CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB068

Onychomycosis Testing

Defines Blue Cross Blue Shield of Oklahoma reimbursement stance for laboratory tests used to screen, diagnose, or confirm onychomycosis (fungal nail infection) and specifies which methods may be reimbursable for members and providers.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyOnychomycosis Testing

Policy CodePolicy CPCPLAB068

Change TypeClarification and addition (NAAT exception)

Effective DateAug 8, 2025

Next Review Date

Key ActionSubmit accurate documentation and be prepared to provide additional records upon request; claims remain subject to review and coding rules.

SourceLink

POLICY UPDATE CHANGES

Added 'signs of' to reimbursement criterion #1 to clarify that direct microscopy, fungal culture, or fungal stain may be reimbursable for individuals with signs of onychomycosis.

Added reimbursement allowance that NAAT may be reimbursable for individuals with onychomycosis when antifungal therapy has failed to resolve infection.

5reimbursement statements

15+listed codes

Since 2022revision history

Onychomycosis Testing Reimbursement Rules

Onychomycosis testing reimbursement rules

Reimbursement position for onychomycosis testing methods:

Covered when performed for individuals with signs of onychomycosis: direct microscopic examination with potassium hydroxide, fungal culture of desquamated subungual material, or fungal stain of a nail clipping(s) may be reimbursable.

NAAT (nucleic acid amplification testing) may be reimbursable only for individuals with onychomycosis for whom antifungal therapy has failed to resolve infection (post-treatment failure).

NAAT is not reimbursable to screen for, diagnose, or confirm onychomycosis (general diagnostic use).

Attenuated total-reflectance Fourier transform infrared (ATR-FTIR) spectroscopy is not reimbursable to screen for, diagnose, or confirm onychomycosis.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyOnychomycosis Testing

Policy CodePolicy CPCPLAB068

Change TypeClarification and addition (NAAT exception)

Effective DateAug 8, 2025

Next Review Date

Key ActionSubmit accurate documentation and be prepared to provide additional records upon request; claims remain subject to review and coding rules.

SourceLink

On This Page

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.

Documentation, Claim Review, and Billing Expectations

Documentation Required

Documentation and claim review

Providers are responsible for submission of accurate documentation of services performed. Claims are subject to claim review, code edit protocols, and may require submission of additional documentation upon request.

Submit accurate documentation of services performed.
Claims are subject to code edit protocols and claim review (including benefit terms, provider contract language, medical policies, clinical payment and coding policies, and coding software logic).
Provide additional documentation upon request.

Billing Rule

Coding and billing expectations

Claims should be coded using valid HIPAA‑approved code sets and in accordance with industry-standard coding guidelines; inclusion of a code on a list does not guarantee coverage.

Use valid code combinations from HIPAA‑approved code sets (e.g., CPT, HCPCS, ICD‑10).
Code appropriately per industry standards (Uniform Billing, AMA CPT guidance, NCCI, CMS guidelines, etc.).
Inclusion of a procedure code does not ensure coverage — claims remain subject to plan documents, provider contracts, and medical policy requirements.

Key Definitions

Nucleic acid amplification testing (NAAT)

DefinitionNucleic acid amplification testing (NAAT): laboratory methods that detect nucleic acids of fungal organisms (examples include PCR, PCR‑RFLP, and next‑generation sequencing/NGS).

When reimbursableMay be reimbursable only for individuals with onychomycosis for whom antifungal therapy has failed to resolve infection (post‑treatment failure).

When not reimbursableNot reimbursable to screen for, diagnose, or confirm onychomycosis in general diagnostic use.

Example targetsIncludes testing for Candida spp., Aspergillus spp., Trichophyton rubrum, T. mentagrophytes, Epidermophyton floccosum, Neoscytalidium dimidiatum, Onychocola canadensis, Scopulariopsis spp., Alternaria spp., Acremonium spp., and Fusarium spp.

Related methods listedExamples named in policy: PCR, PCR‑RFLP, and next‑generation sequencing (NGS).

Policy Revision History

2025-08-08effective_dateLatest

Policy effective date updated to 2025-08-08; added 'signs of' to reimbursement criterion #1 for clarity and literature review conducted.

2024-01-15revision

Document updated with literature review and reimbursement information: added new #2 allowing NAAT for individuals with onychomycosis after antifungal therapy failure; 'nucleic acid testing' changed to 'NAAT' in #3.

2023-06-15revision

Document updated with literature review; reimbursement information revised for clarity and references updated.

2022-11-01new_policy

Policy created and published as a new policy on 2022-11-01.

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OpenPayer

Onychomycosis Testing

Onychomycosis Testing Reimbursement Rules

Procedure Codes and Coding Guidance

Documentation, Claim Review, and Billing Expectations

Key Definitions

Policy Revision History