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    v1.0.28
    OpenPayerPolicy UpdatesDermatologyAmbetter Nevada Onychomycosis Coverage | OpenPayer
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    CurrentAmbetter NevadaPolicy N/A

    Concert Genetic Testing: Dermatology

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    This policy governs outpatient laboratory testing for suspected nail fungus (onychomycosis), including microscopy/peroxidase testing, fungal culture, and culture-independent molecular testing. Coverage depends on clinical signs, symptoms, and whether results will affect management.

    Policy Summary
    PayerAmbetter Nevada
    PolicyConcert Genetic Testing: Dermatology
    Policy CodePolicy N/A
    Change TypeAnnual reviewno material clinical or coverage change
    Effective Date05/01/2026
    Last ReviewNov 1, 2025
    Next Review DateN/A
    Key ActionDocument signs or symptoms of onychomycosis and how test results will influence clinical management.
    SourceLink
    POLICY UPDATE CHANGES

    The policy title was updated to Concert Genetic Testing: Dermatology.

    2Testing categories covered with criteria
    1Testing category not supported
    2

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Required medical-necessity conditions
    3Laboratory testing groups listed

    Medical Necessity Criteria

    Microscopy/Peroxidase Tests for Onychomycosis

    Covered when all of the following are met:

    Microscopy/peroxidase testing for onychomycosis

    • Clinical signs or symptoms: The member/enrollee shows signs or symptoms of onychomycosis.

      Examples include discolored, deformed, brittle, or foul-smelling nails; subungual debris; or separation of the nail from the nail bed.

    • Clinical management impact: Results of testing would influence the member's/enrollee's clinical management.

    Fungal Culture for Onychomycosis

    Covered when all of the following are met:

    Fungal culture for onychomycosis

    • Clinical signs or symptoms: The member/enrollee shows signs or symptoms of onychomycosis.

      Examples include discolored, deformed, brittle, or foul-smelling nails; subungual debris; or separation of the nail from the nail bed.

    • Clinical management impact: Results of testing would influence the member's/enrollee's clinical management.

    Culture-Independent Molecular Tests (NAAT/PCR) for Onychomycosis

    Not supported for any indication.

    Culture-independent molecular tests for onychomycosis: Current evidence does not support culture-independent molecular tests, including NAAT/PCR, for onychomycosis for any indication.

    Microscopy/peroxidase testing for onychomycosis is not supported for indications other than cases in which the member/enrollee has signs or symptoms of onychomycosis and the results are expected to influence clinical management.

    Presumptive and/or definitive fungal culture for onychomycosis is not supported for indications other than cases in which the member/enrollee has signs or symptoms of onychomycosis and the results are expected to influence clinical management.

    Culture-independent molecular tests, including NAAT/PCR, for onychomycosis are not medically supported for any indication.

    Laboratory Testing Codes

    Microscopy/Peroxidase TestsCPT
    87206Microscopy/Peroxidase Tests
    87220Microscopy/Peroxidase Tests
    Fungal CultureCPT
    87101Fungal Culture
    87102Fungal Culture
    87106Fungal Culture
    87107Fungal Culture
    87143Fungal Culture
    87149Fungal Culture
    Culture-Independent Molecular Tests (NAAT/PCR)CPT
    87481Culture-Independent Molecular Tests (NAAT/PCR)
    87500Culture-Independent Molecular Tests (NAAT/PCR)
    87641Culture-Independent Molecular Tests (NAAT/PCR)
    87652Culture-Independent Molecular Tests (NAAT/PCR)
    87653Culture-Independent Molecular Tests (NAAT/PCR)
    87798Culture-Independent Molecular Tests (NAAT/PCR)

    Documentation and Denial Considerations

    Documentation Required

    Document clinical findings and management impact

    Before ordering microscopy/peroxidase testing or fungal culture for onychomycosis, document signs or symptoms such as discolored, deformed, brittle, or foul-smelling nails; subungual debris; or separation of the nail from the nail bed. Also document how the test results would influence the member’s/enrollee’s clinical management.

    Denial Risk

    Avoid unsupported microscopy testing

    Microscopy/peroxidase testing for onychomycosis may be denied when the member/enrollee does not show signs or symptoms of onychomycosis or when the test results would not influence clinical management.

    Denial Risk

    Clinical Context

    Onychomycosis is a fungal infection of the nails that may sometimes involve the surrounding skin. Laboratory confirmation can help distinguish fungal infection from nonfungal dermatologic conditions, identify mixed infections, and guide treatment. KOH preparation with direct microscopy is described as a preferred diagnostic method; additional testing may be considered when KOH results are negative but clinical suspicion remains high.

    Policy Summary
    PayerAmbetter Nevada
    PolicyConcert Genetic Testing: Dermatology
    Policy CodePolicy N/A
    Change TypeAnnual reviewno material clinical or coverage change
    Effective Date05/01/2026
    Last ReviewNov 1, 2025
    Next Review DateN/A
    Key ActionDocument signs or symptoms of onychomycosis and how test results will influence clinical management.
    SourceLink
    On This Page
    Medical Necessity CriteriaLaboratory Testing CodesDocumentation and Denial ConsiderationsClinical Context

    Avoid unsupported fungal culture

    Presumptive or definitive fungal culture for onychomycosis may be denied when the member/enrollee does not show signs or symptoms of onychomycosis or when the test results would not influence clinical management.

    Denial Risk

    Do not order NAAT/PCR testing

    Culture-independent molecular tests, including NAAT/PCR, for onychomycosis are not supported for any indication.