Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesInfectious DiseaseAmbetter Nevada genitourinary testing Coverage Upd…
    Ask Trek AI about this page

    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.

    ModifiedAmbetter NevadaPolicy N/A

    CONCERT INFECTIOUS DISEASE: GENITOURINARY TESTING (coverage for outpatient lab testing of vaginitis/vaginosis and UTI)

    Customize your policy alerts

    Sign up for all Ambetter Nevada policy alerts

    Know when Ambetter Nevada releases new policies or updates existing guidance.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Outpatient clinical coverage policy for laboratory testing of genitourinary infections including targeted and expanded vaginitis/vaginosis panels, urine culture for asymptomatic bacteriuria, and molecular/multiplex UTI panels; intended for providers ordering diagnostic tests.

    Policy Summary
    PayerAmbetter Nevada
    PolicyGenitourinary infectious disease testing (vaginitis/vaginosis, UTI)
    Policy CodePolicy N/A
    Change TypeCoverage stance clarificationscoding/table updatesadded vendor listings
    Effective DateN/A
    Last ReviewOct 22, 2024
    Next Review DateN/A
    Key ActionConfirm prior authorization requirements and reference the updated policy reference table (including newly listed tests like NxGen MDx) when submitting claims.
    SourceLink
    POLICY UPDATE CHANGES

    Added 'lab' to policy title.

    Removed CPT and ICD-10 codes from policy reference table and added a CPT code table; moved the 'coding implications' section.

    For Urine Culture for Asymptomatic Bacteriuria: Addition of Urinary Tract Infection Testing (NxGen MDx, LLC) to Policy Reference Table.

    Changed policy statements for Targeted Vaginitis/Vaginosis Pathogen Testing and Expanded Multiplex Vaginitis/Vaginosis Pathogen Panels from 'may be considered medically necessary' to 'are considered medically necessary'.

    Additional CPT and other codes were added to the coding table (multiple codes listed).

    6maximum targets considered 'targeted' for vaginitis/vaginosis panels
    pregnancypregnant patients — indication for urine culture for ASB
    investigationalmolecular/multiplex UTI panels coverage stance
    ~60+CPT and related codes listed
    ReviewedExternal specialist review noted

    Coverage Criteria — Genitourinary Infectious Disease Testing

    Targeted Vaginitis/Vaginosis Pathogen Testing (medically necessary)

    Considered medically necessary when ALL of the following are met:

    Targeted vaginitis/vaginosis medical necessity

    • Symptomatic criteria: Member/enrollee has >=1 of: abnormal vaginal discharge; vulvovaginal itching, irritation, or redness (e.g., pruritus, erythema, edema); painful sexual intercourse (dyspareunia); painful urination (dysuria); postcoital or contact bleeding.>=1

      Symptomatic indications listed in policy

    Targeted Vaginitis/Vaginosis Pathogen Testing (investigational)

    Investigational (not medically necessary) when ANY of the following applies:

    Targeted testing investigational uses:
    Policy Summary
    PayerAmbetter Nevada
    PolicyGenitourinary infectious disease testing (vaginitis/vaginosis, UTI)
    Policy CodePolicy N/A
    Change TypeCoverage stance clarificationscoding/table updatesadded vendor listings
    Effective DateN/A
    Last ReviewOct 22, 2024
    Next Review DateN/A
    Key ActionConfirm prior authorization requirements and reference the updated policy reference table (including newly listed tests like NxGen MDx) when submitting claims.
    SourceLink
    On This Page
    Coverage Criteria — Genitourinary Infectious Disease TestingCoding and Test CodesProvider Actions, Prior Authorization, and Denial RiskBackgroundDefinitionsRevision History & Policy Changes
    Testing is performed for asymptomatic pregnant members/enrollees (regardless of preterm labor risk) OR for other indications that do not meet the symptomatic criteria required for targeted testing.
    asymptomatic pregnancy or no symptoms

    Policy explicitly lists asymptomatic pregnant members as investigational for targeted testing

    Expanded Multiplex Vaginitis/Vaginosis Pathogen Panels

    Coverage stance:

    Expanded multiplex panels: Any expanded multiplex vaginitis/vaginosis pathogen panel that includes more than six targets.>6 targets

    Considered investigational for all indications

    Urine Culture for Asymptomatic Bacteriuria (medical necessity)

    Urine culture for asymptomatic bacteriuria is considered medically necessary when ANY of the following are met:

    ASB urine culture indications (covered): Member/enrollee is pregnant OR member/enrollee will undergo an endoscopic urologic procedure with mucosal trauma.pregnancy or endoscopic urologic procedure

    IDSA guideline recommendations cited in policy; examples of endoscopic procedures referenced in definitions

    Urine Culture for Asymptomatic Bacteriuria (investigational)

    Investigational (not medically necessary) when:

    ASB not covered: Specimen submitted for asymptomatic bacteriuria screening in any indication not listed as covered (i.e., asymptomatic individuals who are not pregnant and not undergoing an endoscopic urologic procedure with mucosal trauma).other indications

    Policy references IDSA guidance recommending against screening in most other populations

    Molecular/Multiplex UTI Panels

    Coverage stance:

    Molecular/multiplex UTI panels: Any molecular or multiplex urinary tract infection (UTI) panel.all indications

    Considered investigational for all indications; policy notes no professional guidelines supporting use

    Revised coverage stance for vaginitis/vaginosis testing

    Updated medical necessity stance for specific testing categories

    Targeted and Expanded Multiplex Vaginitis/Vaginosis Testing: Policy statements for Targeted Vaginitis/Vaginosis Pathogen Testing and for Expanded Multiplex Vaginitis/Vaginosis Pathogen Panels were changed from 'may be considered medically necessary' to 'are considered medically necessary'.

    Applies to listed tests and vendors added to the policy reference table (e.g., Vaginal Infection Testing, NxGen MDx) per coding implications

    Expanded multiplex vaginitis/vaginosis pathogen panels that include more than 6 targets and any molecular/multiplex urinary tract infection (UTI) panels are classified as investigational (not medically necessary) for all indications. These exclusions apply regardless of clinical presentation and are intended to prevent coverage for broad, multi‑target panels when evidence supporting clinical utility across indications is lacking.

    The policy reference tables and coding lists were updated to remove legacy or deleted entries; specifically, deleted codes such as 0352U were removed and should not be used for claim submission or authorization requests. Providers must use current codes from the policy's CPT/PLA code table when ordering or billing tests.

    Targeted vaginitis/vaginosis pathogen testing is considered investigational (not medically necessary) for asymptomatic pregnant members. In addition, the policy excludes coverage for any expanded multiplex vaginitis panels (>6 targets) and for molecular/multiplex UTI panels for any indication; these tests are not covered even when pregnancy is the context unless the testing meets the policy's specific covered indications elsewhere.

    No explicit additional 'not medically necessary' (NMN) conditions beyond those summarized in the policy chunks provided were identified in the supplied document excerpts. The full policy may include other NMN statements not present in these chunks.

    Coding and Test Codes

    PLA codes referencedmixed
    0321UInfectious agent detection by nucleic acid (DNA or RNA), genitourinary pathogens, identification of 20 bacterial and fungal organisms and identification of 16 associated antibiotic-resistance genes, multiplex amplified probe technique.
    0330UInfectious agent detection by nucleic acid (DNA or RNA), vaginal pathogen panel, identification of 27 organisms, amplified probe technique, vaginal swab.
    0371UInfectious agent detection by nucleic acid (DNA or RNA), genitourinary pathogen, semiquantitative identification, DNA from 16 bacterial organisms and 1 fungal organism, multiplex amplified probe technique via quantitative polymerase chain reaction (qPCR), urine.
    0372UInfectious disease (genitourinary pathogens), antibiotic-resistance gene detection, multiplex amplified probe technique, urine, reported as an antimicrobial stewardship risk score.
    0374UInfectious agent detection by nucleic acid (DNA or RNA), genitourinary pathogens, identification of 21 bacterial and fungal organisms and identification of 21 associated antibiotic-resistance genes, multiplex amplified probe technique, urine.
    0504UInfectious disease (urinary tract infection), identification of 17 pathologic organisms, urine, real-time PCR, reported as positive or negative for each organism.
    CPT and CPT-like codes referencedmixed
    81513Infectious disease, bacterial vaginosis, quantitative real-time amplification of RNA markers for Atopobium vaginae, Gardnerella vaginalis, and Lactobacillus species, utilizing vaginal-fluid specimens, algorithm reported as a positive or negative result for bacterial vaginosis.
    81514Infectious disease, bacterial vaginosis and vaginitis, quantitative real-time amplification of DNA markers for Gardnerella vaginalis, Atopobium vaginae, Megasphaera type 1, Bacterial Vaginosis Associated Bacteria-2 (BVAB-2), and Lactobacillus species, includes separate detection of Trichomonas vaginalis and/or Candida species.
    81515Infectious disease, bacterial vaginosis and vaginitis, real-time PCR amplification of DNA markers for Atopobium vaginae, Atopobium species, Megasphaera type 1, BVAB-2, includes detection of Trichomonas and Candida species, Candida glabrata/krusei when reported.
    87086Culture, bacterial; quantitative colony count, urine.
    87088Culture, bacterial; with isolation and presumptive identification of each isolate, urine.
    87481Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique.
    87482Infectious agent detection by nucleic acid (DNA or RNA); Candida species, quantification.
    87490Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique.
    87491Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique.
    87492Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, quantification.
    1–10 of 15
    1/2
    Selected CPT Codes (excerpt)CPT
    81513Infectious disease, bacterial vaginosis, quantitative real-time amplification of RNA markers for Atopobium vaginae, Gardnerella vaginalis, and Lactobacillus species, algorithm reported as a positive or negative result for bacterial vaginosis
    81514Infectious disease, bacterial vaginosis and vaginitis, quantitative real-time amplification of DNA markers for Gardnerella vaginalis, Atopobium vaginae, Megasphaera type 1, BVAB-2, and Lactobacillus species, includes separate detection of Trichomonas vaginalis and/or Candida species
    81515Infectious disease, bacterial vaginosis and vaginitis, real-time PCR amplification of DNA markers for Atopobium vaginae, Atopobium species, Megasphaera type 1, BVAB-2, includes detection of Trichomonas and Candida species, Candida glabrata/krusei when reported
    87086Culture, bacterial; quantitative colony count, urine
    87088Culture, bacterial; with isolation and presumptive identification of each isolate, urine
    87481Infectious agent detection by nucleic acid; Candida species, amplified probe technique
    87482Infectious agent detection by nucleic acid; Candida species, quantification
    Selected CPT Codes (excerpt)CPT
    87490Infectious agent detection by nucleic acid; Chlamydia trachomatis, amplified probe technique
    87491Infectious agent detection by nucleic acid; Chlamydia trachomatis, amplified probe technique
    87492Infectious agent detection by nucleic acid; Chlamydia trachomatis, quantification
    87498Infectious agent detection by nucleic acid; enterovirus, amplified probe technique, includes reverse transcription when performed
    87500Infectious agent detection by nucleic acid; vancomycin resistance (eg, enterococcus species vanA, vanB), amplified probe technique
    87510Infectious agent detection by nucleic acid; Gardnerella vaginalis, direct probe technique
    87511Infectious agent detection by nucleic acid; Gardnerella vaginalis, amplified probe technique
    87512Infectious agent detection by nucleic acid; Gardnerella vaginalis, quantification
    Selected CPT Codes (excerpt)CPT
    87528Infectious agent detection by nucleic acid; Herpes simplex virus, direct probe technique
    87529Infectious agent detection by nucleic acid; Herpes simplex virus, amplified probe technique
    87530Infectious agent detection by nucleic acid; Herpes simplex virus, quantification
    87531Infectious agent detection by nucleic acid; Herpes virus-6, direct probe technique
    87532Infectious agent detection by nucleic acid; Herpes virus-6, amplified probe technique
    87533Infectious agent detection by nucleic acid; Herpes virus-6, quantification
    87534Infectious agent detection by nucleic acid; HIV-1, direct probe technique
    87535Infectious agent detection by nucleic acid; HIV-1, amplified probe technique, includes reverse transcription when performed
    87536Infectious agent detection by nucleic acid; HIV-1, quantification, includes reverse transcription when performed
    87537Infectious agent detection by nucleic acid; HIV-2, direct probe technique
    1–10 of 12
    1/2
    Selected CPT Codes (excerpt)CPT
    87551Infectious agent detection by nucleic acid; Mycobacteria species, amplified probe technique
    87556Infectious agent detection by nucleic acid; Mycobacteria tuberculosis, amplified probe technique
    87561Infectious agent detection by nucleic acid; Mycobacteria avium-intraculare, amplified probe technique
    87563Infectious agent detection by nucleic acid; Mycoplasma genitalium, amplified probe technique
    87590Infectious agent detection by nucleic acid; Neisseria gonorrhoeae, direct probe technique
    87591Infectious agent detection by nucleic acid; Neisseria gonorrhoeae, amplified probe technique
    87592Infectious agent detection by nucleic acid; Neisseria gonorrhoeae, quantification
    87640Infectious agent detection by nucleic acid; Staphylococcus aureus, amplified probe technique
    Selected CPT Codes (excerpt)CPT
    87641Infectious agent detection by nucleic acid; Staphylococcus aureus, methicillin resistant, amplified probe technique
    87650Infectious agent detection by nucleic acid; Streptococcus, group A, direct probe technique
    87651Infectious agent detection by nucleic acid; Streptococcus, group A, amplified probe technique
    87652Infectious agent detection by nucleic acid; Streptococcus, group A, quantification
    87653Infectious agent detection by nucleic acid; Streptococcus, group B, amplified probe technique
    87660Infectious agent detection by nucleic acid; Trichomonas vaginalis, direct probe technique
    87661Infectious agent detection by nucleic acid; Trichomonas vaginalis, amplified probe technique
    87797Infectious agent detection by nucleic acid; not otherwise specified; direct probe technique, each organism
    87798Infectious agent detection by nucleic acid; not otherwise specified; amplified probe technique, each organism
    87799Infectious agent detection by nucleic acid; not otherwise specified; quantification, each organism
    Selected CPT Codes (excerpt)CPT
    87800Infectious agent detection by nucleic acid, multiple organisms; direct probe(s) technique
    87801Infectious agent detection by nucleic acid, multiple organisms; amplified probe(s) technique
    87808Infectious agent antigen detection by immunoassay with direct optical observation; Trichomonas vaginalis
    87810Infectious agent antigen detection by immunoassay with direct optical observation; Chlamydia trachomatis
    87850Infectious agent antigen detection by immunoassay with direct optical observation; Neisseria gonorrhoeae
    87901Infectious agent genotype analysis by nucleic acid; HIV-1, reverse transcriptase and protease regions
    87903Infectious agent phenotype analysis by nucleic acid with drug resistance tissue culture analysis, HIV-1; first through 10 drugs tested
    87904Infectious agent phenotype analysis by nucleic acid with drug resistance tissue culture analysis, HIV-1; each additional drug tested
    87906Infectious agent genotype analysis by nucleic acid; HIV-1, other region (eg, integrase, fusion)
    Target count threshold for panel designation
    Panel designation thresholdMore than six targets = expanded multiplex (investigational); six targets or fewer = targeted (may be medically necessary when symptomatic criteria are met)
    Numeric cutoff6 targets or fewer = targeted; >6 targets = expanded multiplex
    Coverage implicationExpanded multiplex panels (>6 targets) are investigational for all indications
    Coding: additional notes
    Placeholder — coding detailsSee coding implications section for full list of CPT/CPT‑like and PLA codes referenced in policy (multiple codes listed)
    None specified entryNo additional numeric thresholds specified in coding section
    Action for providersReference policy coding tables when submitting claims to ensure correct test identification

    Provider Actions, Prior Authorization, and Denial Risk

    Prior Authorization

    Referenced test codes — confirm PA requirements

    Confirm whether referenced CPT/PLA/multiplex panel codes require prior authorization or medical review before submission. Some high-complexity multiplex PLA codes (e.g., 0321U, 0330U, 0371U, 0372U, 0374U, 0504U, 81513-81515) and additional CPT codes added in the latest revision may have PA requirements—verify with Ambetter Nevada PA portal or payer contact prior to ordering.

    • Affected PLA/CPT examples: 0321U, 0330U, 0371U, 0372U, 0374U, 0504U, 81513, 81514, 81515, 87510, 87660, 87808, 87810, 87850, 87528–87539, 87901, 87903–87906
    • Check payer PA rules for multiplex panels and high‑complexity molecular tests before ordering
    Prior Authorization

    Prior authorization and updated test listings

    Prior authorization and the policy's updated test listings have changed. Review the updated CPT code table and policy reference table (includes additions such as NxGen MDx and Vaginal Infection Testing entries). Ordering providers should confirm medical necessity per the revised clinical criteria and submit PA when required.

    • Policy revisions added multiple CPT/PLA codes and laboratory test listings (see coding implications and policy reference table)
    • Providers must validate that the ordered test is listed and meets the clinical criteria in the policy prior to submission
    Denial Risk

    ASB urine culture denials — submit only for covered indications

    Urine cultures submitted for asymptomatic bacteriuria without a covered indication may be denied. Only submit urine culture for ASB when the member is pregnant or will undergo an endoscopic urologic procedure with mucosal trauma.

    • Covered indications for ASB urine culture: pregnancy; planned endoscopic urologic procedure with mucosal trauma
    • All other indications are investigational and may be denied
    Denial Risk

    Coverage stance change may affect denials

    A change in coverage language (from 'may be considered medically necessary' to 'are considered medically necessary') for targeted vaginitis/vaginosis testing and some related criteria may change prior denial patterns. Expect that some previously denied claims could now meet medical necessity if documentation aligns with the revised criteria.

    • Re-evaluate previously denied cases where clinical indications now align with the updated 'are considered medically necessary' stance
    • Ensure claims/patient records reflect the timing and specifics of symptoms per the updated criteria
    Documentation Required

    Clinical indication documentation — required to support testing

    Document clinical indications clearly when ordering tests. For vaginitis/vaginosis testing, record at least one qualifying symptomatic sign (e.g., abnormal discharge, vulvovaginal itching/irritation/redness, dyspareunia, dysuria, postcoital/contact bleeding). For ASB testing, document pregnancy or planned urologic procedure as applicable.

    • Include symptom(s), onset, and relevant exam findings in the medical record to support medical necessity
    • For multiplex or investigational tests, include rationale if ordering outside standard criteria (anticipate peer review if submitted)
    Step Therapy

    Step therapy — none specified in policy

    Step therapy: the policy content provided does not specify any step therapy requirements for the covered tests. Do not assume step edits apply unless indicated on payer-specific PA guidance.

    • No step therapy requirements are specified in the policy chunks provided
    • Confirm with Ambetter Nevada PA/medical policy resources if payer-level step edits are enforced

    Background

    Urinary tract infections and vaginitis are common outpatient conditions caused by bacteria, fungi, and protozoa. Symptom presentation for vaginitis is heterogeneous and symptom‑based diagnosis is unreliable because multiple organisms and coinfections are common; therefore targeted testing (culture, microscopy, or molecular NAAT/PCR) is used to guide therapy. The policy applies to outpatient diagnostic laboratory testing and was recently updated to clarify coding and to add specific tests/vendors to the policy reference tables.

    Definitions

    Endoscopic urologic procedure with mucosal trauma (examples)
    Definition — endoscopic urologic procedure with mucosal traumaExamples include transurethral surgery of the prostate or bladder; ureteroscopy including lithotripsy; and percutaneous stone surgery.
    Use in policySuch procedures are an indication for urine culture in asymptomatic bacteriuria when planned
    Scope noteExamples are not exhaustive — policy states 'include, but are not limited to' these procedures
    Molecular/NAAT and antigen testing — definition and included technologies
    Definition — Molecular/NAAT and antigen testingIncludes nucleic acid amplification (DNA/RNA) tests, direct and amplified probe techniques, quantification methods, and antigen immunoassays for genital and urinary pathogens as listed in the coding implications.
    Included technologiesNAAT/PCR, amplified probe techniques, direct probe techniques, real‑time PCR quantification, and antigen immunoassays
    Examples (codes)Representative codes include 87490–87492 (Chlamydia), 87660–87661 (Trichomonas), 87481–87482 (Candida), and multiple multi‑organism NAAT codes (87800–87801)

    Revision History & Policy Changes

    11/23revision

    Policy developed and reviewed by external specialist; initial Coding Implications and external specialist review noted.

    02/24approval_and_revision

    Approval recorded and operational edits: added 'lab' to policy title; removed CPT and ICD-10 codes from policy reference table; added CPT code table and moved the 'coding implications' section; corrected CPT descriptions and removed selected codes.

    03/24revision

    Corrected CPT descriptions and removed additional CPT and PLA codes (87510, 87480, 87660, 0371U, 0372U, 0374U, 0416U).

    11/24annual_review_and_content_update

    Annual review with minor non-clinical rewording; added policy number to header; updated background and references.

    02/25approval_and_material_changeLatest

    Approval recorded; material updates including addition of Urinary Tract Infection Testing (NxGen MDx, LLC) to the policy reference table; changed coverage statements for Targeted Vaginitis/Vaginosis Pathogen Testing and Expanded Multiplex Vaginitis/Vaginosis Pathogen Panels from 'may be considered medically necessary' to 'are considered medically necessary'; added multiple CPT and PLA codes and removed deleted code 0352U.