experimental/investigational and not covered because evidence is insufficient to establish clinical utility; consult the policy lists for specific agents and panels when determining coverage.

Reiterating policy exclusions: C. difficile toxin gene PCR (CPT 87493) is not covered when used in asymptomatic persons or as a routine test of cure and such uses may result in claim denial.

MTHFR gene analysis (CPT 81291) is listed among CPT codes not covered for the indications addressed in this CPB.

The policy lists specific CPT/HCPCS codes and routine screening indications that are not covered (for example, certain pharyngitis panel codes or routine trichomonas screening in asymptomatic individuals); providers should map the claim codes to the CPB selection criteria to verify coverage.

Consumer-oriented commercial panels and certain organism‑quantification assays (for example, EoGenius, uBiome SmartGut, SmartJane, SmartFlu, Explorer) are explicitly excluded from routine coverage in the CPB unless otherwise stated.

Routine PCR testing for bacterial vaginosis is considered investigational or of uncertain clinical utility by multiple guideline bodies; use should be limited to symptomatic patients and validated assays with demonstrated clinical value.

The policy does not support use of investigational molecular assays that lack clinical validation or that may over-diagnose colonization rather than infection; laboratory‑developed tests should be internally validated before clinical use and claims should reflect validated, guideline-supported indications.

PCR assays that are not routinely available or validated in clinical laboratories (for example, PCR for Brucella species, Burkholderia, certain caliciviruses, or unvalidated fungal PCRs) are not supported for routine clinical testing and may be considered investigational.

PCR testing for the detection of metastases from cervical cancer is not supported by the cited NCCN/NCI guidelines and therefore is not considered an appropriate use of PCR in that context.

Dried blood spot (DBS) PCR as a standalone newborn screening method for congenital CMV is not supported in this CPB due to low sensitivity reported in studies compared with saliva rapid culture.

EoGenius and other gene expression / microRNA assays (e.g., 96‑gene arrays) are characterized as investigational and require further validation; they are not established as routine diagnostic replacements.

PCR testing for gonorrhea on non‑recommended specimen sites (vaginal, rectal, conjunctival, pharyngeal) is not recommended by CDC guidance and may not be supported; similarly, routine PCR testing for some agents (e.g., HBoV, HHV‑7) is limited to research and does not usually change management.

Routine PCR testing for HHV‑7 and HHV‑8 is limited to research settings and is of limited clinical utility in most cases; diagnosis typically will not change patient management.

Screening for subclinical genital HPV infection using DNA or RNA tests is not recommended; HPV nucleic acid testing is primarily an adjunct to cervical cancer screening in specified clinical contexts (e.g., women >30 years, ASCUS triage).

RT‑PCR testing to detect circulating melanoma cells or micrometastases is considered experimental/investigational and is not supported as routine diagnostic testing.

PCR testing for Lyme disease (Borrelia burgdorferi) is not validated for routine diagnosis or monitoring and is considered investigational/unsupported for routine clinical use per available guidelines.

Broad multiplex or 'shotgun' panels that test for many pathogens in patients with nonspecific symptoms (for example, malaise or chronic fatigue) are not medically necessary and may be denied; testing should be directed by clinical presentation and suspicion for specific pathogens.

PCR testing for Mycoplasma fermentans and for nanobacteria is considered experimental/investigational and therefore not covered for routine clinical use.

The CPB indicates that PCR is not established for routine management of several infections (for example, parainfluenza, Proteus mirabilis, Plesiomonas shigelloides) where standard culture, serology, or other diagnostic methods remain the recommended approaches.

Definitions

inv-142: Qualitative multiple PCR tests (multiplex panels)

Definition — multiplex panelsMultiplex PCR panels detect multiple pathogen targets simultaneously (e.g., CSF, respiratory, GI, sepsis panels) by amplifying multiple targets in one reaction

Typical target countsPanels commonly reported as 3–5, 6–11, 12–25, or larger (21–22, 22 targets) with corresponding CPT/HCPCS mappings

Use conditionsCoverage contingent on documented clinical criteria and appropriate ICD-10 linkage per policy

inv-143: Quantitative PCR testing

Definition — quantitative PCRPCR assays that provide numeric measurement of nucleic acid (viral load or gene transcript levels) used to monitor disease progression or response to therapy (e.g., CMV, EBV, BK, bcr/abl)

Common usesMonitoring antiviral therapy, assessing minimal residual disease in hematologic malignancy, and guiding immunosuppression adjustments in transplant patients

Coverage noteSpecific quantitative assays covered when clinical criteria met; some qPCR assays listed as experimental/investigational

inv-144: Quantitative PCR tests (qPCR)

qPCR (qPCR) definitionPCR assays that provide quantitative measures of nucleic acid and are used for viral load, mutation burden, or gene expression quantification

Experimental qPCR examplesPolicy lists several quantitative PCR tests considered experimental (e.g., Bartonella, Candida quantification, EoGenius) due to unclear clinical role

NGS cfDNA relationcfDNA/NGS tests (e.g., Karius) are quantitative/NGS-based molecular methods requiring clinical interpretation and not interchangeable with standard qPCR

inv-145: CSF pathogen panel (CPT 87483)

CSF pathogen panel CPTCPT 87483 — multiplex CNS pathogen panel (12–25 targets) including bacterial, viral, and yeast targets

Example platformBioFire FilmArray ME Panel — FDA-cleared, 14-target qualitative multiplex PCR for CSF with ~1-hour runtime

Adjunctive useShould be used alongside standard CSF bacterial culture and other microbiologic tests; not a replacement for culture or susceptibility testing

inv-146: Respiratory multiplex PCR (various CPT/HCPCS)

Respiratory multiplex codesCPT 87631 (3–5 targets), 87632 (6–11), 87633 (12–25); U-codes (0202U/0223U/0225U) for larger 21–22/22-target panels

Typical pathogensPanels detect respiratory viruses/bacteria including SARS-CoV-2, influenza A/B, RSV, adenovirus, metapneumovirus, parainfluenza, rhinovirus

Coverage conditionCovered when selection criteria met: symptomatic, immunocompromised/high-risk, and result will guide therapy

inv-147: PCR (method definition)

Method definitionPCR: exponential amplification of targeted DNA/RNA using primers and DNA polymerase through thermal cycling (denaturation, annealing, extension)

RequirementsKnown target sequence required to design primers; reaction conditions empirically optimized per primer set

Sensitivity considerationsExtremely sensitive — small contamination can produce false positives; laboratory controls and validation required

inv-148: Limitations of PCR

Key limitationsHigh analytic sensitivity may detect colonization, latent infection, or dead organisms and cannot distinguish active disease from residual nucleic acid

Contamination riskAmplification techniques risk cross-specimen contamination leading to false positives; laboratory validation and precautions required

Performance variabilitySensitivities/specificities vary by organism and specimen type; many assays lack large-scale validation

inv-149: AML1/ETO t(8;21)

AML1/ETO (t(8;21)) useRT-PCR detects AML1/ETO fusion mRNA; used for diagnosis and serial monitoring of AML, associated with favorable prognosis

PrevalenceOccurs in ~15% of adult AML cases and higher in certain subtypes

Clinical roleQuantitative RT-PCR useful for minimal residual disease detection and relapse prediction

inv-150: CBFß/MYH11 inv(16)

CBFß/MYH11 (inv(16)) useDetection of CBFß/MYH11 fusion via PCR used for diagnosis and monitoring of acute myelomonocytic leukemia

AssociationAssociated with AML subtype M4E0 and relatively favorable outcomes

Clinical roleQuantitative detection assists in monitoring treatment response and MRD

inv-151: PML/RARA t(15;17)

PML/RARA (t(15;17)) useRT-PCR detection of PML/RARA fusion is diagnostic for acute promyelocytic leukemia (APL) and used for MRD monitoring

Prevalence>99% of APL patients harbor PML/RARA translocation

Therapeutic implicationPositive RT-PCR confirms APL and guides initiation of all-trans retinoic acid therapy

inv-152: Bacterial vaginosis (BV) definition

BV definitionBacterial vaginosis: vaginal dysbiosis with loss of lactobacilli and overgrowth of anaerobes (e.g., G. vaginalis, A. vaginae)

Diagnostic methodsDiagnosed by Nugent score or Amsel criteria; NAAT/PCR assays available and commonly used in symptomatic women

Testing limitationBV NAATs recommended for symptomatic women only; accuracy for asymptomatic screening is not well defined

inv-153: bcl-2 gene translocation

bcl-2 translocation (t(14;18))Rearrangement commonly seen in follicular and other B-cell lymphomas; PCR detection supports diagnosis and monitoring

PrevalenceObserved in 70–90% of follicular NHL and variable in other B-cell lymphomas

Clinical roleUseful for differential diagnosis and monitoring minimal residual disease

inv-154: B- and T-cell clonality testing

Clonality testing definitionBIOMED-2 multiplex PCR assays evaluate IG and TCR gene rearrangements to detect monoclonal B- or T-cell populations

Clinical roleAdjunctive test when morphology/flow cytometry inconclusive; helpful for diagnosis, staging, and reducing re-biopsy need

PerformanceHigh clonality detection rates reported in studies; interpret with morphologic correlation

inv-155: BK and JC viruses (BKV, JCV)

BK and JC virusesBK and JC polyomaviruses are ubiquitous DNA viruses that establish latency and reactivate in immunocompromised hosts; BK associated with nephropathy, JCV with PML

Seroprevalence>70% of adults have antibodies to BKV and JCV

Clinical implicationQuantitative PCR of plasma/urine/CSF used to detect reactivation and guide management in transplant or immunocompromised patients

inv-156: BK viremia / BK viruria definitions

BK viremia definitionQuantitative detection of BK viral DNA in plasma; viremia >5,000 copies/mL associated with BK nephropathy

BK viruria definitionQuantitative detection of BK DNA in urine; viruria >10^7 copies/mL associated with BK nephropathy

UseBoth plasma and urine PCR used in transplant monitoring; thresholds guide immunosuppression adjustments

inv-157: FilmArray ME panel

FilmArray ME panelFDA-cleared qualitative multiplex PCR detecting 14 CSF pathogens with ~1-hour runtime (BioFire FilmArray ME)

Sample volumeUses 0.2 mL CSF per run

PerformanceReported overall sensitivity ~94.2% and specificity ~99.8%; should be adjunctive to culture

inv-158: Clonality testing definition

Clonality testing purposeMolecular determination of B- or T-cell clonality to assist lymphoma diagnosis when morphology or immunophenotyping are inconclusive

Assay exampleBIOMED-2 multiplex PCR is a standardized clonality platform evaluated in multiple studies

Interpretation cautionClonality may be present in reactive conditions; correlate with morphology and clinical context

inv-159: NAAT/PCR definition

NAAT/PCR definitionNucleic acid amplification tests detect pathogen DNA or RNA with high analytic sensitivity and specificity for appropriate specimen types

ExamplesIncludes PCR, TMA, LCR and real-time/quantitative PCR methods

Clinical noteHigh sensitivity requires careful specimen handling and interpretation to avoid false positives from contamination or colonization

inv-160: bcr/abl gene rearrangement (RT-PCR)

bcr/abl (RT-PCR) useRT-PCR detects BCR-ABL transcripts for diagnosis and monitoring in CML and a subset of ALL; highly sensitive for low-level disease

Clinical implicationRising bcr/abl levels correlate with clinical progression and guide therapy adjustments

PrevalenceBCR-ABL present in ~95% of CML patients

inv-161: CMV viral load PCR

CMV viral load PCRQuantitative PCR assays measure CMV DNA in blood/tissues to monitor disease progression and response to therapy

Specimen typesBlood (plasma/whole blood), CSF, tissue, and occasionally dried blood spots (DBS) — DBS has lower sensitivity for newborn screening

Clinical contextsUsed in immunocompromised patients, suspected invasive organ disease, and congenital infection evaluation

inv-162: EoGenius

EoGenius descriptionA 96-gene quantitative PCR array with dual algorithm intended to profile tissue gene expression for eosinophilic esophagitis

Policy stanceListed as experimental/investigational due to uncertain clinical role and validation needs

Clinical roleProposed to support EoE diagnosis but not established as routine comparator to histology

inv-163: NAAT definition

NAAT definitionNucleic acid amplification tests (PCR, TMA, LCR) amplify pathogen nucleic acids for sensitive detection in clinical specimens

Specimen considerationsAppropriate specimen type and timing are critical for NAAT accuracy (e.g., urine vs swab for STIs, CSF for meningitis)

Clinical useNAATs often replace culture for viruses and fastidious organisms but require validation and correct specimen handling

inv-164: HCV RNA assay types

HCV RNA assay typesQualitative assays detect early infection with higher sensitivity; quantitative assays provide viral load for prognosis/therapy decisions but may be less sensitive

Clinical usesHCV RNA PCR used for early diagnosis, infant/perinatal testing, and monitoring antiviral therapy

Interpretation noteQuantitative assays mainly used for treatment decisions; repeat testing guided by clinical course

inv-165: Preferred HIV infant diagnostic test

Preferred infant HIV diagnosticHIV nucleic acid detection by PCR of DNA from peripheral blood mononuclear cells is preferred for infants up to 18 months

ReasonMaternal antibodies confound serologic testing in infants; PCR detects virus directly

Alternate usePlasma HIV RNA PCR may diagnose infection if positive but is FDA-licensed primarily for quantitative monitoring

inv-166: FDA-approved HPV assays examples

Examples of FDA-approved HPV assaysHC II High-Risk and Low-Risk (Qiagen), Cervista HPV 16/18 and Cervista High-Risk (Hologic), Roche cobas 4800 (PCR-based)

Use limitationHPV testing primarily adjunct to cervical cancer screening in women >30 years or ASCUS triage; not for men or routine STI screening

Assay featuresSome PCR-based assays genotype HPV 16/18 separately and detect pooled high-risk types

inv-167: mecA gene / MRSA definition

mecA/MRSA definitionThe mecA gene encodes PBP-2a conferring methicillin resistance; PCR detection of mecA is an accurate method to identify MRSA

Clinical relevanceMolecular detection supports infection control decisions and rapid patient management

Alternative methodsLatex agglutination for PBP-2a also accurate; culture remains standard for susceptibility profiling

inv-168: bcl-1 (t(11;14)) translocation

bcl-1 (t(11;14)) translocationChromosomal translocation associated with mantle cell lymphoma; detection aids differential diagnosis but is present in ~2/3 of cases

Clinical rolePCR detection assists in diagnosis and follow-up but a negative result does not exclude disease

InterpretationCombine molecular results with morphology and immunophenotyping for definitive diagnosis

inv-169: Multiplex PCR (mPCR) definition

Multiplex PCR (mPCR) definitionSimultaneous amplification of multiple targets in a single PCR reaction using distinct primer sets

AdvantageEnables detection of multiple pathogens from a single specimen and faster turnaround

CaveatIncreased complexity requires assay validation; potential for cross-reactivity and interpretation challenges

inv-170: Probable vs Confirmed monkeypox case definitions

Probable monkeypox caseDetection of Orthopoxvirus DNA by PCR on clinical specimen (lesion) constitutes a probable case per 2022 CDC guidance

Confirmed monkeypox caseDemonstration of Monkeypox virus DNA by PCR/NGS or isolation in culture confirms diagnosis

Sample typeLesion swab PCR is recommended; throat swabs mainly for epidemiology and blood/saliva not supported clinically

inv-171: cfDNA/NGS infectious disease test (Karius Test)

cfDNA/NGS infectious disease test (Karius)Next-generation sequencing of microbial cell-free DNA in plasma to detect bacteria, DNA viruses, fungi and protozoa; results require clinical correlation

Performance noteSmall studies show partial concordance (e.g., ~70%) with conventional methods in immunocompromised cohorts; interpret cautiously

Clinical useMay identify pathogens when conventional methods are negative but not substitute for standard diagnostics; payer may require documentation of clinical context

Frequency Limits and Monitoring

inv-219: EBV viral load screening frequency recommendation (at least weekly)

EBV monitoring frequencyFor high-risk allogeneic stem cell transplant recipients, EBV viral load screening should begin at transplantation and continue at least weekly for the first 3 months

Extended monitoringContinue beyond 3 months if treated for graft-versus-host disease, haploidentical graft, or prior EBV viremia

Trigger for more frequent testingConsider more frequent testing if EBV load is rising

inv-220: SARS-CoV-2 high-throughput testing add-on U0005 when completed within 2 calendar days

SARS-CoV-2 add-on codeHCPCS U0005 is an add-on for high-throughput SARS-CoV-2 amplified probe testing when completed within 2 calendar days

Condition for billingU0005 applies only when the high-throughput test run is completed within the 2-calendar-day window

Related codesU0003/U0004/U0001/U0002 referenced for various SARS-CoV-2 testing scenarios in policy

inv-221: Not specified in this document segment

Not specified entriesSome frequency limits and repeat-intervals are not specified in this document segment (policy states 'Not specified' for several tests)

Example unspecifiedBK/JC PCR monitoring frequency guided by clinical protocol — not specified in policy

ActionFollow institutional or transplant-protocol schedules where policy does not specify frequency

inv-222: (blank frequency entry)

Blank frequencyNo explicit frequency entry provided in this segment for certain tests (placeholder)

ImplicationClinicians should follow specialty guidance or institutional protocols when policy silent

ExamplesSeveral panel and pathogen tests lack defined repeat intervals in policy excerpts

inv-223: Adenovirus quantitative PCR — serial monitoring as clinically indicated

Adenovirus monitoringQuantitative adenovirus PCR: serial monitoring as clinically indicated in hematopoietic stem cell transplant recipients

Clinical rationaleRising blood viral loads associate with invasive disease and guide therapy monitoring

Frequency guidanceNo fixed interval specified; follow clinical protocol and respond to trends in viral load

inv-224: BK/JC PCR monitoring frequency guided by clinical protocol (not specified)

BK/JC monitoring frequency guidanceMonitoring frequency for BK and JC PCR should be guided by clinical protocol; policy does not specify fixed intervals

Clinical contextUsed in transplant recipients to evaluate suspected active infection, graft dysfunction, or neurologic disease

DocumentationOrderers should document transplant status and indication to justify serial testing

inv-225: BK/JC PCR — not specified in this segment

BK/JC PCR frequency unspecifiedPolicy segment does not define routine monitoring intervals for BK/JC PCR; follow institutional transplant protocols

Clinical useQuantitative PCR used to guide immunosuppression adjustments in transplant patients

RecommendationDocument clinical context when ordering due to lack of prescriptive policy frequency

inv-226: C. difficile toxin testing or PCR — repeat testing within 7 days

C. difficile repeat testing intervalRepeat C. difficile toxin testing or PCR within 7 days has minimal diagnostic yield; policy notes limited value of repeat testing within 7 days

Recurrence testingTesting for recurrence may be appropriate per clinical scenario; testing <4 weeks useful only when prior result was negative

Guideline alignmentIDSA/AAP statements referenced regarding appropriate testing indications and limitations

inv-227: C. difficile — testing for recurrence

C. difficile recurrence testingPolicy acknowledges testing for recurrence; repeat testing less than 4 weeks is of limited value unless prior test was negative

Clinical noteUse clinical criteria to determine need for repeat testing rather than routine short-interval repeats

EvidenceStudy reported diagnostic gain of ~1.7–1.9% for repeat testing within 7 days

inv-228: CMV quantitative viral load — as clinically indicated

CMV viral load frequencyCMV quantitative viral load testing: as clinically indicated (monitoring and treatment contexts)

Specimen and contextSpecify specimen source (blood, tissue, CSF) and clinical context (suspected invasive disease, congenital infection, monitoring) when ordering

No fixed intervalPolicy does not prescribe routine screening intervals; follow clinical need and institutional protocols

inv-229: HCV RNA repeat testing guided by clinical course/therapy monitoring

HCV RNA repeat testingRepeat HCV RNA (qualitative/quantitative) testing guided by clinical course and therapy monitoring — as clinically indicated

Clinical usesEarly diagnosis, neonatal/perinatal infection detection, and antiviral therapy monitoring

Assay selectionQualitative assays more sensitive early; quantitative assays used for prognosis/therapy decisions

inv-230: Influenza PCR (frequency not specified)

Influenza PCR frequencyNo specific frequency limit specified in this document segment for influenza PCR; follow clinical timing recommendations (specimens ideally within first 72 hours for culture)

Specimen timingSpecimens for viral culture should be obtained within first 72 hours due to decreased shedding; PCR sensitivity may still be affected by timing

Clinical useRT-PCR offers high sensitivity/specificity and is used where available; order based on clinical need

inv-231: Orthopoxvirus PCR on lesion samples (frequency not specified)

Orthopoxvirus PCR sample typePCR for orthopoxvirus (including monkeypox) should be performed on lesion swabs; policy does not specify routine repeat frequency

Epidemiologic usesThroat swabs may be used for epidemiologic purposes but are not primary clinical confirmation specimens

Lab sitesTesting available at LRN sites and certain commercial labs; follow public health guidance for repeat testing if indicated

inv-232: cfDNA/NGS infectious disease testing (frequency not specified)

cfDNA/NGS testing frequencyNo specific frequency limits provided for cfDNA/NGS infectious disease tests (e.g., Karius) in this segment

Interpretation requirementResults require clinical correlation; repeat testing should be guided by clinical course and specialist guidance

Evidence notePreliminary studies show partial concordance with conventional methods; larger validation studies needed

Background and Clinical Considerations

This policy covers a broad set of infectious, genetic, oncologic, and transplant‑related indications where PCR testing may be clinically relevant. Coverage varies by qualitative/multiplex versus quantitative assays and is contingent on meeting the specific selection criteria and documented ICD‑10 diagnoses required by the CPB.

Selected clinical indications include pathogen‑specific PCR uses (eg, CSF pathogen panels for suspected meningitis/encephalitis, GI panels for prolonged/severe infectious diarrhea, respiratory multiplex panels for high‑risk or immunocompromised patients), quantitative viral load testing for transplant monitoring (eg, CMV, EBV, BK), and molecular tests for hematologic malignancy monitoring (eg, AML translocations, BCR‑ABL). Coverage depends on meeting the CPB selection criteria and submitting appropriate documentation and ICD‑10 coding.

Respiratory, gastrointestinal, vaginal, sepsis, and other infection‑related multiplex panels are covered only when the policy's selection criteria are met and the submitted CPT/HCPCS codes are linked to the required ICD‑10 diagnoses. Providers should ensure ordering documentation demonstrates that results will guide therapy and that the correct panel size/code maps to the clinical indication.

Agent‑specific PCR utility and limitations are described throughout the CPB: some assays (for example, CSF multiplex panels, BK/JC quantification in transplant recipients, and certain oncologic fusion transcript PCRs) have established clinical roles, while many other pathogen‑ or condition‑specific PCR tests remain experimental or of limited clinical usefulness pending further validation.

Additional Definitions

inv-172: CSF pathogen panel definition

CSF pathogen panel definitionMultiplex nucleic acid detection for central nervous system pathogens (e.g., bacterial meningitis pathogens, enterovirus, parechovirus, HSV, CMV, VZV, Cryptococcus); typically 12–25 targets (CPT 87483)

Intended useCovered when member has signs consistent with CNS infection and viral etiology suspected or CSF culture inconclusive

Example platformBioFire FilmArray ME Panel (FDA-cleared) detects 14 targets in ~1 hour; high reported sensitivity/specificity

inv-171: cfDNA/NGS infectious disease test (Karius Test)

cfDNA/NGS test (Karius) definitionNext-generation sequencing of microbial cell-free DNA in plasma to detect bacteria, DNA viruses, fungi and protozoa; results require clinical interpretation

Clinical contextMay identify pathogens when conventional methods are negative; preliminary studies show ~70% concordance in small immunocompromised cohorts

LimitationReported organisms may not be etiologic; interpret within clinical and epidemiologic context

Revision History

2024-02-09policy_review

Policy last reviewed (document 'last_review' date).

2002-09-24effective_date

Policy originally became effective on 2002-09-24.

2024-02-09status_updateLatest

Policy status marked CURRENT with next review scheduled 2024-07-11.

Policy Summary

PayerAetna

PolicyPolymerase Chain Reaction (PCR) Testing: Selected Indications

Policy CodePolicy 0650

Change TypeNo material change

Effective DateSep 24, 2002

Next Review DateJul 11, 2024

Key ActionOrder multiplex and quantitative PCR tests only when documented clinical selection criteria are met and appropriate ICD-10 codes are submitted.

SourceLink

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