Arizona Complete Health vaginitis testing Coverage

Coverage Criteria — Diagnostic Testing for Vaginitis

Medically necessary diagnostic tests for symptomatic vaginitis

Covered when ALL of the following are met

Symptomatic women testing: Diagnostic tests for symptomatic women age ≥13 are medically necessary when performing: KOH 'whiff' test (amines); assay for sialidase activity; or direct DNA probe tests to detect Candida and Gardnerella vaginalis.

Refer to Table 1 for covered CPT codes (e.g., 82120, 87480, 87510, 87905).

BV screening in asymptomatic pregnant women

Not medically necessary for screening

Asymptomatic pregnant women BV screening: Screening asymptomatic pregnant women for bacterial vaginosis to reduce preterm birth or other pregnancy complications is not medically necessary.

Rationale: no evidence that treatment of BV in asymptomatic pregnant women reduces these complications.

Not medically necessary: amplified/multiplex molecular testing

Not medically necessary — amplified/multiplex testing

Unspecified amplified DNA-probe testing for asymptomatic care: Unspecified amplified DNA-probe testing for genitourinary conditions during routine exams, contraceptive management, or pregnancy care for asymptomatic women ≥13 is not medically necessary.

Has not been shown to improve clinical outcomes over direct DNA-probe testing.

Amplified DNA-probe testing for symptomatic evaluation: Unspecified amplified DNA-probe testing for diagnostic evaluation of symptomatic women for acute vaginitis or vulvitis (≤4 episodes per year) and for specified gynecologic/obstetric conditions is not medically necessary.

Not shown to improve clinical outcomes over direct DNA-probe testing.

Multiplex PCR panel testing: Multiplex/multitarget PCR panel testing of genitourinary pathogens commonly associated with vaginitis is not supported by current literature and is considered not medically necessary (clinical utility not established).

Although multiplex PCR may have comparable diagnostic sensitivity/specificity to conventional criteria, evidence of clinical utility over direct testing is lacking.

Not Medically Necessary CPT/ICD Combinations

Certain CPT codes are considered not medically necessary when billed with specific ICD-10-CM diagnosis codes listed in the policy tables.

Not medically necessary pairings: CPT 87798 billed with any ICD-10-CM diagnosis code listed in Table 5 is considered not medically necessary; CPT 87481 billed with any ICD-10-CM diagnosis code listed in Table 7 is considered not medically necessary.

See Tables 4–7 for the enumerated CPT codes and corresponding ICD-10-CM diagnosis lists that define not medically necessary combinations.

This policy excludes the routine use of multiplex/multitarget PCR panel testing and amplified probe techniques for evaluation of vaginitis and certain gynecologic/obstetric indications. The policy states that current literature does not support multiplex/multitarget PCR panel testing of genitourinary pathogens commonly associated with vaginitis, and that unspecified amplified DNA-probe testing is considered not medically necessary for many diagnostic and screening uses because it has not been shown to improve clinical outcomes over direct DNA-probe testing. Specific examples of excluded amplified/multiplex assays include CPT codes such as 81513, 81514, 87511, and 87798, which are categorized as not medically necessary in the policy tables.

The policy documentation and revision history clarify that this policy does not apply to the diagnosis of Trichomonas vaginalis, nor does it address point-of-care tests such as vaginal pH testing or wet mount microscopic examinations. These items were specifically noted in the policy revision log as out of scope for the amplified/multiplex testing exclusions.

Unspecified amplified DNA-probe tests and certain multiplex/amplified CPT-coded assays are considered not medically necessary under this policy. The policy expressly lists amplified or multiplex assays—examples include CPT 81513 and 81514 (multiplex PCR panels) and CPT 87511 (Gardnerella vaginalis, amplified probe technique)—and also identifies CPT 87798 (amplified probe, not otherwise specified) as not medically necessary when used for the covered indications described in the policy.

The policy includes specific coding restrictions: CPT 87798 and CPT 87481 are designated as not medically necessary when billed with certain ICD-10-CM diagnosis codes listed in the policy tables. Table 4 lists CPT 87798 as a not medically necessary code, with Table 5 enumerating the ICD-10-CM diagnoses (for example, N76.0 Acute vaginitis; N76.2 Acute vulvitis; N39.0 Urinary tract infection). Table 6 identifies CPT 87481 as not medically necessary when billed with the diagnosis codes listed in Table 7 (the policy provides the full code pairings in those tables).

Coding — CPT and ICD-10 Guidance

Covered CPT Codes (when billed with supporting ICD-10 from Table 2)CPTCovered

82120	Amines, vaginal fluid, qualitative
87480	Infectious agent detection by nucleic acid (DNA or RNA); Candida species, direct probe technique
87510	Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, direct probe technique
87905	Infectious agent enzymatic activity other than virus (eg, sialidase activity in vaginal fluid)

Not Medically Necessary CPT Codes (multiplex/amplified tests)CPTNot Covered

81513	Infectious disease, bacterial vaginosis, quantitative real-time amplification of RNA markers (Atopobium vaginae, Gardnerella vaginalis, Lactobacillus spp.)
81514	Infectious disease, bacterial vaginosis and vaginitis, quantitative real-time amplification of DNA markers (Gardnerella, Atopobium, Megasphaera type 1, BVAB-2, Lactobacillus spp.; may include Trichomonas and Candida species)
87511	Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, amplified probe technique

Not Medically Necessary CPT Codes (amplified probe NOS)CPTNot Covered

87798

Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism

Supporting ICD-10-CM diagnosis codes (Table 2)ICD-10

B37.3	Candidiasis of vulva and vagina
L29.2	Pruritus of genitals
L29.3	Pruritus of genitals
N76.0	Acute vaginitis
N76.1	Subacute and chronic vaginitis
N76.2	Acute vulvitis
N76.3	Subacute and chronic vulvitis
N77.1	Vaginitis, vulvitis, and vulvovaginitis in diseases classified elsewhere
N89.8	Other specific noninflammatory disorders of vagina
O23.511	Infection of genitourinary tract in pregnancy

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ICD-10-CM codes considered not medically necessary when billed with CPT 87798 (Table 5)ICD-10Not Covered

N39.0	Urinary tract infection, site not specified
N72	Inflammatory disease of cervix uteri
N76.0	Acute vaginitis
N76.2	Acute vulvitis
N89.9	Noninflammatory disorder of vagina, unspecified
N90.89	Other specified noninflammatory disorders of vulva and perineum
N90.9	Noninflammatory disorder of vulva and perineum, unspecified
N91.0	Absent menstruation
N91.1	Oligomenorrhea
N91.2	Hypomenorrhea

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CPT codes considered not medically necessary (Table 4)CPTNot Covered

87798

Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism

CPT codes considered not medically necessary (Table 6)CPTNot Covered

87481

Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique

ICD-10-CM diagnosis codes listed as not medically necessary with specific CPT codes (Tables 5 & 7)ICD-10Not Covered

B37.3	Candidiasis of vulva and vagina
L29.2	Pruritus of genitals
L29.3	Pruritus of genitals
N39.0	Urinary tract infection, site not specified
N72	Inflammatory disease of cervix uteri
N76.0	Acute vaginitis
N76.1	Subacute and chronic vaginitis
N76.2	Acute vulvitis
N76.3	Subacute and chronic vulvovaginitis
N76.81	Mucositis (ulcerative) of vagina and vulva

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Provider Actions — Billing, Documentation, and Prior Authorization

Denial Risk

Not Medically Necessary CPT Codes — Denial Risk

Claims for the amplified/multiplex panel and amplified probe CPT codes listed below are considered not medically necessary and are at risk for denial when billed without meeting the policy's medical necessity criteria. Ensure documentation supports the clinical indication and that billed CPT/ICD-10-CM combinations are appropriate per policy tables. Prior authorization requirements (if any) should be verified separately with the payer prior authorization policy.

Not medically necessary CPT codes — denial risk: 81513, 81514, 87511, 87798, 87481
Not medically necessary code pairings: CPT 87798 billed with ICD-10-CM codes listed in Table 5 (e.g., N39.0, N72, N76.0, N76.2, N89.9, N90.89, N91.x–N94.x, etc.) are considered not medically necessary.
Not medically necessary code pairings: CPT 87481 billed with ICD-10-CM codes listed in Table 7 (e.g., B37.3, L29.2, N39.0, N72, N76.0–N76.3, N89.8–N90.9, N91.x–N94.x, etc.) are considered not medically necessary.
Support clinical indication: Documentation in the medical record must justify that the specific CPT code billed is appropriate for the member's clinical presentation; absence of supporting documentation may result in denial.
Provider actions: Review Table 1 and Table 2 for CPT codes that are medically necessary when billed with supporting ICD-10-CM diagnosis codes; avoid billing amplified/multiplex panel codes when direct DNA-probe testing codes are indicated.

Background

Vaginitis is most commonly caused by three etiologies: bacterial vaginosis (BV), trichomoniasis, and vulvovaginal candidiasis (VVC). Typical point-of-care diagnostic approaches include the KOH 'whiff' (amine) test, assessment of vaginal fluid pH, and microscopic examination of saline or KOH wet mounts to identify clue cells, yeast, or motile trichomonads. The policy specifies that for symptomatic women age ≥ 13, medically necessary diagnostic options include the KOH whiff test, an assay for sialidase activity, or direct DNA probe tests for Candida and Gardnerella vaginalis; multiplex PCR panels and unspecified amplified probe techniques are not supported as superior to these direct or point-of-care methods.

Definitions and Diagnostic Thresholds

Amsel's Criteria

Criteria summaryAmsel's Diagnostic Criteria require 3 of 4 clinical findings for BV: homogeneous thin white discharge; clue cells on microscopy; vaginal pH >4.5; positive whiff test (fishy odor after 10% KOH).

CorrelationDetection of three Amsel criteria has been correlated with Gram stain (Nugent) results.

When to useUse Amsel criteria when Gram stain/Nugent scoring is not available as an alternative clinical diagnostic method.

RVVC

DefinitionRecurrent vulvovaginal candidiasis (RVVC) is defined as 4 or more symptomatic episodes of VVC in 1 year.

Clinical implicationRVVC is considered complicated and warrants vaginal cultures to confirm diagnosis and identify nonalbicans species.

OpenPayer

Testing for Select Genitourinary Conditions

Coverage Criteria — Diagnostic Testing for Vaginitis

Coding — CPT and ICD-10 Guidance

Provider Actions — Billing, Documentation, and Prior Authorization

Background

Definitions and Diagnostic Thresholds