CurrentBlue Cross Blue Shield - IllinoisPolicy CPCPLAB052

Testing for Vector-Borne Infections

Lab management reimbursement criteria for testing of vector-borne infections for Blue Cross and Blue Shield of Illinois members; governs reimbursement and coding expectations for providers performing diagnostic testing for various vector-borne pathogens.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyTesting for Vector-Borne Infections

Policy CodePolicy CPCPLAB052

Change TypeNew policy

Effective DateJanuary 1, 2026

Next Review Date

Key ActionSubmit accurate documentation of services performed and provide additional documentation upon request; code claims using valid HIPAA-approved code sets.

SourceLink

POLICY UPDATE CHANGES

New policy.

1.0policy version

2026-01-01effective date

2025-09-25approval date

multiple pathogenscoverage scope

73references

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Coverage and Reimbursement Criteria

Reimbursement criteria by infection

Reimbursable and non-reimbursable testing guidance by suspected infection and clinical context.

Babesiosis: For individuals suspected of having babesiosis, the use of a Giemsa- or Wright-stained blood smear, nucleic acid amplification testing (NAAT), or IgG or IgM indirect immunofluorescence antibody (IFA) assay for Babesia (initial testing and confirmatory testing should occur a minimum of two weeks apart) may be reimbursable.

Relapsing fever (Borrelia spp.): For individuals suspected of having relapsing fever caused by Borrelia spp., the following may be reimbursable depending on the clinical presentation: - Hard tick relapsing fever (HTRF): serologic assays to detect Borrelia antibodies or NAAT testing to detect Borrelia miyamotoi. - Louse-borne relapsing fever (LBRF): peripheral blood smear microscopy or NAAT testing to detect Borrelia recurrentis. - Soft tick relapsing fever (STRF)/tickborne relapsing fever (TBRF): dark-field microscopy of a peripheral blood smear, microscopy of a Wright- or Giemsa-stained blood smear, NAAT testing to detect Borrelia spp., or serologic assays to detect Borrelia antibodies.

Relapsing fever (Borrelia spp.) — not reimbursable: Culture testing for Borrelia is not reimbursable.

Chikungunya: For individuals suspected of having chikungunya, the use of viral culture, NAAT on blood, or IFA assay for IgM antibodies during both the acute and convalescent phases may be reimbursable.

Colorado tick fever (CTF): For individuals suspected of having CTF, the use of NAAT testing or IFA for CTF-specific IgM antibodies may be reimbursable.

Dengue (DENV): For detection of dengue virus, NAAT, IgM antibody capture ELISA (MAC-ELISA), NS1 ELISA, and confirmatory plaque reduction neutralization testing may be reimbursable for individuals suspected of DENV infection or for individuals symptomatic for Zika as specified. The use of IgG ELISA or hemagglutination testing for DENV is not reimbursable.

Ehrlichiosis/Anaplasmosis: For individuals suspected of ehrlichiosis and/or anaplasmosis, NAAT of whole blood, IFA assay for IgG antibodies, or microscopy for morulae detection may be reimbursable. IFA for IgM antibodies and standard blood culture are not reimbursable.

Malaria: For individuals suspected of malaria, rapid immunochromatographic diagnostic tests or smear microscopy to diagnose malaria, determine Plasmodium species, identify life-cycle stage, and/or quantify parasitemia (smears may be repeated up to three times within three days if initial microscopy is negative) may be reimbursable. NAAT may be reimbursable to confirm Plasmodium species. IFA for Plasmodium antibodies is not reimbursable.

Rickettsial disease: For individuals suspected of rickettsial disease, an IFA assay for IgG antibodies (initial and confirmatory testing a minimum of two weeks apart) may be reimbursable. Standard blood culture, NAAT, and IFA for IgM antibodies are not reimbursable.

West Nile virus (WNV): For individuals suspected of WNV disease, IFA for WNV-specific IgG or IgM in serum or CSF and confirmatory plaque reduction neutralization testing may be reimbursable. Nucleic acid detection may be reimbursable for immunocompromised individuals. NAAT for WNV is not reimbursable for immunocompetent individuals.

Yellow fever virus (YFV): For individuals suspected of YFV infection, NAAT for YFV, serologic assays for virus-specific IgM and IgG, and confirmatory plaque reduction neutralization testing may be reimbursable.

Zika virus: NAAT may be reimbursable for specified pregnant and symptomatic individuals per the timeframes and exposure/travel criteria detailed in policy (including up to 12 weeks after symptom onset for certain pregnant individuals and other listed scenarios). Zika NAAT, IgM testing, and confirmatory plaque reduction neutralization testing may be reimbursable in the specified clinical situations. NAAT and/or IgM testing for symptomatic non-pregnant individuals who have not traveled outside the United States and its territories is not reimbursable.

General screening / asymptomatic testing: Testing for babesiosis, chikungunya, CTF, DENV, ehrlichiosis/anaplasmosis, malaria, rickettsial disease, TBRF, WNV, YFV, or Zika virus during a general exam without abnormal findings is not reimbursable.

Coverage criteria

Policy update history entry only; no explicit coverage criteria present in these chunks.

Policy Update History: 09/25/2025, Effective Date; Summary of Changes = 01/01/2026: New policy.

Procedure Codes and Billing

Procedure codes (not exhaustive)mixed

Policy provides a procedure code section but notes the list is not exhaustive and inclusion does not guarantee coverage.

No specific billing or CPT/ICD codes provided in this sectionmixed

No codes listed

Coding — key notes

Procedure codes notePolicy provides a procedure code section but notes the list is not exhaustive and inclusion does not guarantee coverage.

Coding systems requiredClaims must use HIPAA‑approved code sets (e.g., CPT, HCPCS, ICD‑10) and follow industry coding guidelines.

Claim reviewClaims are subject to code edit protocols and may be reviewed against provider contracts, benefit coverage, medical and coding policies.

Provider Responsibilities and Operational Notes

Documentation Required

Documentation and claims review — submit accurate documentation and be prepared to provide additional records

Providers are responsible for submission of accurate documentation of services performed and must submit claims using valid HIPAA‑approved code sets and industry-standard coding guidelines; claims are subject to claim review and providers may be asked to submit additional documentation upon request.

Submit claims using valid code combinations from HIPAA‑approved code sets (e.g., CPT, HCPCS, ICD-10).
Code claims according to industry standard coding guidelines (Uniform Billing, AMA CPT resources, CMS NCCI, etc.).
Be prepared to provide additional documentation upon request for claim review related to benefit coverage, provider contract, medical policies, clinical payment and coding policies, or coding software logic.

Note

References and diagnostic guidance — consult cited clinical resources; no authorization or billing mandates here

A referenced list of clinical and laboratory diagnostic guidance is provided for malaria, dengue, West Nile, Zika, yellow fever and other arboviral/vector-borne diseases; this section does not impose prior authorization, billing, documentation, denial risk, or step therapy requirements.

Plan Definitions and Authority

Plan documents

Included documentsCertificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.

Governing precedenceIf a conflict exists between this policy and a plan document, the plan document governs.

Provider contract precedenceIf a conflict exists between this policy and a provider contract, the provider contract governs.

BCBSIL authority

Discretionary authorityBlue Cross and Blue Shield of Illinois may use reasonable discretion interpreting and applying this policy to services being delivered in a particular case.

Final interpretationBCBSIL has full and final discretionary authority for interpretation and application to the extent provided under applicable plan documents.

Policy Update History

2025-09-25effective_date

Policy effective date recorded; summary of changes notes the new policy effective 2026-01-01.

2026-01-01new_policy_effectiveLatest

New policy becomes effective (Policy CPCPLAB052 Plan Effective Date: 2026-01-01).