ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPLAB052

Testing for Vector-Borne Infections

Laboratory testing and reimbursement criteria for vector-borne infections for Blue Cross Blue Shield of New Mexico members; governs what tests may be reimbursed and for which clinical scenarios.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyTesting for Vector-Borne Infections

Policy CodePolicy CPCPLAB052

Change TypeMaterial updates to reimbursement positions (added IFA timing, NAAT terminology, Zika windows, new NAAT positions)

Effective Date09/26/2025

Next Review DateN/A

Key ActionProviders should order reimbursable tests per the numbered reimbursement positions and submit accurate documentation; note IFA testing requires initial and confirmatory tests at least two weeks apart.

SourceLink

POLICY UPDATE CHANGES

Added 'IgG or IgM indirect immunofluorescence antibody (IFA) assay for Babesia (initial testing and confirmatory testing should occur a minimum of two weeks apart)' to reimbursement information for babesiosis.

Replaced 'PCR testing' with 'NAAT testing' in multiple reimbursement positions.

Clarified Zika virus NAAT reimbursement criteria and reorganized multiple Zika-related positions to specify windows and populations for testing reimbursement.

Added new reimbursement positions allowing NAAT to confirm Plasmodium species and permitting nucleic acid detection of WNV in immunocompromised individuals.

Edited language to change specimen terminology from 'serum sample' to 'blood sample'.

1.0policy version

~20+

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.

09/26/2025effective date

emphasizedplan discretion

Reimbursement Criteria for Vector-Borne Infections

inv-01: Reimbursement criteria by disease

Reimbursable and non-reimbursable tests by suspected diagnosis and clinical scenario.

ALL of the following

ANY of the following
- Giemsa- or Wright-stain blood smear
- Nucleic acid amplification testing (NAAT) on blood
- IgG or IgM indirect immunofluorescence antibody (IFA) assay for Babesia
  Initial and confirmatory IFA testing should occur a minimum of two weeks apart

ALL of the following

HTRF options
- Serologic assays to detect Borrelia antibodies
- NAAT testing to detect Borrelia miyamotoi
LBRF options
- Peripheral blood smear microscopy
- NAAT testing to detect Borrelia recurrentis
STRF/TBRF options
- Dark-field microscopy of a peripheral blood smear
- Microscopy of a Wright- or Giemsa-stained blood smear
- NAAT testing to detect Borrelia spp.
- Serologic assays to detect Borrelia antibodies
Not reimbursable: Culture testing for Borrelia

ALL of the following

ANY of the following
- NAAT
- IgM antibody capture ELISA (MAC-ELISA)
- NS1 ELISA
- Confirmatory plaque reduction neutralization test (PRNT) for DENV
Not reimbursable: IgG ELISA or hemagglutination testing

ALL of the following

NAAT reimbursement windows and populations
- Symptomatic pregnant individuals: NAAT reimbursable up to 12 weeks after symptom onset if during pregnancy they lived in or traveled to areas with current or past Zika transmission or had sex with someone who lived in or recently traveled to such areas
- Symptomatic non-pregnant individuals with recent travel to an area with an active CDC Zika Travel Health Notice or current/past transmission: NAAT reimbursable when symptoms presented within 7 days
- Symptomatic non-pregnant individuals with travel exposure when symptoms presented more than 7 days prior: NAAT reimbursable in specified situations per positions #20-#22
NAAT/IgM with confirmatory PRNT
- Pregnant individuals with fetus having prenatal ultrasound findings consistent with congenital Zika virus infection

ALL of the following

ANY of the following
- NAAT of whole blood
- IFA assay for IgG antibodies
- Microscopy for morulae detection
Not reimbursable: IFA IgM or standard blood culture

ALL of the following

ANY of the following
- Rapid immunochromatographic diagnostic test
- Smear microscopy to diagnose malaria, determine Plasmodium species, identify life-cycle stage, and/or quantify parasitemia
  Microscopy may be repeated up to three times within three days if initial microscopy is negative and clinical suspicion persists
- NAAT to confirm Plasmodium species
Not reimbursable: IFA for Plasmodium antibodies

ALL of the following

ANY of the following
- IFA assay for IgG antibodies
Not reimbursable: Standard blood culture, NAAT, or IFA IgM

ALL of the following

ANY of the following
- IFA for WNV-specific IgG or IgM antibodies in serum or CSF plus confirmatory PRNT
- Nucleic acid detection of WNV may be reimbursable to confirm infection in immunocompromised individuals
Not reimbursable: NAAT for WNV in immunocompetent individuals

ALL of the following

Not reimbursable: Testing for babesiosis, chikungunya, CTF, DENV, ehrlichiosis/anaplasmosis, malaria, rickettsial disease, TBRF, WNV, YFV, or Zika during a general exam without abnormal findings

inv-02: Key coverage criteria (partial, from this document part)

Selected reimbursement criteria and clarifications extracted from the policy update history and positions in this document part:

ALL of the following

Giemsa- or Wright-stained blood smear, NAAT, or IgG/IgM IFA assay may be reimbursable
Operational note: IFA initial and confirmatory tests must occur a minimum of two weeks apart

ALL of the following

NAAT testing may be reimbursable to confirm species in individuals diagnosed with malaria
Note: IFA for Plasmodium antibodies is not reimbursable

ALL of the following

Procedure Codes and Coding Notes

Procedure codes noticemixed

Procedure codes list included but not exhaustive; inclusion does not guarantee coverage.

Newly added/mentioned codesCPT

87164

Code referenced as added in policy update history

inv-05: IFA testing interval — timing requirement

RequirementInitial and confirmatory IFA testing for Babesia and rickettsial disease must be performed at least two weeks apart.

Applicable testsIgG or IgM indirect immunofluorescence antibody (IFA) assay for Babesia; IFA IgG for rickettsial disease (policy specifies paired testing).

Operational noteThe policy text explicitly added IFA for Babesia and clarifies the minimum interval between initial and confirmatory IFA tests.

inv-06: Zika NAAT reimbursement window (pregnant symptomatic)

WindowNAAT reimbursable up to 12 weeks after symptom onset for symptomatic pregnant individuals with relevant exposure (lived in or traveled to areas with current or past Zika transmission, or sexual exposure).

Documentation, Billing, and Operational Notes for Providers

Documentation Required

Documentation and claim submission

Providers are responsible for submission of accurate documentation of services performed and must submit claims using valid HIPAA-approved code combinations. Claims are subject to code edit protocols and claim review against benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, the provider is urged to submit any additional documentation.

Note

Reimbursement position operational notes

Providers should order tests consistent with the numbered reimbursement positions in this policy. Some reimbursable tests require specific specimen pairing or timing — for example, IFA serology for Babesia and rickettsial disease requires initial and confirmatory IFA tests be performed a minimum of two weeks apart, and Zika NAAT reimbursement is limited to specified timing windows for defined populations.

Order reimbursable tests per the policy's numbered positions.
For Babesia and rickettsial IFA: perform initial and confirmatory IFA tests at least two weeks apart.

Policy Terminology and Clinical Notes

inv-10: Plan reimbursement criteria

Plan positionThe Plan has implemented lab management reimbursement criteria; not all requirements apply to each product—providers should review plan documents for eligible coverage.

Ordering guidanceProviders should order tests aligned with the numbered reimbursement positions in the policy; timing windows, specimen requirements, and paired testing may apply.

Claims/documentationClaims are subject to benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and code edit protocols; providers may be asked to provide additional documentation.

inv-11: Clinical presentation notes

BabesiosisSigns/symptoms can include hemolytic anemia, splenomegaly, hepatomegaly, jaundice, fever, chills, body aches, weakness, and fatigue.

Zika virus

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyTesting for Vector-Borne Infections

Policy CodePolicy CPCPLAB052

Change TypeMaterial updates to reimbursement positions (added IFA timing, NAAT terminology, Zika windows, new NAAT positions)

Effective Date09/26/2025

Next Review DateN/A

SourceLink

On This Page

Infants born to individuals who tested positive for Zika during pregnancy

Infants born with signs of congenital Zika syndrome with parental possible exposure during pregnancy

Not reimbursable: NAAT and/or IgM testing for non-pregnant symptomatic individuals who have not traveled outside the United States and its territories

IFA for WNV-specific IgG or IgM in serum or CSF plus confirmatory PRNT may be reimbursable

Nucleic acid detection may be reimbursable for immunocompromised individuals; NAAT not reimbursable for immunocompetent individuals

ALL of the following

Culture testing for Borrelia is not reimbursable for suspected relapsing fever

ALL of the following

Depending on subtype (HTRF, LBRF, STRF/TBRF), reimbursable tests include serology, NAAT, blood smear microscopy, dark-field microscopy, or Wright/Giemsa smear as specified

ALL of the following

Reference to 'serum sample' was replaced with 'blood sample' in at least one reimbursement position

ALL of the following

For symptomatic non-pregnant individuals with travel exposure, NAAT reimbursable when symptoms presented within 7 days; other specified windows apply per positions #20-#22

Additional reimbursable situations

Also reimbursable for pregnant individuals with fetal ultrasound findings consistent with congenital Zika, infants born to infected parents, and infants with signs of congenital Zika syndrome.

Reference guidanceTiming and populations were updated to align with CDC Zika testing recommendations in policy positions #20–#22.

inv-07: Zika NAAT reimbursement window (non-pregnant symptomatic travel-related)

WindowNAAT reimbursable for symptomatic non-pregnant individuals with recent travel to or residence in areas with active or past Zika transmission when symptoms presented within 7 days prior to testing.

Extended timingFor symptomatic travelers whose symptoms presented more than 7 days prior, NAAT and IgM plus PRNT may be reimbursable per specified positions.

ExclusionNAAT/IgM testing is not reimbursable for symptomatic non-pregnant individuals without relevant travel/exposure.

inv-12: NAAT — definition and terminology note

DefinitionNAAT = nucleic acid amplification testing.

Terminology changePolicy replaced prior references to 'PCR testing' with 'NAAT testing' in multiple reimbursement positions to standardize nomenclature.

UsageNAAT is listed as an allowable method for detecting several pathogens (e.g., Babesia, Plasmodium species confirmation, WNV in immunocompromised individuals).

inv-13: IFA — definition and use with timing requirements

DefinitionIFA = indirect immunofluorescence antibody assay used for serologic testing (IgG or IgM) for agents such as Babesia and rickettsial diseases.

Timing requirementInitial and confirmatory IFA assays should be performed a minimum of two weeks apart for Babesia and for rickettsial disease IgG testing as specified in the policy.

ScopePolicy specifies IFA IgG for rickettsial disease and IgG/IgM IFA for Babesia as reimbursable when clinical criteria and timing are met.

Follow Zika NAAT timing windows and population restrictions as specified in the reimbursement positions.

Typical signs include fever, rash, headache, joint pain, conjunctivitis (red eyes), and muscle pain; congenital Zika syndrome signs include microcephaly, feeding problems, hearing loss, seizures, and vision problems.

Rickettsial diseases and othersRickettsial diseases: fever, headache, chills, malaise, myalgia, nausea, vomiting, abdominal pain, photophobia, anorexia, and rash; dengue, WNV, malaria, and others have disease-specific symptom lists provided in notes.