ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPLABO52

Testing for Vector-Borne Infections

Defines BCBSNM reimbursement criteria for laboratory testing of various vector-borne infections (e.g., babesiosis, relapsing fevers, dengue, Zika, malaria, rickettsial diseases, West Nile) and notes that not all requirements apply to every product and plan documents govern coverage.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyTesting for Vector-Borne Infections

Policy CodePolicy CPCPLABO52

Change TypeMaterial clarifications and reorganization (revised/added)

Effective DateOct 30, 2024

Next Review DateN/A

Key ActionSubmit claims with accurate documentation and valid HIPAA-approved codes; reimbursement depends on clinical scenario and specified test types.

SourceLink

POLICY UPDATE CHANGES

Testing indications for Colorado tick fever updated to include PCR testing.

NAAT (PCR) reimbursement policy for Zika virus was clarified with time windows and different rules for pregnant vs non-pregnant individuals.

Guidance on testing for relapsing fevers caused by Borrelia spp. was expanded to specify testing modalities by vector type (hard tick, louse-borne, soft tick) including PCR, microscopy, serology, and dark-field techniques.

For immunocompromised individuals, nucleic acid detection of West Nile virus may be reimbursable; for immunocompetent individuals NAAT for WNV is not reimbursable.

IFA use rules updated: IFA for Plasmodium antibodies is not reimbursable; IFA for WNV IgG or IgM with confirmatory PRNT may be reimbursable.

25+pathogens referenced

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Coverage Criteria by Condition and Test

Coverage criteria by condition and test

Covered when the following condition- and test-specific rules are met:

ALL of the following

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

ALL of the following

HTRF (Borrelia miyamotoi)
- Serologic assays to detect Borrelia antibodies
- PCR testing to detect Borrelia miyamotoi
LBRF (Borrelia recurrentis)
- Peripheral blood smear microscopy
- PCR testing to detect Borrelia recurrentis
STRF/TBRF (soft-tick/tick-borne relapsing fever)
- 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

PCR testing may be reimbursable
IFA for CTF-specific IgM antibodies may be reimbursable

ALL of the following

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

ALL of the following

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

ALL of the following

ANY of the following
- Rapid immunochromatographic diagnostic test
- Smear microscopy to diagnose, speciate, identify life-cycle stage, and/or quantify parasitemiarepeat up to 3 times within 3 days if initial microscopy is negative
- PCR testing may be reimbursable to confirm Plasmodium species in a diagnosed case
ALL of the following
- IFA for Plasmodium antibodies

ALL of the following

IFA IgG may be reimbursable (limited to two tests occurring a minimum of two weeks apart)two tests >= 2 weeks apart
Not reimbursable: standard blood culture or IFA IgM

ALL of the following

IFA for WNV-specific IgG or IgM in serum or CSF and confirmatory PRNT may be reimbursable
NAAT may be reimbursable to confirm WNV infection in immunocompromised individuals
NAAT is not reimbursable for 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

ALL of the following

See disease-specific timing and pregnancy/travel/infant rules in the Zika criteria group

ALL of the following

Plan documents and provider contracts take precedence over this policy

ALL of the following

Providers must submit appropriate documentation and use valid HIPAA-approved code sets; claims are subject to review per plan documents and clinical/coding policies

ALL of the following

Several serologic and culture tests are explicitly not reimbursable per-condition as noted above (e.g., Babesia IFA, Borrelia culture, Plasmodium IFA, certain IFA IgM uses, NAAT for WNV in immunocompetent individuals)

Coverage criteria by disease

Coverage is conditional and varies by pathogen, pregnancy status, symptom timing, recent travel, and immune status:

ALL of the following

NAAT (PCR) may be reimbursable up to 12 weeks after symptom onset for symptomatic pregnant individuals who during pregnancy have lived in or traveled to areas with current or past Zika transmission or who had sexual exposure to someone with recent travel/exposure
Zika NAAT and IgM testing and confirmatory PRNT may be reimbursable for pregnant individuals with prenatal ultrasound findings consistent with congenital Zika or for infants born to individuals who tested positive during pregnancy, and for infants with signs of congenital Zika syndrome

ALL of the following

NAAT may be reimbursable for symptomatic non-pregnant individuals living in or with recent travel to areas with an active CDC Zika Travel Health Notice or current/past Zika transmission when symptoms presented within the last 7 days

Coding and Test References

Procedure codesmixed

Procedure code list exists but is not exhaustive; the inclusion of a code does not guarantee it is a covered service or eligible for reimbursement.

Tests referencedmixed

NAAT/ PCR and serologic tests (specific CPT/HCPCS codes not listed in this excerpt)

inv-05: Malaria microscopy repeats — up to three repeat smears within three days if initial microscopy is negative

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

PurposeRepeats used to diagnose malaria, determine Plasmodium species, identify life-cycle stage, and quantify parasitemia.

Confirmatory testingPCR may be reimbursable to confirm the species of Plasmodium in an individual diagnosed with malaria.

inv-06: Rickettsial serology limitation — IFA IgG limited to two tests occurring a minimum of two weeks apart

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

Documentation, Submission, and Reimbursement Conditions

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 sets. Claims should be coded according to industry-standard coding guidelines (for example: UB, AMA CPT, HCPCS, ICD-10-CM/PCS, DRG rules, CMS NCCI edits). Claim submissions are subject to review and may be audited; upon request, providers should submit additional clinical documentation to support medical necessity and coding.

Submit claims using valid HIPAA-approved code sets
Document clinical indications and timing (e.g., pregnancy status, symptom onset, immune status) when relevant
Be prepared to provide additional documentation upon request for claim review

Billing Rule

Condition Definitions and Notes

inv-10: Babesiosis — signs/symptoms and brief definition

Typical signs and symptomsHemolytic anemia, splenomegaly, hepatomegaly, jaundice, and nonspecific flu-like symptoms (fever, chills, body aches, weakness, fatigue).

Clinical contextFindings suggestive of babesiosis should prompt appropriate diagnostic testing (e.g., blood smear, NAAT) per reimbursement criteria.

ReferenceSigns and symptoms summarized from CDC guidance as cited in policy notes.

inv-11: HTRF — hard tick relapsing fever (Borrelia miyamotoi) signs/symptoms

Typical signs and symptomsChills or shakes, fatigue, nausea or vomiting, headache, and muscle and joint aches are typical for hard tick relapsing fever (Borrelia miyamotoi).

Testing modalities

Policy Updates and Material Changes

2024-10-30material_revisionLatest

Policy reorganized and renumbered items; testing recommendations for relapsing fevers were expanded and Colorado tick fever testing updated to include PCR; Zika NAAT reimbursement windows clarified for pregnant and non-pregnant individuals; IFA usage rules and WNV NAAT distinctions by immune status were added.

2023-11-01revision

Document reorganized alphabetically by infection name and Zika content moved from separate risk assessment policy into this document; notes and Zika-related sections added and updated.

2023-08-15revision

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyTesting for Vector-Borne Infections

Policy CodePolicy CPCPLABO52

Change TypeMaterial clarifications and reorganization (revised/added)

Effective DateOct 30, 2024

Next Review DateN/A

Key ActionSubmit claims with accurate documentation and valid HIPAA-approved codes; reimbursement depends on clinical scenario and specified test types.

SourceLink

On This Page

inv-07: Time-window thresholds for Zika NAAT reimbursement — pregnant symptomatic up to 12 weeks; non-pregnant symptomatic with recent travel within 7 days; other distinctions

Pregnant symptomatic windowNAAT (PCR) may be reimbursable up to 12 weeks after symptom onset for symptomatic pregnant individuals with relevant travel/exposure during pregnancy or sexual exposure to a partner with travel/exposure.

Non‑pregnant symptomatic with recent travelNAAT may be reimbursable for symptomatic non-pregnant individuals who live in or recently traveled to areas with active Zika transmission when symptoms presented within the last seven days.

Non‑pregnant without travelFor non-pregnant individuals who have not traveled outside the United States/territories and are symptomatic, NAAT and/or IgM testing for Zika is not reimbursable.

Reimbursement for laboratory testing is contingent on clinical indications and the member’s specific clinical scenario. Coverage may depend on factors such as pregnancy status, timing of symptoms relative to specimen collection, travel/exposure history, and immune status. Not all tests or criteria apply to every product — providers should review applicable plan documents for coverage details. Claims that do not meet clinical indications or plan-specific criteria may be denied or subject to further review.

inv-13: Relapsing fevers taxonomy — HTRF, LBRF, STRF/TBRF distinctions and testing modalities

Relapsing fever taxonomyRelapsing fevers include hard tick relapsing fever (HTRF), louse-borne relapsing fever (LBRF), and soft-tick/tick-borne relapsing fever (STRF/TBRF).

Distinct testing by vectorHTRF: serology or PCR for B. miyamotoi; LBRF: peripheral blood smear microscopy or PCR for B. recurrentis; STRF/TBRF: dark-field microscopy, Wright- or Giemsa-stained smear microscopy, PCR, or serology.

LimitationsCulture testing for Borrelia is not reimbursable for soft-tick/TBRF per policy notes.