ModifiedBlue Cross Blue Shield - LouisianaPolicy AHS - G2157

Diagnostic Testing of Common Sexually Transmitted Infections

Governs coverage for laboratory testing of common STIs (C. trachomatis, N. gonorrhoeae, T. pallidum, T. vaginalis, HSV, HPV, and M. genitalium) and related indications/limitations 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 TypeMultiple material edits (coverage clarifications, new CCs, coding updates)

Effective DateMar 15, 2026

Next Review DateN/A

Key ActionDocument clinical indication, specimen type, and applicable CC/Note when ordering NAATs to support coverage and billing review.

SourceLink

POLICY UPDATE CHANGES

Added the word 'qualitative' to multiple coverage criteria and edited Note 2 for clarity.

Individual organism amplified probe testing for T. vaginalis now solely addressed in this policy; multi-organism vaginitis panels remain in M2057.

CC10 now specifies coverage for qualitative NAAT for T. vaginalis in symptomatic individuals, follow-up testing ≥3 months after diagnosis, annual screening for high-risk asymptomatic individuals (Note 8), annual screening for asymptomatic individuals with HIV, and as part of sexual assault follow-up.

CC21 and CC22 updated to focus STI screens for individuals considered for or receiving PrEP and removed references to non-STI screens.

Added CPT code 87800 and removed CPT codes 82565, 82575, 84702, 84703, 86701, 86702, 86703, 86705.

New Note 8 lists high-risk features (e.g., care in high-prevalence settings, multiple partners, sex work, prior/concurrent STI, drug misuse, incarceration, HIV-positive).

CC24 updated to explicitly state that direct probe detection and/or quantitative NAAT for listed microorganisms does not meet coverage criteria.

Added coverage criteria allowing NAAT testing for Mycoplasma genitalium for symptomatic individuals and not covering screening in asymptomatic individuals (CC12 and CC13).

Expanded multitarget PCR panel coverage to include C. trachomatis, N. gonorrhoeae, T. vaginalis, and M. genitalium when conditions are met.

Multiple off-cycle coding modifications and code list housekeeping (adds/removals including 0353U/0354U and others).

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

20+coverage statements

9organisms addressed

NAATNAAT preferred

~3 monthsretest interval example

~60+CPT codes listed

CPT +1 / -8coding net change

Coverage Criteria and Clinical Indications

Covered testing by organism and clinical scenario

Covered when specific organism testing scenarios are met as described below

Syphilis antibody testing: Treponemal and nontreponemal antibody testing meets coverage for: annual screening for asymptomatic high-risk persons; diagnosis of symptomatic persons; every 3 months for HIV-positive men/MSM; pretransplant donor/recipient testing once prior to allo-HCT; nontreponemal testing when used as test-of-cure.

Reverse or standard algorithm acceptable; PCR/NAAT for syphilis DO NOT meet coverage.

Testing indications and methods

General testing guidance and clinical indications described in document excerpts:

NAAT preferred for CT/NG: Nucleic acid amplification testing (NAAT) is the preferred method for Chlamydia trachomatis and Neisseria gonorrhoeae diagnosis; culture retained for gonorrhea antimicrobial susceptibility testing.

Specimen- and anatomy-based testing recommended (first-catch urine, vaginal/cervical swabs, rectal/pharyngeal as indicated).

Symptomatic testing for M. genitalium: Test individuals with symptoms consistent with M. genitalium (urethritis/cervicitis: dysuria, discharge, pelvic pain) using FDA-cleared NAAT when available.

Consider resistance testing if available to guide therapy.

Syphilis serologic algorithm: Use two-tier serologic testing (treponemal AND nontreponemal tests) for syphilis diagnosis; NAAT/PCR for genital syphilis is not routinely performed and DOES NOT meet coverage.

Darkfield or lesion PCR may be used when appropriate but routine NAAT for syphilis is not covered.

PrEP screening frequency: When evaluating or monitoring persons on HIV PrEP, perform baseline and repeat STI screening including NAAT for chlamydia and gonorrhea and serologic testing for syphilis every 3–6 months per guidance.every 3-6 months

Ensure HIV antigen/antibody and hepatitis B testing per PrEP protocols.

Coverage criteria referenced from authoritative bodies

Covered testing and screening recommendations referenced from USPSTF and CDC (as described in source):

Chlamydia and Gonorrhea Screening (USPSTF): Screen sexually active females ≤24 years and women ≥25 years at increased risk using NAATs; evidence insufficient to recommend routine screening in men.

USPSTF Grade B recommends NAAT-based screening.

Syphilis screening: Screen persons at increased risk; use both treponemal and nontreponemal serologic tests for presumptive diagnosis and screen early in pregnancy or at first available opportunity if missed.

CDC and USPSTF guidance support two-test serologic approach.

HSV testing: Do not perform routine serologic screening for asymptomatic persons; type-specific serology useful for symptomatic patients, discordant virologic results, or when partner has genital herpes.

USPSTF recommends against routine HSV serologic screening in asymptomatic individuals.

Coverage criteria for STI diagnostic testing

Testing recommendations and when tests are indicated per referenced guidance:

HSV-2 serology: Type-specific HSV-2 serologic assays are appropriate for recurrent or atypical genital symptoms with negative PCR/culture, for clinical diagnosis without confirmatory lesion testing, or when partner has genital herpes; not recommended for general population screening.

CDC 2021 guidance, reaffirmed 2025.

Syphilis serology: A presumptive diagnosis of syphilis requires both a nontreponemal test (RPR/VDRL) AND a treponemal test (TP-PA, EIA/CLIA); CSF-VDRL indicated when neurosyphilis suspected.

CDC recommends two-test algorithm and lesion/darkfield testing where appropriate.

Chlamydia testing: Use NAATs on first-catch urine or swab specimens for screening and diagnosis; annual screening for sexually active women <25 and at-risk older women; anatomy-based extragenital testing at exposure sites.

CDC recommends NAATs and exposure-site testing.

Guideline-aligned testing criteria

Covered when testing aligns with guideline-indicated indications and methods:

Chlamydia testing: Test symptomatic and asymptomatic sexually active individuals per risk using NAAT on appropriate specimens (vaginal/cervical swabs or first-void urine for females; first-void urine for males); obtain pharyngeal or rectal specimens when exposure indicates. Retest 3 months after treatment.

IUSTI, PHAC, AAP, BASHH recommendations support NAAT and retesting.

Gonorrhea testing: Use NAAT on urine, vaginal, cervical, or urethral swabs; use NAAT for extragenital sites if available; culture when needed for antimicrobial susceptibility. Rescreen for reinfection at ~3 months; higher-risk MSM screened every 3–6 months.

MTC, PHAC, AAP guidance cited.

Syphilis testing: Serologic testing is the usual method across stages using two-test approach; perform darkfield microscopy or PCR on lesions when appropriate and repeat quantitative testing per guideline timelines.

BASHH, IUSTI, PHAC recommendations.

Guideline-based coverage criteria

Guideline-aligned testing recommendations summarized from cited societies and agencies

HPV testing for cervical cancer screening: HPV tests are recommended for cervical cancer screening in women aged 30 or older; co-testing Pap + hr-HPV every 5 years or Pap alone every 3 years as indicated; not recommended for screening men or women <30 for routine STI testing.age >= 30 for cervical screening

CDC 2021 guidance.

Chlamydia and Gonorrhea testing: NAATs are recommended for chlamydia testing; NAATs are more sensitive than culture for gonorrhea detection but culture is required to determine antimicrobial susceptibility when needed.use NAAT when available; use culture for susceptibility

CDC and IUSTI recommendations.

HSV testing: Do not routinely test asymptomatic patients for HSV; for symptomatic genital herpes, NAAT (HSV DNA) is preferred and has replaced culture as the diagnostic gold standard.

Updated and New Coverage Criteria

Selected coverage criteria and changes described in the revision history:

CC10 (expanded): Qualitative NAAT for T. vaginalis MEETS COVERAGE CRITERIA in the following situations: a) For symptomatic individuals. b) Follow-up testing a minimum of three months after initial diagnosis. c) Annual screening for asymptomatic individuals in a high-risk group (see Note 8). d) Annual screening for asymptomatic individuals with HIV infection. e) As part of follow-up in a victim of sexual assault.

Note 8 defines high-risk features for Trichomoniasis.

CC12: For symptomatic individuals, testing for Mycoplasma genitalium using qualitative NAAT MEETS COVERAGE CRITERIA.

New CC12 added in revision history.

CC13: For asymptomatic individuals, screening for Mycoplasma genitalium using NAAT DOES NOT MEET COVERAGE CRITERIA.

New CC13 added in revision history.

Covered and restricted STI testing scenarios

Coverage decisions distinguished by organism and clinical context

M. genitalium testing: When an individual is symptomatic (per policy notes), NAAT testing for Mycoplasma genitalium MEETS COVERAGE CRITERIA; screening asymptomatic individuals for M. genitalium using NAAT DOES NOT MEET COVERAGE CRITERIA.symptomatic vs asymptomatic

CC12 (symptomatic covered) and CC13 (asymptomatic not covered).

Multitarget PCR panel: When an individual meets applicable covered conditions for chlamydia and gonorrhea, multitarget PCR testing limited to C. trachomatis, N. gonorrhoeae, T. vaginalis, and M. genitalium MEETS COVERAGE CRITERIA.eligibility criteria for CT/NG apply

Former CC10 renumbered and expanded to CC14 to include additional targets.

Trichomonas testing: NAAT/PCR testing for T. vaginalis MEETS COVERAGE CRITERIA in symptomatic individuals and in specified high-risk asymptomatic groups (concurrent or prior STI, high-prevalence settings, exchanging sex for payment); rapid enzyme immunoassay DOES NOT MEET COVERAGE CRITERIA.

Polymerase chain reaction (PCR) and other NAAT methods are generally valuable for many sexually transmitted infections but PCR/NAAT for syphilis DO NOT MEET COVERAGE CRITERIA and should not be relied upon in place of the recommended two-test serologic approach (treponemal + nontreponemal) for syphilis diagnosis and screening. Treponemal and nontreponemal antibody testing remains the covered method for routine screening, diagnosis of symptomatic persons, testing of high-risk asymptomatic persons, and pretransplant donor/recipient assessment. Additionally, clinicians should note that rapid enzyme immunoassay-based tests for Trichomonas are explicitly stated as not meeting coverage criteria; NAATs are the preferred method when testing for T. vaginalis is indicated.

Exercise caution when selecting specimen types and assays: pooled studies show NAATs perform well across specimen types for chlamydia and gonorrhea, but PCR assays for gonorrhea on female urine have demonstrated low specificity in some studies and therefore are not recommended for routine use. Also, NAAT/PCR for syphilis is not an FDA-approved routine diagnostic method and does not meet coverage criteria, so serologic testing using both treponemal and nontreponemal methods is the supported approach.

Antigen-based point-of-care tests (POCTs) for chlamydia and gonorrhea have substantially lower sensitivity than NAATs and therefore are not recommended as standalone screening tests. Reviews show POCT sensitivity for chlamydia varies widely (approximately 37–63% for some specimen types) compared with near-patient NAAT sensitivities >95–98%; similar low sensitivities have been reported for some gonorrhea antigen POCTs. Use NAAT-based testing or near-patient NAAT platforms when high sensitivity is required for clinical decision-making.

HSV and HPV testing have discrete, limited indications: qualitative NAAT for HSV-1 or HSV-2 is covered for individuals with active genital ulcers or mucocutaneous lesions. In contrast, routine serologic screening for HSV (HSV-1 or HSV-2) in asymptomatic individuals DOES NOT MEET COVERAGE CRITERIA. For HPV, testing for high-risk types is covered only in the context of diagnosing or assessing cancer or cancer therapy (for example, p16 immunohistochemistry or NAAT for HR-HPV); routine HPV testing as part of general STI screening is not supported.

HPV testing has important limitations in the STI context: HPV testing is NOT indicated to diagnose anogenital warts and should not be used as a general STI screen for asymptomatic individuals. For cervical cancer screening, HPV testing is recommended in women aged 30–65 per established cervical screening guidance, but HPV testing for asymptomatic men or women under 30 DOES NOT MEET COVERAGE CRITERIA under this policy.

Additional HPV testing notes: HPV assays and cervical screening are governed by separate cervical cancer screening guidance; within this STI policy HPV testing is limited to cancer diagnosis/assessment. There is no approved routine HPV test for men, and routine HPV screening for men or for asymptomatic individuals is not recommended.

The policy explicitly excludes certain molecular approaches: direct probe detection and/or quantitative NAAT for the listed microorganisms DOES NOT MEET COVERAGE CRITERIA (CC24). Such quantitative/direct-probe assays are not acceptable substitutes for the qualitative NAATs and serologic tests specified in the covered criteria.

Rapid Trichomonas enzyme immunoassays are specifically not covered: rapid enzyme immunoassay identification of T. vaginalis DOES NOT MEET COVERAGE CRITERIA. Use qualitative NAAT/PCR methods for Trichomonas testing when coverage criteria are otherwise met.

General exclusions summarized: several tests are identified as not meeting coverage criteria due to insufficient evidence or lack of FDA-approval. Notable exclusions include PCR/NAAT for syphilis, serologic testing for chlamydia/LGV, rapid Trichomonas enzyme immunoassay, non-type-specific HSV immunoassays, nucleic acid testing for antimicrobial susceptibility (N. gonorrhoeae and macrolide resistance in M. genitalium), and direct probe detection/quantitative NAAT approaches.

Specimen-type warnings: select specimen types supported by the assay and guidance. In particular, evidence indicates that PCR-based gonorrhea testing on female urine may have low specificity (reported specificity ≈55.6% for PCR in one pooled study); clinicians should preferentially use validated NAAT platforms and recommended specimen types (vaginal/cervical swabs or first-void urine as appropriate) to avoid inaccurate results and potential coverage issues.

HSV serologic screening guidance: authoritative reviews conclude routine serologic screening for genital herpes in asymptomatic adolescents and adults (including pregnant persons) is not recommended because of high false-positive rates and potential psychosocial harms. Type-specific HSV-2 serology is appropriate only in defined clinical situations (e.g., recurrent or atypical symptoms with negative PCR/culture, partner with genital herpes, or clinical diagnosis when lesion testing is not possible).

HPV testing policy statement: HPV testing is not to be used for male partners of women with HPV, for diagnosis of genital warts, or as a general STI panel in asymptomatic individuals. HPV testing as part of cervical cancer screening is guided by age-based recommendations outside this policy (women ≥30 years).

Routine HSV testing statement: consistent with CDC and USPSTF guidance, routine serologic testing for HSV in asymptomatic patients is not recommended. Type-specific testing is limited to the clinical scenarios described in the policy (e.g., symptomatic or specific partner/clinical circumstances).

Oncogenic HPV testing exclusions: this policy aligns with CDC guidance that oncogenic HPV testing is not recommended for asymptomatic men, for routine screening of women under 30, or as a general STI test, and HPV testing should not be used to diagnose anogenital warts.

Mycoplasma genitalium testing summary (CC12/CC13): NAAT testing for M. genitalium MEETS COVERAGE CRITERIA for symptomatic individuals. However, screening asymptomatic individuals for M. genitalium using NAAT DOES NOT MEET COVERAGE CRITERIA and would be considered not medically necessary.

The policy explicitly states that screening for M. genitalium in asymptomatic individuals is not covered (CC13). Providers ordering M. genitalium NAAT should document symptomatic indications to support medical necessity; requests for asymptomatic screening are subject to denial.

Procedure Codes and Coding Changes

Provider Responsibilities, Documentation, and Billing Guidance

Documentation Required

Coverage depends on individual benefit and documentation

Coverage and billing depend on the member's individual benefits at the time of service. Before ordering or submitting claims, verify the member's plan coverage and document clinical signs/symptoms, timing of exposure or testing, and clinical rationale in the medical record to support medical necessity.

Coverage determinations are subject to applicable state and federal regulations (LCD/NCD/Medicaid) which take precedence if conflicts exist.
Document presenting signs/symptoms, risk factors, and timing relative to exposure or treatment when submitting authorization requests or claims.

Documentation Required

Assay indication, specimen documentation, and LDT/CLIA validation

When using proprietary or FDA-cleared assays, document the assay name, intended FDA indication, and the specimen types on which the assay is validated. For laboratory-developed tests (LDTs), document that the assay has been validated and is performed under CLIA high-complexity rules.

Include assay name and manufacturer (e.g., Cepheid Xpert CT/NG, BD Onclarity) on requisitions and in the chart.

Clinical Background and Evidence Summary

Background overview: sexually transmitted infections encompass bacterial and viral pathogens that can cause significant morbidity. Untreated infections may lead to complications including pelvic inflammatory disease and infertility (chlamydia/gonorrhea), and neurologic or cardiac manifestations of syphilis. Many STIs are asymptomatic, so testing is targeted to symptoms, risk groups, screening intervals, and specific clinical indications described elsewhere in the policy.

Key Definitions and Terms

Policy scope — organisms covered

Organisms coveredChlamydia trachomatis (CT); Neisseria gonorrhoeae (NG); Treponema pallidum (TP); Trichomonas vaginalis (TV); Herpes simplex virus (HSV); Human papillomavirus (HPV); Mycoplasma genitalium (Mgen).

Panel testing noteMultitarget PCR panels are limited to targets listed above (CT, NG, TV, Mgen) when coverage criteria are met.

Pregnancy screening referenceSTI screening in pregnant individuals is addressed separately (see AHS-G2035 Prenatal Screening).

Allo-HCT definition

DefinitionAllo-HCT = Allogeneic haematopoietic stem cell transplantation.

Context of useTreponemal and nontreponemal testing are recommended once prior to allo-HCT for donors and recipients as part of pre-transplant assessment.

Policy Changes and Revision Notes

2026-03-15RevisionLatest

Reviewed and updated policy background, guidelines, and evidence; clarified language by adding 'qualitative' to multiple NAAT coverage statements; expanded CC10 for T. vaginalis with new Note 8 defining high-risk features; refocused CC21/CC22 on PrEP-related STI screening; added CPT code 87800 and removed listed CPT codes; CC24 updated to include direct probe detection.

2025-03-15Revision

Reviewed and updated background, guidelines, and evidence; added CC23 specifying that nucleic acid testing to determine antimicrobial susceptibility in N. gonorrhoeae or macrolide resistance in M. genitalium does not meet coverage; added CPT codes 0483U and 0484U.

Policy Summary

PayerBlue Cross Blue Shield - Louisiana

PolicyDiagnostic Testing of Common Sexually Transmitted Infections

Policy CodePolicy AHS - G2157

Change TypeMultiple material edits (coverage clarifications, new CCs, coding updates)

Effective DateMar 15, 2026

Next Review DateN/A

Key ActionDocument clinical indication, specimen type, and applicable CC/Note when ordering NAATs to support coverage and billing review.

SourceLink

On This Page

Use of NAAT/POCT for CT/NG: Near-patient NAATs provide high sensitivity and specificity and can support same-day treatment; antigen-based POCTs with low sensitivity are not recommended as sole screening tests.

Guidance notes markedly lower sensitivity of antigen POCTs versus NAATs.

Gonorrhea testing: NAATs are preferred for most specimen types; maintain culture capability to determine antimicrobial susceptibility and for suspected treatment failures; perform extragenital testing as indicated.

CDC emphasizes culture for susceptibility despite NAAT sensitivity.

Mycoplasma genitalium: Test men with recurrent nongonococcal urethritis and women with recurrent cervicitis using FDA-cleared NAAT when available; resistance testing recommended if available; do not screen asymptomatic persons routinely.

CDC guidance discourages asymptomatic screening for M. genitalium.

Trichomonas testing and follow-up: Perform diagnostic testing for women with vaginal discharge; consider annual screening in high-prevalence settings and retest all sexually active women approximately 3 months after treatment due to high reinfection rates; NAATs preferred over wet mount when possible.~3 months

CDC recommends retesting at ~3 months and annual screening in high-risk settings.

Genital herpes testing: Use HSV DNA detection (NAAT) on lesions as gold standard; type-specific serology reserved for limited clinical scenarios (pregnancy, partner exposure, recurrent/atypical disease) and not for routine asymptomatic screening.

IUSTI, PHAC, BASHH support DNA detection as gold standard.

Mycoplasma genitalium: NAAT may be performed on urine, cervical, vaginal, urethral or meatal swabs and endometrial biopsies when clinically indicated.

PHAC guidance on specimen types.

LGV testing: For suspected LGV or MSM with proctitis, confirm a CT-positive specimen with LGV-discriminatory NAAT/genotyping.

BASHH, PHAC recommend two-step confirmation for LGV.

HPV and anogenital warts: Do not use HPV testing to diagnose anogenital warts; HPV testing is recommended for cervical cancer screening in women ≥30 per separate guidance.

PHAC and CDC guidance; HPV testing not indicated for AGW diagnosis.

symptomatic lesions preferred for NAAT

IUSTI 2017 guidance.

LGV (lymphogranuloma venereum): For suspected LGV, a CT-positive specimen by commercial NAAT should be confirmed with an LGV-discriminatory NAAT; a two-step procedure is recommended.positive CT NAAT then LGV discriminatory NAAT

IUSTI 2019 guidance.

Screening frequency for at-risk groups: Annual NAAT screening recommended for at-risk groups with more frequent (3–6 month) intervals for higher-risk populations; those who test positive should be retested ~3 months after treatment.annual or every 3-6 months depending on risk

AAP, MTC guidance.

symptomatic or high-risk asymptomatic

CC17/18 additions restored T. vaginalis coverage outside vaginitis policy.

HPV and prenatal cross-references: HPV testing for cervical screening is addressed in a separate policy; references to non-STI prenatal screens were removed and cross-referenced to the prenatal screening policy.n/a

Cross-reference to G2002 and AHS-G2035.

Record the specimen type collected and ensure it matches the assay's validated specimen types (e.g., urine, endocervical, vaginal, rectal, pharyngeal).

For LDTs, indicate validation status and CLIA complexity on the lab report or claim documentation.

Documentation Required

Specimen-type compliance and specimen source documentation

Specimen source must be appropriate for the ordered test and consistent with the assay's validated specimen types. Using unsupported specimen types can yield invalid results and may lead to claim denial.

Follow FDA or manufacturer specimen-type instructions (e.g., Cepheid Xpert CT/NG supports urine, clinician- or patient-collected vaginal swabs, endocervical swabs, pharyngeal and rectal swabs).
Document the anatomic source (urethral, cervical, vaginal, rectal, pharyngeal, CSF, lesion exudate) and clinical indication on the requisition.

Documentation Required

Near-patient NAAT justification and rapid testing in ED

Near-patient (point-of-care) NAATs may be used when clinically justified (for example, to enable same-day treatment or to reduce overtreatment in ED settings). Document why a near-patient NAAT was used and how results impacted clinical management.

When ordering a near-patient NAAT (e.g., GeneXpert), note the expected turnaround time and the clinical decision supported (e.g., same-day antibiotic prescribing).
In emergency department use, document that rapid testing changed treatment decisions to reduce overtreatment or undertreatment.

Documentation Required

Gonorrhea culture referral for susceptibility testing

Culture referral for Neisseria gonorrhoeae is recommended when antimicrobial susceptibility testing is needed (e.g., treatment failure, suspected resistance). Document referrals for culture and susceptibility testing when indicated.

If an individual does not respond to initial therapy, order gonorrhea culture for susceptibility testing and document the clinical reason for culture referral.
Maintain or partner with laboratories that can perform gonococcal culture for urethral, cervical, ocular, pharyngeal, or rectal specimens per public health recommendations.

Billing Rule

Procedure code documentation, review, and coding verification

Providers must ensure correct procedure code selection and include adequate documentation to support billing. Off-cycle coding changes occur — verify current code lists before claim submission and prior-authorization requests.

Review and use the listed CPT/HCPCS codes that correspond to the performed test(s) (see policy code lists).
Confirm additions (e.g., CPT 87800) or removals in the policy's revision history before billing.
Document the test performed, specimen type, assay name, and clinical indication to support the chosen CPT/HCPCS code.

Documentation Required

Syphilis reflex testing, confirmatory testing, and PCR/NAAT exclusion

Syphilis testing: a single serologic test is insufficient for diagnosis. When screening algorithms or single-test approaches are used, ensure reflex and confirmatory testing are performed and documented per guidance.

If a treponemal test (TT) is used alone and is positive, perform reflex quantitative non-treponemal testing (NTT) on the same serum (e.g., RPR with titers).
If an NTT is used as primary screening and is positive, perform reflex TT on the same serum; ensure quantitative NTT if not initially done.
Document CSF testing and neurologic signs/symptoms when evaluating for neurosyphilis (reactive CSF-VDRL and CSF cell count/protein as indicated).
Note that PCR/NAAT for syphilis does NOT meet coverage criteria—do not bill PCR/NAAT for syphilis as routine covered testing.

Denial Risk

M. genitalium asymptomatic screening—denial risk

Mycoplasma genitalium testing: screening asymptomatic individuals for M. genitalium does not meet coverage criteria and may be denied. Testing is covered for symptomatic individuals when criteria are met—document symptoms and risk factors.

Order NAAT for M. genitalium only for symptomatic patients per policy criteria and document the clinical indication.
Do not submit claims for asymptomatic screening for M. genitalium; include documentation of symptoms if testing is performed.

Documentation Required

PrEP-associated STI screening and documentation

PrEP-related STI screening: when evaluating patients for PrEP or during PrEP use, perform baseline and ongoing STI screening per guidelines and document testing rationale in the chart.

Document that STI screening (chlamydia, gonorrhea, syphilis) was performed prior to initiating or restarting PrEP and at recommended 3–6 month intervals during ongoing PrEP.
Record HIV antigen/antibody testing within one week before starting or restarting PrEP and hepatitis B testing prior to initiation.

Documentation Required

Document clinical rationale and cite coverage criteria/notes

Clinical rationale and note references: reference the appropriate coverage criteria codes and internal notes (e.g., CC10, CC12/13, Note 8) when ordering tests and in patient records to support medical necessity.

When relying on a specific coverage criterion (CC) or Note (e.g., Note 8 high-risk definitions), cite the CC/Note in the clinical record or authorization request.
Ensure chart notes explicitly state which coverage criterion is being met and why (e.g., symptomatic presentation, high-risk status, post-treatment test-of-cure).

Documentation Required

Documentation of risk factors in minors for screening eligibility

When ordering tests for minors under 18, document CDC-defined risk factors if asserting screening eligibility for sexually active youth.

Record specific risk factors from CDC guidance (e.g., multiple partners, detention, exchange of sex for resources, STI history) when requesting annual screening for sexually active minors.
Include age, sexual activity status, and which CDC risk factors apply in the medical record.

Note

State/Federal policy precedence

State and federal policies take precedence. If there is a conflict between this policy and an applicable government policy (LCD/NCD/Medicaid), the government policy governs the coverage decision.

Check Medicare LCDs/NCDs and state Medicaid rules for members covered by those programs prior to ordering or adjudicating claims.
Use the CMS Medicare Coverage Database and applicable state Medicaid resources for the most current guidance.

Source moduleTerminology table provides standardized definition used in coverage statements.

NAAT definition

DefinitionNAAT = Nucleic acid amplification testing; molecular methods that detect organism-specific nucleic acid (DNA or RNA).

Clinical rolePreferred method for diagnosing Chlamydia trachomatis and Neisseria gonorrhoeae and recommended for multiple other pathogens (e.g., M. genitalium, TV, HSV DNA detection).

Specimen guidanceAnatomy-based specimen collection (vaginal/cervical swabs, first-void urine, pharyngeal/rectal swabs) recommended per exposure site.

Mgen — Mycoplasma genitalium

DefinitionMgen = Mycoplasma genitalium, a sexually transmitted bacterium associated with urethritis in men and cervicitis and pelvic infections in women.

Clinical relevanceAssociated with urethritis and cervicitis; testing with NAAT is indicated for symptomatic individuals and not for asymptomatic screening per policy updates.

Specimen typesNAATs for M. genitalium may be performed on urine, cervical, vaginal, urethral or meatal swabs and endometrial biopsies when indicated.

NAAT (technical) — PCR/TMA/SDA

Technical modalitiesNAAT modalities include polymerase chain reaction (PCR), transcription-mediated amplification (TMA), and strand displacement amplification (SDA).

Analytic validityPooled studies across PCR, TMA, and SDA demonstrate high specificity (>97%) for CT/NG in urine vs swab specimens, though PCR from female urine for gonorrhea had lower specificity in some assays.

ApplicationThese molecular modalities are used across assays and specimen types per FDA-cleared or laboratory-validated testing platforms.

Two-test syphilis algorithm — definition & rationale

DefinitionTwo-test syphilis algorithm = use of a nontreponemal test (e.g., RPR or VDRL) PLUS a treponemal test (e.g., TP-PA, EIA/ELISA/CLIA) for presumptive diagnosis of syphilis.

RationaleUsing only one type of serologic test is insufficient and can yield false negatives in early infection or false positives in previously treated persons; two-test approach improves diagnostic accuracy.

Follow-up for neurosyphilisWhen neurosyphilis suspected, perform CSF testing including CSF-VDRL and document neurologic signs/symptoms.

Nontreponemal test (NTT) — definition and use

DefinitionNontreponemal tests (NTT) detect lipoidal antibodies (e.g., RPR, VDRL) and are used quantitatively to detect active syphilis and monitor treatment response.

UseNTTs are used as part of the two-test algorithm and should be performed quantitatively when used for screening or follow-up.

LimitationsNTTs may be negative in very early syphilis and require reflex treponemal testing or repeat testing per guidance.

Treponemal test (TT) — definition and use

DefinitionTreponemal tests (TT) detect antibodies directed against Treponema pallidum (e.g., TP-PA, TPHA, EIA/ELISA/CLIA) and identify current or past infection.

UseTTs are paired with NTTs in a two-test algorithm; positive TT may require quantitative NTT reflex to inform treatment decisions.

Screening characteristicsSome TT-based screening algorithms are sensitive for early infection but can yield false positives in low-prevalence populations and may need confirmatory testing.

NAAT (summary) — primary diagnostic recommendation

Summary statementNAATs are recommended as the primary diagnostic method for chlamydia and gonorrhea and are preferred for HSV DNA and M. genitalium detection when indicated.

AdvantagesNAATs offer superior sensitivity and specificity compared with culture or antigen-based POCTs for many STIs.

Specimen considerationsAppropriate specimen type (anatomy-based) is necessary; extragenital testing recommended when exposure at those sites is reported.

LGV discriminatory NAAT / genotyping

LGV testing approachTwo-step molecular approach: confirm C. trachomatis-positive specimens with an LGV-discriminatory NAAT or genotyping to identify LGV-associated genotypes.

IndicationsSuspected LGV (e.g., proctitis, MSM with proctitis) or contacts of confirmed LGV cases warrant discriminatory testing.

RationaleGenotyping/targeted NAAT distinguishes LGV from non-LGV chlamydial infections to guide management.

NAAT (reiteration) — CT/NG preference and specimen notes

RecommendationNAAT is recommended for chlamydia and gonorrhea due to higher sensitivity compared with culture; use appropriate specimen types (vaginal/cervical swabs, first-void urine, extragenital swabs as indicated).

Specimen cautionPCR on female urine for gonorrhea had low specificity in some assays; follow assay-specific specimen guidance to avoid inaccurate results.

Culture roleCulture retained for gonorrhea when antimicrobial susceptibility testing or evaluation of treatment failure is required.

LDT — laboratory-developed test definition

DefinitionLDT = Laboratory-Developed Test; tests developed and validated in-house and regulated under CLIA as high-complexity tests (not FDA-approved).

Regulatory noteLDTs must be validated and performed in-house and are subject to CLIA requirements; FDA clearance/approval is not required for clinical use but LDTs are not FDA-approved.

DocumentationLaboratories should document CLIA validation when LDTs are used for clinical testing.

Culture for gonorrhea — role in susceptibility testing

Purpose of cultureCulture for Neisseria gonorrhoeae is required to determine antimicrobial susceptibility and is indicated when treatment failure or resistance is suspected.

Sensitivity noteNAATs are more sensitive than culture for detection, but culture provides phenotypic susceptibility data necessary for resistance monitoring.

Operational noteMaintain laboratory capacity or referral pathways for gonococcal culture when antimicrobial susceptibility testing is clinically indicated.

High-risk for Trichomoniasis — Note 8 features

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

Screening implicationAnnual NAAT screening for T. vaginalis is recommended for asymptomatic individuals who meet these high-risk criteria per Note 8.

Policy changeNote 8 was newly added in the revision history to define high-risk for Trichomoniasis explicitly.

CDC-defined risk factors (minors)

CDC-defined risk factors (minors)Factors include early sexual initiation; living in detention facilities; receiving services at STD clinics; commercial sex exploitation/exchanging sex for drugs/money/food/housing; multiple or concurrent partners; inconsistent barrier protection; lower socioeconomic status; barriers to accessing healthcare; includes YMSM and transgender youths and youths with disabilities/substance abuse/mental health disorders.

Use in policyDocumented CDC-defined risk factors should be included when asserting eligibility for STI screening in sexually active individuals under 18, per new Note 1.

ReferenceNote 1 added to clarify screening eligibility for sexually active children and adolescents under 18 as defined by CDC guidance.

2025-01-01Coding modification

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

2024-10-01Coding modification

Off-cycle coding modification: removed CPT code 0167U.

2024-07-01Coding modification

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

2024-05-01Revision

Reviewed and updated background, guidelines, and evidence; added treponemal and nontreponemal testing (once prior to transplant) as part of pre-transplant assessment (CC1d).

2024-04-01Coding modification

Off-cycle coding modification: removed CPT code 0354U.

2023-10-01Coding modification

Off-cycle coding modification: added CPT code 87563 and 0402U.

2023-06-01Off-cycle review

Updates aligned with pediatric preventive screening (G2042) resulted in changes to this policy; T. vaginalis coverage outside vaginitis was reconsidered.

2023-03-10Revision

Updated background, guidelines, and references; restored coverage for T. vaginalis to this policy with new CC17/CC18 describing covered and non-covered trichomonas testing and added Note 1 defining CDC risk factors for sexually active individuals under 18.

2022-05-15Initial implementation

Policy initially implemented and CPT code additions/removals recorded (adds: 0353U, 0354U; removes: 87660, 87661, 87808).