CurrentArizona Complete HealthPolicy N/A

Concert Infectious Disease: Dermatologic Testing (PDF)

Outpatient policy governing medical necessity coverage criteria for microscopy/peroxidase tests, fungal culture (presumptive and/or definitive), and culture-independent molecular (NAAT/PCR) tests for onychomycosis (nail fungal infection).

Policy Summary

PayerArizona Complete Health

PolicyConcert Infectious Disease: Dermatologic Testing (PDF)

Policy CodePolicy N/A

Change TypeRevisions to medical necessity language and coding table adjustments

Effective Date

Next Review Date

Key ActionProviders must document that the member shows signs or symptoms of onychomycosis and that test results would influence clinical management to meet medical necessity.

SourceLink

POLICY UPDATE CHANGES

For Fungal Culture for Onychomycosis and Microscopy/Peroxidase Tests for Onychomycosis, reworded policy statements from 'may be considered medically necessary' to 'are considered medically necessary.'

Added 'Lab' to policy title and moved/adjusted CPT code table.

Corrected CPT code descriptions in CPT code table.

3Test categories addressed

2Medically necessary when criteria met

1Not supported by evidence

Coverage Summary

Outpatient policy governing medical necessity coverage for diagnostic testing of onychomycosis (nail fungal infection). Microscopy/peroxidase tests (e.g., KOH preparation) and fungal culture (presumptive and/or definitive) are considered medically necessary when the member shows signs or symptoms of onychomycosis (for example, nails that are discolored, deformed, brittle, and/or foul-smelling; subungual debris; separation of the nail from the nail bed) and when test results would influence clinical management. Culture-independent molecular tests (NAAT/PCR) are not supported by current evidence for onychomycosis. Policy status: CURRENT; last review: 2025-02.

Quick facts

Test categories addressed3

Medically necessary when criteria met2

Not supported by evidence1

Last review2025-02

Medical-Necessity Criteria

Microscopy/Peroxidase Tests for Onychomycosis — Medically Necessary

Microscopy/peroxidase tests for onychomycosis are considered medically necessary when the following criteria are met:

ALL of the following

Member/enrollee shows signs or symptoms of onychomycosis (e.g., nails that are discolored, deformed, brittle, and/or foul-smelling; subungual debris; separation of the nail from the nail bed)
Results of testing would influence the member/enrollee's clinical management

Microscopy/Peroxidase Tests for Onychomycosis — Not Medically Necessary / Not Supported

Not supported when criteria above are not met:

Current evidence does not support the use of microscopy/peroxidase tests for onychomycosis for all other indications

Fungal Culture for Onychomycosis (presumptive and/or definitive) — Medically Necessary

Fungal culture (presumptive and/or definitive) for onychomycosis is considered medically necessary when the following criteria are met:

ALL of the following

Member/enrollee shows signs or symptoms of onychomycosis (e.g., nails that are discolored, deformed, brittle, and/or foul-smelling; subungual debris; separation of the nail from the nail bed)
Results of testing would influence the member/enrollee's clinical management

Fungal Culture for Onychomycosis — Not Medically Necessary / Not Supported

Not supported when criteria above are not met:

Current evidence does not support the use of fungal culture for onychomycosis (presumptive and/or definitive) for all other indications

Culture-Independent Molecular Tests (NAAT/PCR) for Onychomycosis — Not Supported

Policy position:

Current evidence does not support the use of culture-independent molecular tests (NAAT/PCR) for onychomycosis for all indications

Coding

CPT codes referenced (informational)CPT

87101	Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; skin, hair, or nail
87102	Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; other source (except blood)
87106	Culture, fungi, definitive identification, each organism; yeast
87107	Culture, fungi, definitive identification, each organism; mold
87143	Culture, typing; gas liquid chromatography (GLC) or high pressure liquid chromatography (HPLC) method
87147	Culture, typing; immunologic method, other than immunofluorescence (eg, agglutination grouping), per antiserum
87149	Culture, typing; identification by nucleic acid (DNA or RNA) probe, direct probe technique, per culture or isolate, each organism probed
87150	Culture, typing; identification by nucleic acid (DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed
87206	Smear, primary source with interpretation; fluorescent and/or acid fast stain for bacteria, fungi, parasites, viruses or cell types
87220	Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites (eg, scabies)

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Background & Evidence

Onychomycosis is common (more often affecting toenails) and is characterized by discoloration, splitting, deformation, and brittleness; non-fungal infections and non-infectious nail conditions can mimic onychomycosis. Because of diagnostic overlap, guideline sources recommend laboratory confirmation before initiating antifungal therapy. Available outpatient tests include microscopy (KOH preparation/direct microscopy), fungal culture (presumptive and definitive identification), and molecular (PCR/NAAT) techniques, though guidelines note KOH/direct microscopy is a preferred initial method and culture and microscopy are traditional confirmatory methods.

Definitions

Evidence / Guidelines

Revision History

11/24RevisedLatest

03/24Clarified