ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPLAB052

Testing for Vector-Borne Infections

This Clinical Payment and Coding Policy (CPCP) defines reimbursement rules for laboratory testing of various vector-borne infections for Blue Cross and Blue Shield of New Mexico products; providers should consult specific plan documents for product-level applicability.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyTesting for Vector-Borne Infections

Policy CodePolicy CPCPLAB052

Change TypeMaterial revisions with added/clarified reimbursement conditions (Zika timing, PCR for Plasmodium, WNV exceptions)

Effective DateJanuary 15, 2025

Next Review Date

Key ActionSubmit appropriate clinical documentation with claims; testing is reimbursable only when criteria and timing windows in the policy are met.

SourceLink

POLICY UPDATE CHANGES

Document updated with literature review and multiple reorganizations and clarifications to the Reimbursement Information section, including renumbering of items and updates to Zika testing recommendations.

New testing allowances: PCR testing may be reimbursable to confirm Plasmodium species and nucleic acid detection of WNV may be reimbursable for immunocompromised individuals.

Zika NAAT and IgM reimbursement criteria were updated to specify distinct scenarios for pregnant individuals, infants, and symptomatic non-pregnant individuals with travel or exposure histories.

Testing recommendations for relapsing fevers caused by Borrelia spp. were reorganized and specified by vector/type (HTRF, LBRF, STRF/TBRF), and culture testing for Borrelia was made not reimbursable.

AddedPCR added for Plasmodium

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.

Reimbursement Criteria by Condition

Reimbursement criteria by condition

Reimbursable and non-reimbursable testing by suspected condition and situation.

ALL of the following

ANY of the following
- Giemsa- or Wright-stained blood smear (diagnostic microscopy)
- Nucleic acid amplification testing (NAAT)
ALL of the following
- IgG or IgM indirect immunofluorescence antibody (IFA) assay for Babesia

ALL of the following

HTRF
- Serologic assays to detect Borrelia antibodies
- PCR testing to detect Borrelia miyamotoi
LBRF
- Peripheral blood smear microscopy
- PCR testing to detect Borrelia recurrentis
STRF/TBRF
- Dark-field microscopy of a peripheral blood smear
- Microscopy of a Wright- or Giemsa-stained blood smear
- PCR testing to detect Borrelia spp.
- Serologic assays to detect Borrelia antibodies
ALL of the following
- Culture testing for Borrelia

ALL of the following

ANY of the following
- Viral culture
- NAAT on serum
- IFA IgM during acute and convalescent phases

ALL of the following

ANY of the following
- PCR testing
- IFA for CTF-specific IgM antibodies

ALL of the following

ANY of the following
- NAAT
- IgM MAC-ELISA
- NS1 ELISA
- Confirmatory PRNT (plaque reduction neutralization test)
ALL of the following
- IgG ELISA
- Hemagglutination testing

ALL of the following

ANY of the following
- NAAT of whole blood
- IFA IgG
- Microscopy for morulae detection
ALL of the following
- IFA IgM
- Standard blood culture

ALL of the following

ANY of the following
- Rapid immunochromatographic diagnostic test
- Smear microscopy to diagnose, speciate, stage, and quantify parasitemia (may be repeated up to 3 times within 3 days if initial microscopy is negative in suspected cases)
ALL of the following
- PCR testing to confirm Plasmodium species in an individual diagnosed with malaria
ALL of the following
- IFA for Plasmodium antibodies

ALL of the following

ANY of the following
- IFA assay for IgG antibodies (limited to two tests occurring a minimum of two weeks apart)
ALL of the following
- Standard blood culture
- IFA IgM

ALL of the following

ANY of the following
- IFA for WNV-specific IgG or IgM in serum or CSF
- Confirmatory PRNT
ALL of the following
- Nucleic acid detection (NAAT) of WNV may be reimbursable to confirm infection in immunocompromised individuals
- NAAT for WNV is not reimbursable for immunocompetent individuals

ALL of the following

ANY of the following
- NAAT for YFV
- Serologic assays for virus-specific IgM and IgG
- Confirmatory PRNT

ALL of the following

ALL of the following
- NAAT up to 12 weeks after symptom onset for symptomatic pregnant individuals with relevant travel/exposure or sexual exposure history
- NAAT for symptomatic non-pregnant individuals living in or with recent travel to areas with an active CDC Zika Travel Health Notice or areas with current or past Zika transmission when symptoms presented within the last 7 days
- NAAT and IgM testing with confirmatory PRNT may be reimbursable for specified pregnancy/fetal/infant scenarios (pregnant individuals with fetal ultrasound findings consistent with congenital Zika; infants born to individuals who tested positive during pregnancy; infants born with signs of congenital Zika syndrome)
- NAAT and/or IgM testing is not reimbursable for non-pregnant individuals who have not traveled outside the United States and its territories and are symptomatic

ALL of the following

ALL of the following
- Testing for babesiosis, chikungunya, CTF, DENV, ehrlichiosis/anaplasmosis, malaria, rickettsial disease, TBRF, WNV, YFV, or Zika

Reimbursable testing criteria (selected)

Selected reimbursement criteria and limitations (partial list from this document portion):

ALL of the following

ANY of the following
- Serologic assays to detect Borrelia antibodies
- PCR testing to detect Borrelia miyamotoi
ANY of the following
- Peripheral blood smear microscopy
- PCR testing to detect Borrelia recurrentis
ANY of the following

Procedure Codes and Coding Limits

Procedure codes (non-exhaustive)mixed

Procedure code list is present but not exhaustive; inclusion does not guarantee coverage.

Not specified in this document portionmixed

Not specified in this document portion.

inv-05: Repeat smear microscopy for malaria

Repeat smear microscopy allowanceSmear microscopy for malaria may be repeated up to three times within three days if initial microscopy is negative in suspected cases.

PurposeTo diagnose malaria, determine Plasmodium species, identify life-cycle stage, and quantify parasitemia.

Associated confirmatory testingPCR may be reimbursable to confirm Plasmodium species in an individual diagnosed with malaria.

inv-06: Rickettsial IgG paired testing limit

IFA IgG paired testing limitIFA assay for rickettsial IgG is limited to two tests occurring a minimum of two weeks apart.

Not reimbursable

Documentation, Claim Review, and Provider Responsibilities

Documentation Required

Documentation and Claim Review

Providers are responsible for submission of accurate documentation of services performed. Providers must submit claims using valid, industry-standard code sets and coding guidelines. Claims are subject to review against benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and code edit protocols. Upon request, providers should furnish additional documentation to support medical necessity and coding. Inaccurate or insufficient documentation may result in claim denial or recoupment.

Submit claims with valid HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, etc.)
Be prepared to provide additional documentation upon request for claim review
Claims are subject to code edit protocols and plan/contract terms

Billing Rule

Clinical Definitions and Abbreviations

inv-14: Clinical signs/symptoms (document notes)

BabesiosisHemolytic anemia, splenomegaly, hepatomegaly, jaundice, fever, chills, body aches, weakness, and fatigue.

Relapsing fevers (HTRF, LBRF, STRF/TBRF)HTRF: chills/shakes, fatigue, nausea/vomiting, headache, muscle/joint aches; LBRF: fever, headache, chills/shakes, muscle/joint aches, nausea; STRF/TBRF: fever, headache, muscle aches, chills, dizziness, joint pain, nausea/vomiting, appetite loss, and rarely facial paralysis or vision changes.

Chikungunya, CTF, Dengue, Zika, Ehrlichiosis/Anaplasmosis, Malaria, WNV, Yellow FeverChikungunya: high fever, symmetric polyarthralgia, headache, myalgia, conjunctivitis, rash; CTF: fever, chills, headache, myalgia, malaise, sore throat, vomiting, abdominal pain, rash; Dengue: fever, headache, retro-orbital pain, myalgia, arthralgia, rash, bleeding tendencies; Zika: fever, rash, headache, joint pain, conjunctivitis; Ehrlichiosis/Anaplasmosis: fever, headache, malaise, myalgia, shaking chills; Malaria: fever, influenza-like symptoms, anemia, jaundice, seizures; WNV: headache, myalgia, arthralgia, GI symptoms, rash; Yellow fever: toxic-phase symptoms including jaundice and hemorrhage plus nonspecific influenza-like illness.

inv-15: HTRF, LBRF, STRF/TBRF

Document Changes and Review Dates

2025-01-15effective_dateLatest

Document updated with literature review and multiple reorganizations and clarifications to the Reimbursement Information, including renumbering of items and updates to relapsing fever testing and Zika testing recommendations.

2024-10-30last_review

Approval/last review date recorded for the current version prior to the 2025-01-15 effective updates.

2024-10-30material_change

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyTesting for Vector-Borne Infections

Policy CodePolicy CPCPLAB052

Change TypeMaterial revisions with added/clarified reimbursement conditions (Zika timing, PCR for Plasmodium, WNV exceptions)

Effective DateJanuary 15, 2025

Next Review Date

Key ActionSubmit appropriate clinical documentation with claims; testing is reimbursable only when criteria and timing windows in the policy are met.

SourceLink

On This Page

ALL of the following

NAAT and IgM (with confirmatory PRNT) may be reimbursable up to 12 weeks after symptom onset for symptomatic pregnant individuals with relevant travel/exposure or sexual exposure history
NAAT may be reimbursable for symptomatic non-pregnant travelers living in or with recent travel to areas with an active CDC Zika Travel Health Notice when symptoms presented within 7 days (and in some scenarios more than 7 days)
NAAT and/or IgM testing is not reimbursable for symptomatic non-pregnant individuals who have not traveled outside the United States and its territories

inv-08: Zika NAAT timing for symptomatic non-pregnant travelers

Non-pregnant traveler acute windowFor symptomatic non-pregnant individuals living in or with recent travel to areas with an active CDC Zika Travel Health Notice or areas with current/past Zika transmission, NAAT may be reimbursable when symptoms presented within the last seven days.

Non-pregnant traveler later windowPer item #21 (and policy update language), NAAT (and IgM with PRNT) may also be reimbursable for symptomatic non-pregnant travelers when symptoms presented more than seven days prior to testing in specified scenarios.

Non-travel symptomatic exclusionNAAT and/or IgM testing is not reimbursable for non-pregnant individuals who have not traveled outside the U.S. and its territories and are symptomatic for Zika infection.

Billing Rule

Zika Testing Reimbursement Conditions

Zika virus testing (NAAT and IgM, with confirmatory plaque reduction neutralization test when indicated) is reimbursable only in specified clinical scenarios. Coverage depends on pregnancy status, timing of symptom onset, maternal travel or exposure history, and infant clinical findings. Document the applicable scenario and timing on the claim and in the medical record.

NAAT reimbursable up to 12 weeks after symptom onset for symptomatic pregnant individuals who during pregnancy lived in or traveled to areas with current or past Zika transmission, or who had sexual exposure to someone with such travel/exposure
NAAT reimbursable for symptomatic non-pregnant individuals living in or with recent travel to an area with an active CDC Zika Travel Health Notice when symptoms presented within the last 7 days
Zika NAAT and IgM (and confirmatory PRNT) reimbursable for: 1) symptomatic pregnant individuals up to 12 weeks after symptom onset with relevant travel/exposure; 2) pregnant individuals with a fetus showing prenatal ultrasound findings consistent with congenital Zika; 3) infants born to individuals who tested positive for Zika during pregnancy; 4) infants born with signs/symptoms of congenital Zika syndrome when the birthing parent had possible exposure during pregnancy; 5) symptomatic non-pregnant individuals with travel/exposure when symptoms presented >7 days prior to testing
For non-pregnant individuals without travel outside the U.S./territories, testing is limited to those symptomatic with documented possible exposure per policy notes

HTRF definitionHard tick relapsing fever (HTRF) — caused by Borrelia miyamotoi; testing reimbursable: serologic assays to detect Borrelia antibodies or PCR for B. miyamotoi.

LBRF definitionLouse-borne relapsing fever (LBRF) — caused by Borrelia recurrentis; testing reimbursable: peripheral blood smear microscopy or PCR for B. recurrentis.

STRF/TBRF definitionSoft tick relapsing fever (STRF)/tick-borne relapsing fever (TBRF) — caused by Borrelia hermsii, B. turicatae, and other Borrelia spp.; testing reimbursable: dark-field microscopy of peripheral blood smear, Wright-/Giemsa-stained smear microscopy, PCR for Borrelia spp., or serologic assays for Borrelia antibodies; culture testing is not reimbursable.