CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLABO68

Onychomycosis Testing

Defines Blue Cross Blue Shield of Oklahoma's reimbursement stance for laboratory and diagnostic testing used to diagnose or confirm onychomycosis, and indicates which tests may or may not be reimbursable for covered members.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyOnychomycosis Testing

Policy CodePolicy CPCPLABO68

Change TypeAdded NAAT reimbursement for treatment-failureterminology and references updated

Effective DateApr 29, 2024

Next Review Date

Key ActionSubmit accurate documentation and appropriate claim coding; coverage may vary by product and plan documents govern eligibility.

SourceLink

POLICY UPDATE CHANGES

For individuals with onychomycosis and for whom anti-fungal therapy has failed to resolve infection, nucleic acid amplification testing/NAAT may be reimbursable.

Changed terminology from 'nucleic acid testing' to the abbreviation 'NAAT' in the reimbursement list.

Reimbursement information and references were updated following a literature review.

5reimbursement positions

13procedure codes listed

1.0policy version

04/29/2024last updated

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 Positions and Criteria

Coverage criteria

Reimbursement positions for diagnostic tests in individuals with suspected or confirmed onychomycosis:

Covered when ALL of the following are met:

Direct microscopic examination with potassium hydroxide, fungal culture of desquamated subungual material, or fungal stain of a nail clipping(s) may be reimbursable.

Conditional reimbursement

For individuals with onychomycosis and for whom anti-fungal therapy has failed to resolve infection, nucleic acid amplification testing/NAAT may be reimbursable.

Not reimbursable for initial diagnosis or screening

To screen for, diagnose, or confirm onychomycosis, NAAT is not reimbursable.
To screen for, diagnose, or confirm onychomycosis, attenuated total-reflectance Fourier transform infrared/ATR-FTIR spectroscopy is not reimbursable.
Testing for the presence of fungal-derived sterols (e.g., ergosterol) is not reimbursable.

Note 1 — Organisms included in NAAT references

NAAT methods referenced include testing for Candida species; Aspergillus species; Trichophyton rubrum; Trichophyton mentagrophytes; Epidermophyton floccosum; Neoscytalidium dimidiatum; Onychocola canadensis; Scopulariopsis species; Alternaria species; Acremonium species; and Fusarium species.

Procedure and Diagnostic Codes

Listed procedure/diagnostic codesCPT

82542
87101
87149
87150
87153
87205
87206
87220
87480
87481

1–10 of 16

1/2

Documentation and Plan-Specific Coverage

Documentation Required

Submit accurate documentation and plan-specific coding

Providers must submit accurate documentation of services performed and submit claims using valid, appropriately selected codes from standard HIPAA-approved code sets; claim submissions are subject to claim review and plan- or contract-specific terms. Plan documents govern coverage when they conflict with this policy, and providers may be asked to supply additional documentation upon request.

Use industry-standard coding guidelines (CPT, HCPCS, ICD-10-CM/PCS, NDCs, DRG, etc.) and follow National Correct Coding Initiative edits and other CMS guidelines.
Claims are subject to code edit protocols and claim review, including benefit coverage terms, provider contract language, medical policies, and coding software logic.
If a conflict exists between this policy and a plan document or provider contract, the plan document or provider contract governs.
Be prepared to provide additional documentation upon request to support the claim.

Key Definitions

NAAT (Nucleic acid amplification testing) — definition and scope

DefinitionNucleic acid amplification testing (NAAT) — includes PCR, PCR-RFLP, and next-generation sequencing (NGS) for fungal organisms listed in Note 1.

Included methodsPolymerase chain reaction (PCR); PCR-restriction fragment length polymorphism (PCR-RFLP); next-generation sequencing (NGS).

Organisms referenced (Note 1)Candida spp., Aspergillus spp., Trichophyton rubrum, Trichophyton mentagrophytes, Epidermophyton floccosum, Neoscytalidium dimidiatum, Onychocola canadensis, Scopulariopsis spp., Alternaria spp., Acremonium spp., Fusarium spp.

Permitted use per policyMay be reimbursable for individuals with onychomycosis when antifungal therapy has failed to resolve infection.

Not reimbursable use per policyNot reimbursable to screen for, diagnose, or confirm onychomycosis in initial evaluation.