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    v1.0.28
    OpenPayerPolicy UpdatesLaboratory/PathologyAmbetter Nevada CMV Testing Coverage | OpenPayer
    Ask Trek AI about this page
    ModifiedAmbetter NevadaPolicy CG.CP.MP.02

    Concert Infectious Disease: Multisystem Testing

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    This outpatient policy governs medical-necessity criteria for targeted cytomegalovirus antibody and nucleic acid/PCR or antigen detection testing, as well as untargeted metagenomic sequencing for pathogen detection. It applies to members and enrollees receiving these laboratory services.

    Policy Summary
    PayerAmbetter Nevada
    PolicyConcert Infectious Disease: Multisystem Testing
    Policy CodePolicy CG.CP.MP.02
    Change TypeModified
    Effective DateN/A
    Last ReviewNov 1, 2024
    Next Review DateN/A
    Key ActionUse CMV antibody and molecular testing only for the covered clinical indications; untargeted metagenomic sequencing is investigational for all indications.
    SourceLink
    POLICY UPDATE CHANGES

    The annual review revised policy-statement wording so that the applicable tests are described as considered medically necessary rather than using the prior wording.

    CPT/PLA code 0323U was removed from the coding table.

    CPT code descriptions in the coding table were corrected.

    Bacteria, viruses, fungus, and parasite metagenomic sequencing of spinal fluid (MSCSF) was added to the policy reference table.

    3Testing categories addressed
    12 monthsYoungest covered age pathway
    <1500 g

    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.

    Very-low-birth-weight threshold
    <37 weeksPrematurity threshold
    InvestigationalOutside stated criteria
    6CPT codes listed

    Medical Necessity Criteria

    CMV Antibody Tests

    CMV antibody tests are considered medically necessary when at least one of the following indications is met:

    Covered CMV antibody testing indications

    • Pre-transplant evaluation: The member/enrollee is a prospective organ transplant donor or recipient undergoing pre-transplant evaluation.
    • Suspected mononucleosis: The member/enrollee has suspected mononucleosis and had negative testing for Epstein-Barr Virus (EBV).
    • Pregnancy with active CMV symptoms: The member/enrollee is pregnant and has symptoms of active CMV infection.
    • Pregnancy with fetal ultrasound findings: The member/enrollee is pregnant and has ultrasound findings consistent with in utero CMV infection.

    CMV Nucleic Acid/PCR or Antigen Detection Tests

    CMV nucleic acid/PCR or antigen detection tests are considered medically necessary when at least one of the following indications is met:

    Covered CMV nucleic acid/PCR or antigen detection indications

    • Immunocompromised member: The member/enrollee is immunocompromised.

    • Young prospective transplant donor or recipient

      • The member/enrollee is 12 months of age or younger and is a prospective organ transplant donor or recipient undergoing pretransplant evaluation.12 months of age or younger
    • Post-transplant monitoring: The member/enrollee is undergoing post-transplant monitoring.

    Untargeted Metagenomic Sequencing Tests for Pathogen Detection

    These tests are not considered medically necessary under this policy.

    Investigational status: Untargeted metagenomic sequencing tests for pathogen detection are considered investigational for all indications.

    Coding Implications

    CPT CodesCPT
    86644Antibody; cytomegalovirus (CMV).
    86645Antibody; cytomegalovirus (CMV), IgM.
    87495Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, direct probe technique.
    87496Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, amplified probe technique.
    87497Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, quantification.
    0152UInfectious disease (bacteria, fungi, parasites, and DNA viruses), microbial cell-free DNA, plasma, untargeted next-generation sequencing, report for significant positive pathogens
    CPT CodesCPT
    86644Antibody; cytomegalovirus (CMV).
    86645Antibody; cytomegalovirus (CMV), IgM.
    87495Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, direct probe technique.
    87496Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, amplified probe technique.
    87497Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, quantification.
    0152UInfectious disease (bacteria, fungi, parasites, and DNA viruses), microbial cell-free DNA, plasma, untargeted next-generation sequencing, report for significant positive pathogens
    Very Low Birth Weight
    Applies toNewborns with very low birth weight
    Metric thresholdLess than 1500 grams
    Imperial equivalentLess than 3 lbs 4.9 oz
    Prematurity
    Applies toPremature newborns
    Gestational-age thresholdBorn before 37 weeks 0 days gestation
    WHO definitionBorn before 37 0/7 weeks of gestation

    Investigational and Denial-Risk Rules

    Denial Risk

    CMV Antibody Testing: Investigational Outside Covered Indications

    Do not bill CMV antibody testing as medically necessary when the member does not meet a listed covered indication. Testing for all other indications is considered investigational and may be denied.

    • Covered indications are limited to prospective organ transplant donor or recipient pre-transplant evaluation; suspected mononucleosis with negative EBV testing; or pregnancy with symptoms of active CMV infection or ultrasound findings consistent with in utero CMV infection.
    Denial Risk

    CMV Molecular Testing: Investigational Outside Covered Criteria

    Do not bill CMV nucleic acid/PCR or antigen detection testing as medically necessary outside the policy’s listed criteria. Testing for all other indications is considered investigational and may be denied.

    • Covered criteria include immunocompromised status; qualifying transplant evaluation or monitoring; very low birth weight or premature newborn status; suspected congenital CMV infection; pregnancy with ultrasound findings consistent with in utero CMV infection; or suspected mononucleosis with negative EBV testing.

    Policy Background

    Some pathogens cause infections affecting multiple body systems. Testing may be targeted to detect a specific pathogen or non-targeted to broadly detect nucleic acid from potential pathogens. CMV is usually not a serious health problem in healthy individuals but can cause significant disease in people with weakened immune systems, organ transplant recipients, pregnant patients, and infants with congenital infection or premature or very-low-birth-weight status. Metagenomic sequencing can detect genomes from multiple organisms in a single specimen, but concerns remain about distinguishing pathogen material from host material and active infection from colonization. This policy is intended for the outpatient setting.

    Clinical Definitions

    Congenital CMV Infection
    Skin and eye findingsRash and jaundice, including yellowing of the skin or whites of the eyes
    Neurologic findingsMicrocephaly and seizures
    Other featuresLow birth weight, hepatosplenomegaly, and retinitis
    Ultrasound Findings Consistent With In Utero CMV Infection
    Head and brain findingsMicrocephaly; brain abnormalities such as ventriculomegaly, intra- or parenchymal cysts, corpus callosum abnormalities, and cortical malformations
    Calcifications and bowelCalcifications of the brain and liver, and echogenic bowel
    Other findings

    Covered Testing Indications

    Covered Indications: CMV Antibody Testing

    CMV antibody testing is considered medically necessary when at least one of the following covered indications is met. All other indications are investigational.

    Covered CMV antibody testing indications

    • Prospective organ transplant donor or recipient: The member/enrollee is a prospective organ transplant donor or recipient undergoing pre-transplant evaluation.
    • Suspected mononucleosis: The member/enrollee has suspected mononucleosis and had negative testing for Epstein-Barr Virus (EBV).
    • Pregnancy with active CMV infection symptoms: The member/enrollee is pregnant and has symptoms of active CMV infection.

    Not Covered Services

    Untargeted metagenomic sequencing tests for pathogen detection are considered investigational for all indications and are not covered under this policy.

    Policy Summary
    PayerAmbetter Nevada
    PolicyConcert Infectious Disease: Multisystem Testing
    Policy CodePolicy CG.CP.MP.02
    Change TypeModified
    Effective DateN/A
    Last ReviewNov 1, 2024
    Next Review DateN/A
    Key ActionUse CMV antibody and molecular testing only for the covered clinical indications; untargeted metagenomic sequencing is investigational for all indications.
    SourceLink
    On This Page
    Medical Necessity CriteriaCoding ImplicationsInvestigational and Denial-Risk RulesPolicy BackgroundClinical DefinitionsCovered Testing IndicationsNot Covered Services
    Very-low-birth-weight newborn: The member/enrollee is a newborn with very low birth weight.Less than 1500 grams or 3 lbs 4.9 oz
  1. Premature newborn: The member/enrollee is a premature newborn.Born before 37 weeks 0 days gestation
  2. Suspected congenital CMV infection: The member/enrollee is an infant with suspected congenital CMV infection, including signs or symptoms such as congenital hearing loss, documented maternal CMV infection, or ultrasound findings consistent with in utero CMV infection.
  3. Pregnancy with fetal ultrasound findings: The member/enrollee is pregnant and has ultrasound findings consistent with in utero CMV infection.
  4. Suspected mononucleosis: The member/enrollee has suspected mononucleosis and had negative testing for Epstein-Barr Virus (EBV).
    5. Age
    Age threshold12 months of age or younger
    Applies toMembers or enrollees undergoing the qualifying transplant-evaluation pathway
    Related requirementThe member or enrollee must be a prospective organ transplant donor or recipient undergoing pretransplant evaluation
    Denial Risk

    Untargeted Metagenomic Sequencing: Investigational for All Indications

    Untargeted metagenomic sequencing tests for pathogen detection are considered investigational for all indications and carry denial risk when submitted for coverage.

    • No covered indication is identified for untargeted metagenomic sequencing for pathogen detection.
    Hepatosplenomegaly and intraventricular hemorrhages
    Active CMV Infection Symptoms
    Systemic symptomsFever, sore throat, and swollen glands
    Constitutional symptomsExtreme fatigue or malaise
    Associated conditionsMononucleosis or hepatitis
    Mononucleosis
    Constitutional symptomsMalaise or fatigue, sweats, fever, or chills
    Throat and gland findingsSore throat and swollen glands
    Other symptoms and signsAnorexia, nausea, headache, or splenomegaly
    Very Low Birth Weight
    DefinitionA birth weight below 1.5 kg
    Gram equivalentBelow 1500 grams
    Clinical contextThe definition applies to birth weight
    Preterm Infant
    DefinitionBirth before 37 0/7 weeks of gestation
    Gestational-age wordingBefore 37 weeks and 0 days
    Clinical contextThe definition applies to an infant’s gestational age at birth
    Pregnancy with ultrasound findings: The member/enrollee is pregnant and has ultrasound findings consistent with in utero CMV infection.

    Covered Indications: CMV Nucleic Acid/PCR or Antigen Detection Testing

    CMV nucleic acid/PCR or antigen detection testing is considered medically necessary when at least one of the following covered indications is met. All other indications are investigational.

    Covered CMV nucleic acid/PCR or antigen detection indications

    • Immunocompromised member: The member/enrollee is immunocompromised.
    • Young prospective transplant donor or recipient: The member/enrollee is 12 months of age or younger and is a prospective organ transplant donor or recipient undergoing pretransplant evaluation.12 months of age or younger
    • Post-transplant monitoring: The member/enrollee is undergoing post-transplant monitoring.
    • Very-low-birth-weight newborn: The member/enrollee is a newborn with very low birth weight.Less than 1500 grams or 3 lbs 4.9 oz
    • Premature newborn: The member/enrollee is a premature newborn.Born before 37 weeks 0 days gestation
    • Suspected congenital CMV infection: The member/enrollee is an infant with suspected congenital CMV infection, including signs or symptoms such as congenital hearing loss, documented maternal CMV infection, or ultrasound findings consistent with in utero CMV infection.
    • Pregnancy with ultrasound findings: The member/enrollee is pregnant and has ultrasound findings consistent with in utero CMV infection.
    • Suspected mononucleosis: The member/enrollee has suspected mononucleosis and had negative testing for Epstein-Barr Virus (EBV).