Concert Infectious Disease: Dermatologic Testing (PDF)
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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).
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.
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.
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:
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:
Culture-Independent Molecular Tests (NAAT/PCR) for Onychomycosis — Not Supported
Policy position:
Coding
| 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) |
Provider Actions
Document signs/symptoms and influence on management
Providers must document that the member shows signs or symptoms of onychomycosis and that test results would influence clinical management to meet medical necessity.
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
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.'
Corrected CPT code descriptions in CPT code table.
Added 'Lab' to policy title and moved/adjusted CPT code table.
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