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ModifiedBlue Cross Blue Shield - LouisianaPolicy AHS - G2157

Diagnostic Testing of Common Sexually Transmitted Infections

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Coverage policy for laboratory testing of common STIs (Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum, Trichomonas vaginalis, HSV, HPV, and select others) describing when tests meet or do not meet coverage criteria for Blue Cross and Blue Shield of Louisiana members.

Policy Summary

PayerBlue Cross Blue Shield - Louisiana

PolicyDiagnostic Testing of Common Sexually Transmitted Infections

Policy CodePolicy AHS - G2157

Change TypeMaterial coverage criteria and coding updates

Effective DateSep 15, 2026

Last ReviewMay 1, 2024

Next Review DateN/A

Key ActionDocument clinical indication, specimen type, pregnancy and risk status when ordering STI tests to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Moved prenatal STI screening from the Prenatal Screening policy into this policy, adding new coverage criteria items (CC2.a., 5.e., 6.a., and 10.a.).

Clarified and reorganized multiple coverage criteria (renumbering CC3→CC4, CC6→CC7, CC7→CC8, CC12→CC13, CC13→CC14, CC16→CC18, etc.) and added/removed specific test modalities (e.g., antigen testing, culture testing).

Qualitative NAAT for Trichomonas vaginalis explicitly MEETS coverage criteria in defined situations and multi-organism vaginitis panels reallocated between policies.

Added and removed multiple CPT codes across review cycles (e.g., added 87494, 0483U/0484U, 87626, 0455U/0463U; removed several older codes).

20+coverage items

7pathogens in scope

3–12 moscreening cadence noted

Multipletests not covered

~40+code entries

Coverage Criteria for STI Testing

Syphilis antibody testing (treponemal and nontreponemal)

Covered only when ANY of the following are met:

ref":"b0_1","title":"Syphilis antibody screening in asymptomatic, not high-risk individuals"},{

citations":["5"],"intro":"","nodes":["{\"operator\":\"all\",\"n\":null,\"label\":\"Not covered methods for syphilis\",\"text\":\"Polymerase chain reaction (PCR), nucleic acid amplification testing (NAAT), and antigen testing for syphilis do not meet coverage criteria.\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}"],

ref":"b0_2","title":"Syphilis testing methods not covered"},{

citations":["5"],"intro":"Qualitative NAAT for chlamydia meets coverage when ANY of the following are met:","nodes":["{\"operator\":\"any\",\"n\":null,\"label\":\"Chlamydia NAAT indications\",\"text\":\"a) Annual assessment for asymptomatic persons in a high-risk category. b) Diagnosis in symptomatic persons. c) Diagnosis of suspected lymphogranuloma venereum (LGV). d) Test-of-cure: at least 3 months after initial diagnosis for non-pregnant individuals; at least 4 weeks after initial diagnosis for pregnant individuals.\",\"threshold\":\"timing for TOC specified\",\"note\":\"Culture, antibody, and antigen testing for chlamydia or LGV do not meet coverage\",\"children\":[]}"]

Policy Summary

PayerBlue Cross Blue Shield - Louisiana

PolicyDiagnostic Testing of Common Sexually Transmitted Infections

Policy CodePolicy AHS - G2157

Change TypeMaterial coverage criteria and coding updates

Effective DateSep 15, 2026

Last ReviewMay 1, 2024

Next Review DateN/A

Key ActionDocument clinical indication, specimen type, pregnancy and risk status when ordering STI tests to support medical necessity.

SourceLink

On This Page

ref":"b0_3","title":"Chlamydia NAAT coverage"},{

citations":["5","66"],"intro":"Covered only when ANY of the following are met:","nodes":["{\"operator\":\"any\",\"n\":null,\"label\":\"Limited chlamydia NAAT screening\",\"text\":\"a) Pregnant individuals 24 years or younger at first prenatal visit. b) Newborn screening. c) Follow-up in a victim of sexual assault. d) Sexually active individuals <18 years (annual).\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}"]

ref":"b0_4","title":"Chlamydia NAAT screening in asymptomatic, not high-risk individuals"},{

citations":["5","6"],"intro":"Qualitative NAAT for gonorrhea meets coverage in these situations; culture meets coverage for antimicrobial susceptibility when indicated:","nodes":["{\"operator\":\"any\",\"n\":null,\"label\":\"Gonorrhea NAAT indications\",\"text\":\"a) Annual assessment for asymptomatic persons in a high-risk category. b) Diagnosis in symptomatic persons. c) Test-of-cure at least 3 months after initial diagnosis.\",\"threshold\":\"\",\"note\":\"For individuals not responding to initial treatment, culture testing to determine antimicrobial susceptibility meets coverage.\",\"children\":[]}","{\"operator\":\"any\",\"n\":null,\"label\":\"Gonorrhea limited screening (not high-risk)\",\"text\":\"a) Pregnant individuals 24 years or younger at first prenatal visit. b) Newborn screening. c) Follow-up in a victim of sexual assault. d) Sexually active individuals <18 years (annual).\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}"]

ref":"b0_5","title":"Gonorrhea NAAT and culture coverage"},{

citations":["6","64","7"],"intro":"Qualitative NAAT for T. vaginalis meets coverage when ANY of the following are met:","nodes":["{\"operator\":\"any\",\"n\":null,\"label\":\"Trichomonas NAAT indications\",\"text\":\"a) Symptomatic individuals. b) Follow-up testing a minimum of 3 months after initial diagnosis. c) Annual screening for asymptomatic high-risk individuals. d) Annual screening for asymptomatic individuals with HIV. e) Follow-up in victims of sexual assault.\",\"threshold\":\"3 months for follow-up\",\"note\":\"Rapid enzyme immunoassay identification does not meet coverage.\",\"children\":[]}"]

ref":"b0_6","title":"Trichomonas vaginalis testing coverage"},{

citations":["7","62"],"intro":"","nodes":["{\"operator\":\"any\",\"n\":null,\"label\":\"M. genitalium NAAT coverage\",\"text\":\"a) Qualitative NAAT for Mycoplasma genitalium meets coverage for symptomatic individuals. b) NAAT screening for asymptomatic individuals does not meet coverage.\",\"threshold\":\"\",\"note\":\"Nucleic acid testing to determine antimicrobial susceptibility in M. genitalium (macrolide resistance) does not meet coverage.\",\"children\":[]}"]

ref":"b0_7","title":"Mycoplasma genitalium testing stance"},{

citations":["7","55","56"],"intro":"","nodes":["{\"operator\":\"any\",\"n\":null,\"label\":\"HSV testing indications\",\"text\":\"a) Qualitative NAAT for HSV-1 or HSV-2 from active genital ulcers or mucocutaneous lesions meets coverage. b) Type-specific HSV-2 (gG2) antibody testing meets coverage for recurrent or atypical genital symptoms with negative PCR/culture, for clinical diagnosis when PCR/culture negative or unavailable, and when a partner has genital herpes. c) Antibody/antigen non-type-specific HSV tests and antigen testing for HSV-2 do not meet coverage. d) Screening asymptomatic individuals for HSV-1 or HSV-2 does not meet coverage.\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}"]

ref":"b0_8","title":"Herpes simplex virus testing"},{

citations":["8","91","93"],"intro":"","nodes":["{\"operator\":\"any\",\"n\":null,\"label\":\"HPV testing indications\",\"text\":\"a) NAAT or p16 IHC testing for high-risk HPV meets coverage for diagnosis/assessment of cancer or cancer therapy. b) HPV testing does not meet coverage when used as part of general STI screening panels for asymptomatic individuals, for anogenital wart diagnosis, for low-risk HPV types, or routine testing in men.\",\"threshold\":\"\",\"note\":\"HPV screening for cervical cancer addressed in separate policy G2002.\",\"children\":[]}"]

ref":"b0_9","title":"HPV testing coverage"},{

citations":["8","22"],"intro":"","nodes":["{\"operator\":\"all\",\"n\":null,\"label\":\"PrEP-associated screening\",\"text\":\"Before and during PrEP: a) Qualitative NAAT screening for gonorrhea and chlamydia: once every 3 months for MSM; once every 6 months for sexually active individuals. b) Blood testing for syphilis: once every 3 months for MSM; once every 6 months for sexually active individuals.\",\"threshold\":\"3 or 6 months as specified\",\"note\":\"These monitoring intervals meet coverage for PrEP management.\",\"children\":[]}"]

ref":"b0_10","title":"STI screening frequency for individuals on PrEP"},{

citations":["9","129","131"],"intro":"","nodes":["{\"operator\":\"all\",\"n\":null,\"label\":\"Not covered assay methods\",\"text\":\"Direct probe detection and/or quantitative NAAT for C. trachomatis, N. gonorrhoeae, HSV-1, HSV-2, Treponema pallidum, and T. vaginalis do not meet coverage criteria.\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}"]

ref":"b0_11","title":"Assay methods explicitly not covered"},{

citations":["51","53","54","55"],"intro":"Covered when consistent with guideline-recommended indications:","nodes":["{\"operator\":\"all\",\"n\":null,\"label\":\"CT/NG screening (USPSTF)\",\"text\":\"Screen sexually active females ≤24 years and females ≥25 years at increased risk for chlamydia and gonorrhea using NAATs; pregnant individuals follow same age/risk recommendations.\",\"threshold\":\"USPSTF Grade B\",\"note\":\"Both chlamydia and gonorrhea should be tested using NAATs.\",\"children\":[]}","{\"operator\":\"any\",\"n\":null,\"label\":\"Syphilis screening (USPSTF/CDC)\",\"text\":\"Screen persons at increased risk (including MSM, persons with HIV) at recommended intervals; universal early pregnancy screening and if missed, screen at first opportunity; treponemal or nontreponemal tests are accurate but require confirmation.\",\"threshold\":\"per USPSTF/CDC guidance\",\"note\":\"Screening frequency (eg, every 3 months for some high-risk groups) associated with improved detection.\",\"children\":[]}","{\"operator\":\"all\",\"n\":null,\"label\":\"HSV serology\",\"text\":\"Do not perform routine serologic screening for genital herpes in asymptomatic adolescents and adults; type-specific serology may be used for symptomatic patients with negative PCR/culture or when partner has genital herpes.\",\"threshold\":\"USPSTF recommendation against routine screening\",\"note\":\"High false-positive rate and psychosocial harms cited.\",\"children\":[]}","{\"operator\":\"all\",\"n\":null,\"label\":\"HPV testing\",\"text\":\"HPV testing (eg, Cobas) is more sensitive than cytology for detection of CIN3+ and may be used in cervical cancer screening strategies; assay and triage choice affects referrals.\",\"threshold\":\"per NCCN/ATHENA evidence\",\"note\":\"Choice of assay and triage strategy affects referrals for colposcopy.\",\"children\":[]}"]

ref":"b0_12","title":"Guideline-aligned testing indications"},{

citations":["54","56","58","59","60","62","64","66","67"],"intro":"Covered/recommended testing when clinical scenario or screening criteria met per CDC/IUSTI guidance:","nodes":["{\"operator\":\"any\",\"n\":0,\"label\":\"Genital/anal/perianal ulcers (syphilis/HSV evaluation)\",\"text\":\"Persons with genital, anal, or perianal ulcers should be evaluated with syphilis serology AND darkfield examination from lesion exudate or tissue or NAAT if available; HSV NAAT or culture from lesions; type-specific HSV serology as indicated.\",\"threshold\":\"\",\"note\":\"CDC recommends combined serologic testing and direct detection methods for early syphilis.\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"Syphilis serologic testing\",\"text\":\"Diagnosis requires use of two serologic tests: a nontreponemal test (eg, RPR/VDRL) AND a treponemal test (eg, TP-PA, EIA/CIAs); CSF analysis and CSF-VDRL indicated when neurologic/ocular/otologic signs present.\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"Chlamydia testing\",\"text\":\"NAAT testing of first-catch urine or swab specimens is recommended; obtain anatomy-site specimens for extragenital exposures and screen annually for sexually active women <25 years and older women at increased risk.\",\"threshold\":\"\",\"note\":\"NAAT preferred over culture and serology.\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"Gonorrhea testing\",\"text\":\"NAAT is preferred for urogenital and many nongenital sites; culture should be maintained for antimicrobial susceptibility and suspected treatment failure or public health needs.\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}","{\"operator\":\"any\",\"n\":0,\"label\":\"Mycoplasma genitalium testing\",\"text\":\"Test men with recurrent nongonococcal urethritis and women with recurrent cervicitis for M. genitalium using an FDA-cleared NAAT; consider testing in PID; resistance testing recommended if available.\",\"threshold\":\"\",\"note\":\"Screening asymptomatic persons or extragenital sites is not recommended.\",\"children\":[]}","{\"operator\":\"any\",\"n\":0,\"label\":\"HSV testing\",\"text\":\"HSV NAAT assays from genital ulcers or mucocutaneous lesions are most sensitive; type-specific serologic assays useful in select scenarios; routine HSV serologic screening in pregnancy is not recommended.\",\"threshold\":\"\",\"note\":\"Direct immunofluorescence lacks sensitivity and is not recommended.\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"Trichomoniasis testing\",\"text\":\"Women with vaginal discharge should have diagnostic testing for T. vaginalis; NAATs are highly sensitive and preferred over wet mount; consider annual screening in high-prevalence settings and routine annual screening for sexually active women with HIV; retest ~3 months due to reinfection.\",\"threshold\":\"\",\"note\":\"Retest ~3 months for positives.\",\"children\":[]}","{\"operator\":\"any\",\"n\":0,\"label\":\"HPV testing\",\"text\":\"HPV tests should be used for cervical cancer screening in persons aged 30–65 years per cervical screening intervals; HPV testing is not recommended for diagnosis of genital warts or routine testing in men or persons <30 years.\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"Pregnancy-specific STI screening\",\"text\":\"All pregnant people should be tested early in pregnancy for syphilis, HIV, hepatitis B and C; chlamydia and gonorrhea screening recommended for pregnant people <25 years and those 25+ at increased risk with retesting in third trimester for those under 25 or at risk; syphilis testing repeated at 28 weeks and at delivery if increased risk.\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"PrEP monitoring\",\"text\":\"Before initiating PrEP, screen for STIs and hepatitis B; repeat HIV antigen/antibody and HIV-1 RNA and assess for other STIs at least every 3 months; screen chlamydia and gonorrhea at appropriate anatomic sites at least every 3–6 months depending on risk and population.\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}"]

ref":"b0_13","title":"Organism-specific testing recommendations"},{

citations":["74","75","78","80","89"],"intro":"Guideline-based testing recommendations and algorithms:","nodes":["{\"operator\":\"all\",\"n\":0,\"label\":\"Syphilis serologic testing algorithm\",\"text\":\"Either a treponemal-test (TT)-first (automated EIA/ELISA/CLIA) or a non-treponemal-test (NTT; RPR/VDRL) algorithm may be used. If TT used alone and positive, perform reflex quantitative NTT on same serum (target dilutions at least 1:8 to 1:16); if TT positive but NTT negative with no suspicion of early syphilis, repeat both in 1 month. Reflex confirmatory TPHA/TPPA recommended when EIA/CLIA specificity suboptimal.\",\"threshold\":\"reflex NTT dilution >=1:8\",\"note\":\"IUSTI guidance\",\"children\":[]}","{\"operator\":\"any\",\"n\":0,\"label\":\"Direct detection of T. pallidum\",\"text\":\"Direct detection methods (PCR preferred for lesions; darkfield microscopy not recommended for routine diagnosis) are appropriate for lesion specimens when available; choose validated PCR assays with quality controls.\",\"threshold\":\"PCR preferred for lesion specimens\",\"note\":\"IUSTI guidance\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"Chlamydia testing\",\"text\":\"Use NAATs for detection; screen females with vaginal/cervical swabs or first-void urine and males with first-void urine; obtain extragenital specimens as indicated. Repeat test at 3 months after treatment for positives.\",\"note\":\"PHAC, MTC, AAP guidance\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"Gonorrhea testing\",\"text\":\"Use NAATs on urine or genital swabs; culture may be used to obtain antimicrobial susceptibility for treatment/public health surveillance; test extragenital sites as indicated and re-screen for reinfection at 3 months when positive.\",\"note\":\"PHAC, MTC, AAP guidance\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"HSV testing\",\"text\":\"HSV DNA detection by NAAT is preferred for diagnosis of lesions; serology not routinely recommended in asymptomatic patients but may be useful in specific situations (pregnancy, partner evaluation, recurrent atypical disease).\",\"note\":\"IUSTI, PHAC, BASHH guidance\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"M. genitalium testing\",\"text\":\"NAATs may be performed on urine, cervical, vaginal, urethral or meatal swabs and endometrial biopsies when testing is indicated; resistance testing recommended if available.\",\"note\":\"PHAC guidance\",\"children\":[]}"]

ref":"b0_14","title":"Testing algorithms and specimen/site-specific recommendations"},{

citations":["77","83","85"],"intro":"Recommended screening intervals and target populations:","nodes":["{\"operator\":\"any\",\"n\":0,\"label\":\"At-risk population screening frequency\",\"text\":\"Annual testing for chlamydia, gonorrhea, syphilis, HIV and Hep C for at-risk populations; more frequent screening (every 3–6 months) for MSM with high-risk behaviors, sex workers, and others exchanging sex for drugs. MSM on PrEP should have STI screening every 3 months.\",\"note\":\"MTC, AAP, NICE guidance\",\"children\":[]}"]

ref":"b0_15","title":"Screening frequency"},{

citations":["91","92","93","95","97"],"intro":"Coverage considerations reflect guideline recommendations from multiple bodies; testing is recommended based on organism, clinical presentation, and patient risk factors:","nodes":["{\"operator\":\"all\",\"n\":0,\"label\":\"Syphilis testing\",\"text\":\"Serologic testing for syphilis is recommended for specified populations (eg, pre-transplant allo-HCT candidates) and diagnostic evaluation of ulcers; use combinations of non-treponemal (eg, RPR/VDRL) and treponemal tests; confirm positive non-treponemal with treponemal test.\",\"threshold\":\"\",\"note\":\"Supported by BASHH and CDC guidance.\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"Chlamydia and Gonorrhea\",\"text\":\"NAATs are recommended for detection in symptomatic and specified asymptomatic at-risk populations (eg, sexually active women <25, MSM and others at risk); culture required when antimicrobial susceptibility testing for gonorrhea is needed.\",\"threshold\":\"\",\"note\":\"Supported by CDC, USPSTF, IUSTI, AAP guidance.\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"HSV testing\",\"text\":\"Do not routinely test asymptomatic patients for HSV-2 (per USPSTF); for genital ulcers, PCR/NAAT for HSV and type-specific serology when indicated; NAAT/DNA detection preferred over culture.\",\"threshold\":\"\",\"note\":\"Supported by USPSTF, CDC, IUSTI, BASHH.\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"HPV testing\",\"text\":\"HPV testing is recommended for cervical cancer screening in women ≥30 as part of co-testing or primary HPV testing per guidelines; routine HPV testing is not recommended for asymptomatic men or general STI panels.\",\"threshold\":\"\",\"note\":\"Supported by CDC, NCCN, USPSTF, IUSTI.\",\"children\":[]}"]

ref":"b0_16","title":"Guideline-based coverage considerations"},{

citations":["128","129","130","131","132","133","134","135"],"intro":"Policy contains multiple coverage criteria (CC) with specific MEETS COVERAGE CRITERIA (MCC) and DOES NOT MEET COVERAGE CRITERIA (DNMCC) statements and renumbered CC items across revisions:","nodes":["{\"operator\":\"all\",\"n\":0,\"label\":\"Prenatal screening\",\"text\":\"Prenatal STI screening was moved into this policy with new subcriteria specifying testing at the first prenatal visit for pregnant individuals and timing for test-of-cure for chlamydia and retesting recommendations in the third trimester when indicated.\",\"threshold\":\"\",\"note\":\"See revision history for CC numbering details.\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"Syphilis testing restrictions\",\"text\":\"PCR, NAAT, and antigen testing for syphilis DO NOT MEET COVERAGE CRITERIA; treponemal Ig testing is not covered in individuals with current or past syphilis except where explicitly noted (eg, pre-transplant).\",\"threshold\":\"\",\"note\":\"Multiple CC renumberings and clarifications documented.\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"Chlamydia/LGV testing restrictions\",\"text\":\"Culture testing, antibody testing, and antigen testing for chlamydia or LGV DO NOT MEET COVERAGE CRITERIA.\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"Trichomonas (T. vaginalis)\",\"text\":\"Qualitative NAAT for T. vaginalis MEETS COVERAGE CRITERIA for symptomatic individuals; follow-up testing a minimum of 3 months after diagnosis; annual screening for asymptomatic high-risk individuals and persons with HIV; rapid enzyme immunoassay does NOT MEET COVERAGE CRITERIA.\",\"threshold\":\"minimum 3 months for follow-up\",\"note\":\"Note 8 defines high-risk groups.\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"Multitarget PCR panels\",\"text\":\"Multitarget PCR testing is allowed when targets are limited to C. trachomatis, N. gonorrhoeae, T. vaginalis, and M. genitalium and the individual meets stated conditions for panel testing.\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}","{\"operator\":\"any\",\"n\":0,\"label\":\"M. genitalium testing\",\"text\":\"NAAT for M. genitalium MEETS COVERAGE CRITERIA for symptomatic individuals; screening asymptomatic individuals for M. genitalium DOES NOT MEET COVERAGE CRITERIA.\",\"threshold\":\"\",\"note\":\"New CC12 and CC13 added.\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"HSV testing\",\"text\":\"Antibody and antigen testing for HSV-1 and antigen testing for HSV-2 DO NOT MEET COVERAGE CRITERIA in specified contexts; HSV criteria were reordered and clarified.\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"HPV testing\",\"text\":\"HPV testing as a cervical cancer screen is addressed in separate policy G2002; this policy retains coverage for NAAT or p16 IHC for high-risk HPV in cancer assessment.\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"Antimicrobial resistance testing\",\"text\":\"Nucleic acid testing to determine antimicrobial susceptibility in N. gonorrhoeae or macrolide resistance in M. genitalium DOES NOT MEET COVERAGE CRITERIA.\",\"threshold\":\"\",\"note\":\"New CC23 added.\",\"children\":[]}"]

ref":"b0_17","title":"Summary coverage criteria and notable logic groups"}]}]}

Multiple test modalities are explicitly listed in the policy as excluded from coverage. Examples include PCR, NAAT, and antigen testing for syphilis, and for chlamydial infections the policy specifically states that culture testing, antibody testing, and antigen testing for Chlamydia trachomatis or LGV DO NOT MEET COVERAGE CRITERIA. The policy also lists direct probe detection and/or quantitative NAAT for several organisms among methods that do not meet coverage criteria, reflecting a deliberate narrowing of covered assay types.

These exclusions are operational: tests described as 'DO NOT MEET COVERAGE CRITERIA' are treated as non-covered modalities and may trigger claim denials if submitted as standalone covered services. Providers should therefore select and document covered, guideline-aligned methods (for example, serology for syphilis and NAAT for CT/NG where indicated) or follow the explicit coverage criteria when ordering tests.

The policy notes that NAAT/PCR for genital syphilis is not FDA‑approved for routine testing in this excerpt and is not typically performed for genital syphilis. There is no internationally approved PCR for Treponema pallidum, and molecular methods must be strictly validated and used with appropriate quality controls when applied.

Consequently, the policy classifies PCR, NAAT, and antigen testing for syphilis as not meeting coverage criteria, and recommends the standard two‑tiered serologic approach (nontreponemal plus treponemal testing) as the primary diagnostic method for most clinical scenarios.

Routine serologic screening for genital herpes in asymptomatic adolescents and adults is not recommended. The USPSTF systematic review and CDC guidance cited in the policy indicate a high false‑positive rate with population screening (example: in a population prevalence of 16% the positive predictive value was ~50%), and potential psychosocial harms from false positives.

Accordingly, type‑specific HSV serology is reserved for selected clinical situations (for example, recurrent or atypical genital symptoms with negative lesion testing, or evaluation when a partner has genital herpes) rather than for routine population screening.

The policy does not support routine population‑wide serologic screening for HSV‑2, routine asymptomatic screening for Mycoplasma genitalium using NAAT, nor routine HPV testing in men or for diagnosis of anogenital/penile warts. CDC guidance cited in the policy explicitly advises against HPV testing in men and states HPV testing does not guide anogenital wart management.

For M. genitalium, CDC guidance and the policy limit NAAT testing to symptomatic indications (e.g., recurrent nongonococcal urethritis, recurrent cervicitis, or consideration in PID) and state that screening asymptomatic individuals with NAAT does not meet coverage criteria.

The policy describes older direct detection techniques for syphilis (e.g., darkfield microscopy, Warthin‑Starry staining, direct fluorescent antibody) as having limited routine utility. IUSTI and CDC guidance note that darkfield examination was historically a gold standard but is labor intensive, subjective, and produces variable sensitivity and specificity; it is therefore not recommended for routine diagnosis where more sensitive, validated molecular or serologic methods are available.

Immunohistochemistry and tissue hybridization also have limited routine roles, and direct fluorescent antibody testing is characterized as obsolete in the guideline summaries included in the policy.

HPV testing within this policy is limited to indications consistent with cancer screening or assessment (for example, testing for high‑risk HPV in cervical cancer screening or pathology‑directed assays such as p16 immunohistochemistry). The CDC guidance cited in the policy states there is no approved HPV test for men, and HPV testing is not recommended for diagnosing anogenital warts because results do not guide management.

Therefore, the policy does not support routine HPV NAAT as a general STI screen in men or for anogenital wart diagnosis; HPV testing for cervical cancer screening follows separate, age‑based guideline recommendations.

Procedure and HCPCS/CPT codes included in Medical Policy documents are provided as a general reference tool and may not be all‑inclusive. The policy explicitly advises that listed procedure codes should be used only as reference and that providers should verify coding, billing, and payer requirements prior to submission.

Because codes are updated off‑cycle and changes are recorded in the revision history, clinicians and billing staff should confirm the current code set and any payer‑specific authorization rules when ordering or submitting claims for STI testing.

The policy explicitly identifies specific test types that DO NOT MEET COVERAGE CRITERIA. These include PCR/NAAT/antigen testing for syphilis, and for chlamydia/LGV the policy lists culture, antibody, and antigen testing as non‑covered methods. The revision history documents reassignments and clarifications that added or moved these modalities between 'meets' and 'does not meet' coverage lists.

These reassignments are operational: tests listed as not meeting coverage criteria may be denied when billed as standalone covered services, so ordering clinicians should select covered methods and document the clinical indication and specimen type to support medical necessity where testing is performed.

The policy states that screening asymptomatic individuals for HSV‑1 or HSV‑2 does not meet coverage criteria. This aligns with USPSTF and CDC guidance that routine serologic screening for genital herpes in asymptomatic adolescents and adults is not recommended due to high false‑positive rates and limited clinical benefit.

HSV type‑specific serology is still appropriate in targeted clinical contexts (for example, recurrent or atypical genital symptoms with negative lesion PCR/culture, or partner evaluation) but not for population screening of asymptomatic people.

The policy clarifies that NAAT screening for Mycoplasma genitalium in asymptomatic individuals does not meet coverage criteria. CDC guidance incorporated into the policy recommends M. genitalium NAAT testing only for symptomatic patients (such as men with recurrent nongonococcal urethritis or women with recurrent cervicitis) and suggests resistance testing when available to guide therapy.

Asymptomatic population screening for M. genitalium is therefore not supported by the policy and may be considered not medically necessary.

Antigen‑detection point‑of‑care tests (POCTs) for Chlamydia trachomatis and Neisseria gonorrhoeae demonstrate markedly lower sensitivity than laboratory NAATs and are therefore not recommended as sole screening tests. The policy cites systematic reviews showing POCT antigen tests have sensitivities as low as ~37–63% for CT depending on specimen, while near‑patient NAATs and laboratory NAATs have sensitivities >95%.

Because of their limited sensitivity, antigen‑detection POCT immunochromatographic/optical assays are not generally recommended for routine screening or diagnosis when a higher‑sensitivity NAAT is available.

The policy reiterates that routine HSV‑2 serologic screening in the general population is not supported and that routine asymptomatic testing for M. genitalium or HPV outside recommended screening contexts is not covered. CDC guidance states type‑specific HSV testing is useful only in select clinical scenarios and that HPV testing is not recommended for men or for diagnosis of anogenital warts.

Additionally, the policy lists nucleic acid testing to determine antimicrobial susceptibility in N. gonorrhoeae or macrolide resistance in M. genitalium as not meeting coverage criteria, further limiting routine molecular testing outside of specified clinical indications.

Darkfield examination is described as labor intensive, operator dependent, and subject to variable sensitivity and specificity; guideline excerpts cited in the policy conclude that darkfield microscopy is not recommended for routine diagnosis because modern molecular assays (when appropriate and validated) and serologic testing offer improved performance.

As a consequence, the policy discourages routine use of darkfield and describes direct fluorescent antibody tests and certain older staining techniques as having limited or obsolete roles in routine clinical practice.

Per USPSTF and CDC guidance summarized in the policy, testing asymptomatic patients for HSV‑2 is not recommended and may be considered not medically necessary absent symptoms, exposure, or other specific indications. The policy highlights the low positive predictive value of HSV serology in low‑prevalence populations and potential psychosocial harms from false positives.

Ordering clinicians should therefore reserve HSV serologic testing for the scenarios identified in the coverage criteria (for example, recurrent/atypical symptoms with negative lesion PCR/culture or partner evaluation) and document the clinical rationale.

Screening asymptomatic individuals for M. genitalium using NAAT DOES NOT MEET COVERAGE CRITERIA. This policy position aligns with CDC recommendations that limit M. genitalium NAAT to symptomatic patients (e.g., recurrent NGU or recurrent cervicitis) and advise against routine asymptomatic screening.

Clinicians should order M. genitalium testing only when specific clinical indications are present and should document symptoms and risk factors to support medical necessity.

Applicable Procedure and Proprietary Codes

Covered CPT Codes (selection)CPTCovered

86592	Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART)
86593	Syphilis test, non-treponemal antibody; quantitative
86631	Antibody; Chlamydia
86632	Antibody; Chlamydia, IGM
86694	Antibody; herpes simplex, non-specific type test
86695	Antibody; herpes simplex, type 1
86696	Antibody; herpes simplex, type 2
86780	Antibody; Treponema pallidum
87081	Culture, presumptive, pathogenic organisms, screening only
87110	Culture, Chlamydia, any source

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Covered CPT Codes (continued)CPTCovered

87492	Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, quantification
87494	Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis and Neisseria gonorrhoeae, multiplex amplified probe technique
87528	Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, direct probe technique
87529	Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, amplified probe technique
87530	Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, quantification
87563	Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma genitalium, amplified probe technique
87590	Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, direct probe technique
87591	Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique
87592	Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, quantification
87623	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types

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Covered CPT Codes (continued)CPTCovered

87660	Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, direct probe technique
87661	Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, amplified probe technique
87797	Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism
87798	Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism
87799	Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; quantification, each organism
87800	Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique
87808	Infectious agent antigen detection by immunoassay with direct optical observation; Trichomonas vaginalis
87810	Infectious agent antigen detection by immunoassay with direct optical observation; Chlamydia trachomatis
88341	Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure
88342	Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure

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Proprietary and Other HCPCS CodesHCPCSCovered

0065U	Syphilis test, non-treponemal antibody, immunoassay, qualitative (BioPlex 2200 RPR Assay)
0096U	Human papillomavirus (HPV), high-risk types, male urine (Proprietary test)
0210U	Syphilis test, non-treponemal antibody, immunoassay, quantitative (BioPlex 2200 RPR Assay - Quantitative)
0402U	Probe technique, vaginal, endocervical, or male urine, each pathogen reported as detected or not detected (Abbott Alinity™ m STI Assay)
0483U	Infectious disease (Neisseria gonorrhoeae), sensitivity, ciprofloxacin resistance (gyrA S91F point mutation)
0484U	Infectious disease (Mycoplasma genitalium), macrolide sensitivity (23S rRNA point mutation)

Proprietary HCPCS molecular/infectious-disease testsHCPCS

0483U	Infectious disease (Neisseria gonorrhoeae), sensitivity, ciprofloxacin resistance (gyrA S91F point mutation), oral, rectal, or vaginal swab, algorithm reported as probability of fluoroquinolone resistance; Proprietary test: Ciprofloxacin Susceptibility of Neisseria gonorrhoeae; Lab/Manufacturer: MedArbor Diagnostics, SpeeDx, Inc
0484U	Infectious disease (Mycoplasma genitalium), macrolide sensitivity (23S rRNA point mutation), oral, rectal, or vaginal swab, algorithm reported as probability of macrolide resistance; Proprietary test: Macrolide Resistance of Mycoplasma genitalium; Lab/Manufacturer: MedArbor Diagnostics, SpeeDx, Inc

Coding changes (added and removed codes across revision history)CPT

87494	CPT code added (off-cycle modification)
0483U	Added CPT code
0484U	Added CPT code
87626	Added CPT code
0455U	Added CPT code
0463U	Added CPT code
0167U	Removed CPT code
0353U	Removed CPT code
0354U	Removed CPT code
87660	Previously added/removed in revisions

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Removed codesmixed

87800	Added CPT code referenced in Note
82565	Removed CPT code
82575	Removed CPT code
84702	Removed CPT code
84703	Removed CPT code
86701	Removed CPT code
86702	Removed CPT code
86703	Removed CPT code
86705	Removed CPT code
86803	Removed CPT code

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HSV serology positive predictive value example

HSV serology PPV exampleIn a population with HSV-2 prevalence of 16%, the pooled USPSTF estimates yield a positive predictive value of approximately 50% (15,840 true-positives vs 15,960 false-positives per 100,000).

Screening age / target groups — examples

Chlamydia/Gonorrhea screening - age/targetsScreen sexually active females ≤24 years and females ≥25 years at increased risk using NAATs; pregnant individuals follow same age/risk recommendations.

Chlamydia/Gonorrhea - adolescentsSexually active individuals <18 years: annual screening and covered in prenatal or forensic (sexual assault) follow-up contexts.

HPV screening - age/targetsHPV testing for cervical cancer screening is recommended for women aged 30–65 years per cervical screening guidelines (co-testing or primary HPV strategies).

Provider Actions, Documentation, and Billing Considerations

Prior Authorization

Prior authorization not specified

The policy excerpt does not state routine prior authorization requirements for the STI tests listed; follow payer-specific administrative rules and member benefit coverage for any authorization needs.

If local payer or government (Medicare/Medicaid) policies require prior authorization, those rules apply.
No standalone prior‑auth language for listed CPT/HCPCS codes is present in the policy excerpt; verify in the payer portal before billing.

Prior Authorization

Prior authorization — none specified in excerpt

No explicit prior authorization conditions are described in the document excerpts; when ordering FDA‑approved assays, document clinical indication and specimen type and follow Blue Cross Blue Shield of Louisiana administrative rules.

Providers should check member benefits and payer portals for any local prior‑auth requirements.
Document clinical indication and specimen to support medical necessity if requested.

Note

Rapid/near-patient NAAT use

Near‑patient/rapid molecular NAATs (e.g., Cepheid GeneXpert Xpert CT/NG) offer high sensitivity and rapid turnaround and can influence same‑day treatment decisions; document clinical indication and use of the rapid NAAT when performed.

Use validated near‑patient NAAT platforms as appropriate (e.g., GeneXpert) and record the assay name and result timing.
Document that rapid testing informed same‑day management when used to guide treatment.

Prior Authorization

Prior authorization — none specified

The policy fragment contains no explicit prior authorization statements for listed CPT/HCPCS codes; providers must verify payer and government policy requirements prior to submission.

Confirm prior‑auth needs for individual member plans and for any codes added via off‑cycle coding.
Codes listed in this policy are for reference and may not reflect payer billing rules.

Prior Authorization

Prior authorization not specified in guideline excerpts

Guideline excerpts and the policy do not include routine prior authorization triggers for STI testing; always follow applicable payer and government policies when ordering.

If conflict exists between this policy and LCD/NCD/state Medicaid, government policy prevails and may impose authorization requirements.
Check the Medicare and state Medicaid coverage databases when treating beneficiaries.

Prior Authorization

Prior authorization for listed codes

No explicit prior authorization requirements are stated for the CPT/HCPCS codes listed in the policy fragment; verify payer rules before billing the included procedure codes.

Procedure codes in the policy are provided as a reference and may not be all‑inclusive.
Confirm code-specific prior‑auth requirements in the payer portal or member benefit documents.

Billing Rule

Check proprietary test coding

Certain proprietary molecular or infectious‑disease tests are mapped to HCPCS (for example, Abbott Alinity m STI Assay and proprietary resistance assays); verify billing and medical‑policy requirements for these proprietary HCPCS codes before submission.

When ordering a proprietary test, document the manufacturer/lab and specific assay (e.g., Abbott Alinity™ m STI Assay).
Confirm that the provider’s billing system maps the proprietary assay to the correct HCPCS code (e.g., 0402U, 0483U, 0484U).

Billing Rule

Coding updates — verify payer authorization requirements

After off‑cycle coding or other code changes, verify whether newly added CPT/HCPCS codes require payer notification or prior authorization per local administrative rules.

Examples of off‑cycle additions include 87494, 0483U, 0484U, 87626; confirm payer systems recognize these codes.
If a code is new to the policy, validate billing guidance with the payer before claim submission.

Step Therapy

Step to culture for treatment non-response

If a patient does not respond to initial gonorrhea therapy, culture testing for N. gonorrhoeae to determine antimicrobial susceptibility MEETS COVERAGE CRITERIA and should be performed to guide treatment.

Order culture and susceptibility testing when there is clinical or microbiologic evidence of treatment failure.
Document prior treatment, timing, and clinical response to justify culture for antimicrobial susceptibility.

Step Therapy

Step therapy — not applicable in excerpt

No step‑therapy restrictions are described in the excerpt; the policy does not impose prior therapeutic trial requirements for listed STI diagnostic tests.

Step therapy is not specified for diagnostic testing in this policy excerpt.
Follow clinical guidelines for test sequencing (e.g., NAAT preferred for CT/NG) rather than a payer step‑therapy mandate.

Note

Documentation Required

Supporting clinical documentation recommended

Document the patient's risk group status, presenting symptoms, pregnancy status, HIV status, timing relative to prior diagnosis or treatment, and PrEP or transplant status when ordering STI tests to support medical necessity.

Include pregnancy status and gestational timing for prenatal testing documentation.
Record prior infection dates and dates of treatment when ordering tests as tests of cure or follow‑up.

Documentation Required

Assay, specimen, and indication documentation

Record the specific assay used, specimen type (e.g., first‑void urine, clinician‑ or patient‑collected vaginal swab, endocervical swab, pharyngeal swab, rectal swab) and the indication (screening vs symptomatic) because product performance varies by specimen and indication.

Document assay name/manufacturer (e.g., Cepheid Xpert CT/NG, Abbott Alinity m STI) and specimen type in the medical record and lab requisition.
For extragenital exposure, document the anatomic site to justify extragenital NAAT collection.

Documentation Required

Specimen and test documentation for ulcerative disease

For evaluation of genital, anal, or perianal ulcers, include syphilis serology and direct detection (darkfield or lesion NAAT/PCR) when available; for suspected HSV, perform NAAT from lesion specimens and document lesion testing.

Order both treponemal and nontreponemal serology and lesion NAAT/darkfield if available for ulcerative disease.
Document lesion site, timing of lesion onset, and specimen type collected for HSV or T. pallidum testing.

Documentation Required

For syphilis, document results of both a nontreponemal and a treponemal test

When diagnosing syphilis, document results of both a nontreponemal test (e.g., RPR or VDRL) and a treponemal test (e.g., TP‑PA, EIA/CLIA); for neurologic/ocular/otologic signs, document CSF analysis and CSF‑VDRL.

If a treponemal test is positive but the nontreponemal test is negative, repeat both tests in one month when early infection is suspected.
Record quantitative NTT titers (and dilutions) when used for diagnosis or test‑of‑cure monitoring.

Documentation Required

Prenatal syphilis testing documentation

For prenatal care in areas with outbreaks or ongoing maternal risk, repeat maternal syphilis serology at 28–32 weeks and at delivery; ensure documentation and do not discharge newborns until maternal syphilis results are known when relevant.

Document maternal syphilis test dates and results in the prenatal record.
Ensure timing of repeat testing (28–32 weeks and at delivery) is recorded when indicated by local outbreak or risk status.

Documentation Required

LDT validation/documentation

Laboratory‑developed tests (LDTs) used by clinical laboratories must be validated per CLIA requirements; document LDT validation and that the test was performed in a CLIA‑certified high‑complexity lab when applicable.

If using an LDT for T. pallidum or other organisms, include validation documentation and performance characteristics in the lab record.
FDA approval status and CLIA validation should be documented for proprietary vs in‑house assays.

Note

Documentation Required

Document relevant signs/symptoms for syphilis-related testing

Document clinical signs and symptoms that support syphilis‑related testing, including neurologic, ocular, otologic, or late/tertiary signs, to support medical necessity for advanced testing and CSF analysis when present.

When ordering CSF‑VDRL or neurosyphilis workup, record specific neurologic or ocular findings prompting the test.
Include physical exam findings (e.g., cranial nerve dysfunction, vision or hearing changes) in the chart to justify expanded testing.

Denial Risk

Denial risk for non-covered test methods

Tests explicitly listed as DO NOT MEET COVERAGE CRITERIA (for example: PCR/NAAT/antigen testing for syphilis; culture/antigen/antibody for chlamydia; rapid EIA for Trichomonas; nucleic acid susceptibility testing for N. gonorrhoeae or macrolide resistance in M. genitalium) may trigger claim denials when billed as covered services.

Before ordering or billing a modality listed as DNMCC, verify that an alternative covered test is not indicated.
If ordering a DNMCC test for research or public health reasons, obtain prior authorization or document exceptional circumstances per payer rules.

Documentation Required

Specimen-dependent performance

Specimen type and collection method affect test performance; document that an appropriate specimen was collected (e.g., first‑void urine, appropriate rectal swab technique) because improper collection can reduce sensitivity and affect claim validity.

Record collection method (self‑collected vs clinician‑collected) and time of collection (first‑void urine) in the requisition.
For rectal specimens, note collection technique and rationale because sensitivity is lower and may require documentation.

Note

Testing method recommendation — use NAATs for CT/NG

Testing for chlamydia and gonorrhea should be performed using NAATs as the preferred method; failure to use recommended NAAT methods may represent inappropriate testing choices.

Order NAATs for urogenital and indicated extragenital sites (pharyngeal, rectal) per exposure history.
If a non‑NAAT method is used, document clinical justification and that NAAT was unavailable or inappropriate.

Documentation Required

Using only one type of serologic test is insufficient for syphilis diagnosis

Using only a single serologic test (either nontreponemal or treponemal alone) is insufficient to diagnose syphilis and can produce false‑negative or false‑positive interpretations; document both test results per the two‑test algorithm.

When a treponemal test is positive and NTT is negative, repeat testing in one month if early infection suspected.
Perform and document quantitative NTT titers when using NTTs for diagnosis or test‑of‑cure.

Note

Government policy precedence

If this policy conflicts with any government coverage policy (LCD/NCD/state Medicaid), the government policy takes precedence and noncompliance with applicable government policy may lead to denials.

Check Medicare LCD/NCD and state Medicaid rules for beneficiaries before ordering or billing.
Document adherence to applicable government policy when it differs from this policy to support coverage.

Billing Rule

Procedure codes appearing in Medical Policy

Procedure codes listed in Medical Policy documents are provided as a general reference and may not be all‑inclusive; verify coding completeness before submission.

Use the policy code lists as a guide but confirm with current CPT/HCPCS manuals and payer code lists.
If a required billing code is missing from the policy, contact the payer’s provider relations for clarification prior to claim submission.

Denial Risk

Tests listed as not meeting coverage criteria may be denied

Testing modalities explicitly listed as 'DO NOT MEET COVERAGE CRITERIA' (for example PCR/NAAT/antigen for syphilis; culture, antibody, and antigen testing for chlamydia/LGV; nucleic acid susceptibility testing for N. gonorrhoeae or macrolide resistance in M. genitalium) are triggers for denial when submitted as standalone covered services.

Avoid ordering or billing DNMCC modalities as covered services unless there is a documented exception or prior authorization.
If a DNMCC test is required for public health, surveillance, or research, obtain payer confirmation and document the reason.

Background and Scope

Sexually transmitted infections (STIs) are caused by a variety of pathogens including bacteria (e.g., Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum, Mycoplasma genitalium), viruses (e.g., herpes simplex virus, human papillomavirus), and protozoa (e.g., Trichomonas vaginalis). These infections can lead to significant morbidity including pelvic inflammatory disease, infertility, adverse pregnancy outcomes, neurologic and cardiovascular complications (notably with syphilis), and increased susceptibility to HIV.

Public health guidance emphasizes targeted screening and use of the most appropriate diagnostic methods for each pathogen: molecular NAATs are preferred for chlamydia, gonorrhea, M. genitalium, and trichomoniasis in indicated scenarios; serologic two‑tiered testing is the mainstay for syphilis diagnosis; and HPV testing is focused on cervical cancer screening in eligible age groups. The policy organizes coverage around these organism‑specific recommendations and documents clinical scenarios where testing meets or does not meet coverage criteria.

STI overview — pathogens & associated complications

Key pathogensChlamydia trachomatis; Neisseria gonorrhoeae; Treponema pallidum; Human papillomavirus (HPV); Herpes simplex virus (HSV).

Major complicationsPID, infertility, and pregnancy complications (CT/NG); neurologic and cardiac disease including neurosyphilis (T. pallidum); HPV-associated cervical and other cancers; HSV-associated meningitis or proctitis and increased HIV susceptibility.

Testing implicationsNAATs preferred for CT/NG due to high sensitivity/specificity; syphilis diagnosis relies on serologic algorithms (treponemal + nontreponemal); HSV lesion NAAT preferred over serology for active lesions.

Definitions and Terminology

Allo-HCT — terminology

TermAllo-HCT

DefinitionAllogeneic haematopoietic stem cell transplantation (donor and recipient transplant context).

Policy relevancePre-transplant treponemal and nontreponemal testing once prior to transplant is included in coverage criteria for donors and recipients of allo-HCT.

NAAT — definition & methods

DefinitionNAAT (nucleic acid amplification test): molecular assays that detect pathogen DNA/RNA using methods such as polymerase chain reaction (PCR), transcription-mediated amplification (TMA), and strand displacement amplification (SDA).

Common methodsPCR, TMA, SDA — used for detection of STI nucleic acids (e.g., CT/NG, M. genitalium, T. vaginalis).

Specimen considerationsFirst-catch urine and site-specific swabs (cervical, vaginal, urethral, rectal, pharyngeal) as indicated by exposure; NAAT preferred over culture for many STIs.

PID — pelvic inflammatory disease

DefinitionPelvic inflammatory disease (PID): a clinical syndrome that can result from untreated infections such as Chlamydia trachomatis, Neisseria gonorrhoeae, or Mycoplasma genitalium and may lead to infertility and other reproductive complications.

Clinical relevancePID is a key complication prompting diagnostic testing and treatment of underlying STIs to prevent long-term sequelae.

Testing noteNAATs are preferred to identify causative organisms to guide management of PID where indicated.

Mgen — Mycoplasma genitalium

DefinitionMycoplasma genitalium (Mgen): a sexually transmitted bacterium associated with urethritis in men, cervicitis and pelvic inflammatory disease in women; prevalence higher in clinical populations.

Testing stanceQualitative NAAT for M. genitalium meets coverage for symptomatic individuals; NAAT screening of asymptomatic individuals does not meet coverage.

Resistance testing noteNucleic acid testing to determine macrolide resistance in M. genitalium is listed as not meeting coverage criteria (see antimicrobial resistance policy notes).

NAAT — examples & methods

NAAT examplesExamples of NAAT methods include PCR, transcription-mediated amplification (TMA), and strand displacement amplification (SDA).

Assay formatsLaboratory-based NAATs and near-patient/POC NAATs (e.g., GeneXpert Xpert CT/NG) are used; POCT antigen tests have lower sensitivity and are generally not recommended as sole screening tests.

Specimen typesFirst-void urine, clinician- or patient-collected vaginal swabs, endocervical swabs, and extragenital swabs (pharyngeal, rectal) per exposure site and product labeling.

Type‑specific HSV serologic assays

DefinitionType-specific HSV serologic assays: serologic tests that distinguish HSV-1 from HSV-2 antibodies (e.g., gG2-based assays) used in select clinical scenarios.

Clinical useUseful for recurrent or atypical genital symptoms with negative lesion PCR/culture, for diagnosing when clinical confirmation is lacking, or when a partner has genital herpes; not recommended for routine population screening due to false positives/psychosocial harms.

LimitationsHigh false-positive rates in low-prevalence populations reduce positive predictive value; USPSTF/CDC recommend against routine serologic screening in asymptomatic individuals.

Nontreponemal and treponemal tests

Nontreponemal tests (NTT)Detect lipoidal antibodies (examples: RPR, VDRL); useful for indicating active disease and for quantitative monitoring (titers).

Treponemal tests (TT)Detect antibodies to Treponema pallidum (examples: TP-PA, TPHA, EIA/ELISA/CLIA); usually remain reactive for life and are used in combination with NTTs for diagnosis and confirmation.

Testing algorithmA two-test strategy using both NTT and TT is required for presumptive diagnosis; use of only one serologic test is insufficient and can lead to false-negative or false-positive interpretations.

NAAT — recommended uses

NAAT recommended usesPreferred method for chlamydia and gonorrhea testing due to higher sensitivity and specificity; recommended for first-catch urine and anatomic site swabs, including extragenital sites.

Culture roleCulture is reserved primarily for antimicrobial susceptibility testing for N. gonorrhoeae and for surveillance or treatment-failure investigations; NAAT cannot reliably provide susceptibility data from nonculture specimens.

POC/near-patient NAATNear-patient NAATs (e.g., Cepheid Xpert) have high sensitivity (>95–98%) and can facilitate same-day diagnosis and treatment decisions where available.

Primary / Secondary / Tertiary syphilis

Primary syphilisCharacterized by a chancre (ulcer) and regional lymphadenopathy; consider direct detection methods from lesion exudate.

Secondary syphilisMultisystem illness due to bacteremia that may include rash, lymphadenopathy, arthritis, hepatitis, and possible early neurosyphilis manifestations.

Tertiary syphilisLate manifestations such as gummatous disease, late neurosyphilis, and cardiovascular syphilis (e.g., aortitis); may include neurologic and ocular involvement requiring CSF evaluation.

Treponemal test (TT) vs Non-treponemal test (NTT)

Treponemal test (TT)Detects antibodies specific to Treponema pallidum (examples: TPHA, TPPA, EIA/ELISA/CLIA); usually remain reactive for life and are sensitive for past or present infection.

Non-treponemal test (NTT)Detects lipoidal (non-treponemal) antibodies (examples: RPR, VDRL); titers correlate with disease activity and are used for quantitative monitoring and test-of-cure assessment.

Key differenceNTTs are useful for assessing active infection and monitoring response to therapy; TTs confirm exposure/infection but do not distinguish active vs past treated infection.

Two-test syphilis algorithm

Two-test algorithmUse both a non-treponemal test (e.g., RPR or VDRL) and a treponemal test (e.g., TP-PA, TP-EIA) for diagnosis; a positive NTT should be confirmed with a TT; if TT-first algorithms are used, reflex quantitative NTT on same serum is recommended.

Reflex testingIf TT positive and NTT negative without suspicion of early syphilis, repeat both tests in 1 month; reflex quantitative NTT should reach dilutions of at least 1:8 to 1:16 when used for confirmation or monitoring.

CSF indicationCSF-VDRL and CSF analysis indicated when neurologic, ocular, or otologic signs suggest neurosyphilis or related severe manifestations.

NAAT — preferred method for CT/NG; culture for susceptibility

Preferred testing for CT/NGNAAT is the preferred diagnostic method for Chlamydia trachomatis and Neisseria gonorrhoeae due to superior sensitivity and specificity.

Culture reserved for susceptibilityCulture for N. gonorrhoeae is reserved for antimicrobial susceptibility testing and for suspected treatment failures or public health surveillance.

Specimen sitesObtain first-void urine or site-specific swabs (cervical, vaginal, urethral, rectal, pharyngeal) per exposure; check product inserts for specimen-specific performance.

Proprietary test HCPCS entries — examples

Example mapping - 0483U0483U: Neisseria gonorrhoeae ciprofloxacin resistance (gyrA S91F point mutation) — Proprietary test: Ciprofloxacin Susceptibility of N. gonorrhoeae; Lab/Manufacturer examples: MedArbor Diagnostics, SpeeDx, Inc.

Example mapping - 0484U0484U: Mycoplasma genitalium macrolide resistance (23S rRNA point mutation) — Proprietary test: Macrolide Resistance of M. genitalium; Lab/Manufacturer examples: MedArbor Diagnostics, SpeeDx, Inc.

Example mapping - Proofer 7Proofer '7 HPV mRNA E6 and E7 Biomarker Test: proprietary NASBA-based HPV mRNA assay described in HCPCS listings for HPV mRNA testing.

High-risk for Trichomoniasis — definition

High-risk groups for Trichomoniasis (Note 8)Receiving care in high-prevalence settings (e.g., STI clinics, correctional facilities); multiple sexual partners; exchanging sex for money or drugs; previous or concurrent STI; drug misuse; history of incarceration; sexually active individuals with HIV-positive status.

Screening implicationAnnual screening for T. vaginalis is recommended for asymptomatic individuals in high-risk groups and for sexually active individuals with HIV.

DocumentationProviders should document risk-group status to support testing and coverage determinations.

Syphilis severe manifestations — signs & symptoms

Neurosyphilis signs/symptomsSevere headache, cranial nerve dysfunction, meningitis, stroke, altered mental status, motor or sensory deficits; may require CSF analysis and CSF-VDRL.

Otosyphilis signsHearing loss, tinnitus (ringing/buzzing), balance difficulties, dizziness or vertigo; ophthalmic evaluation indicated for visual symptoms.

Late/tertiary syphilis signsCardiovascular involvement (aortitis, coronary vessel disease), gummatous lesions of skin or viscera, and bone involvement (osteitis).

Policy Changes and Revision History

2026-09-15major_revisionLatest

Clinical Advisory Board review approved relocation of prenatal STI screening into this policy and added new coverage subcriteria (CC2.a., 5.e., 6.a., 10.a.), plus renumbering and reorganization of multiple coverage criteria.

2026-01-01off-cycle_coding

Off-cycle coding modification: added CPT code 87494.

2025-03-15off-cycle_coding

Reviewed and updated policy with additions of CPT codes 0483U and 0484U and creation of new CC23 (nucleic acid testing for antimicrobial susceptibility does not meet coverage).

2025-01-01off-cycle_coding

Off-cycle coding modification: added CPT code 87626 and removed CPT code 0500T; revised code description for CPT 87624.

2024-05-01off-cycle_coding

Off-cycle coding modification: added CPT codes 0455U and 0463U and removed CPT code 0353U.

2026-01-01codes_removed

Removed a set of legacy CPT and HCPCS codes during the 01/01/2026 update (including 82565, 82575, 84702, 84703, 86701, 86702, 86703, 86705, 86803, 86804, 87660 and several G- and S-codes).

2024-04-01codes_removed

Removed CPT code 0354U as part of an off-cycle coding modification noted 04/01/2024.

2024-05-01codes_removed

Removed CPT code 0353U during the 05/01/2024 off-cycle coding modification.