ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLAB051

Diagnostic Testing of Common Sexually Transmitted Infections

Defines Blue Cross Blue Shield of Oklahoma's reimbursement criteria for diagnostic testing of selected STIs (chlamydia, gonorrhea, syphilis, trichomonas, HSV, HPV, Mycoplasma genitalium) and when testing is reimbursable or not reimbursable for covered members and providers.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyDiagnostic Testing of Common Sexually Transmitted Infections

Policy CodePolicy CPCPLAB051

Change TypeCodes added/removedclarified M. genitalium and NAAT susceptibility positions

Effective DateApril 15, 2025

Next Review DateN/A

Key ActionSubmit claims with accurate documentation and appropriate industry-standard codes; claims are subject to review and may require additional documentation.

SourceLink

POLICY UPDATE CHANGES

Added code 87626.

For symptomatic individuals, testing for Mycoplasma genitalium using NAAT may be reimbursable; for asymptomatic individuals, screening for M. genitalium using NAAT is not reimbursable.

Added T. vaginalis and M. genitalium to list #11 and added several proprietary and CPT/HCPCS codes (87563, 0402U, 0455U, 0463U, 0483U, 0484U); removed codes 0167U, 0353U, 0354U.

Nucleic acid testing to determine antimicrobial susceptibility in N. gonorrhoeae or macrolide resistance in M. genitalium is not reimbursable.

When an individual meets conditions for both chlamydia and gonorrhea, multitarget PCR testing (targets limited to C. trachomatis and N. gonorrhoeae) may be reimbursable.

Document updated with literature review and reimbursement information revised for clarity (10/30/2024 and 11/01/2023 updates).

Apr 15, 2025plan effective date

Jan 23, 2025approval / last review

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Reimbursement and Coverage Criteria

Reimbursement criteria

Situations where specific STI tests are reimbursable or not reimbursable.

ALL of the following

ANY of the following
- Once a year assessment for any asymptomatic person in a high-risk category (See Notes 1 & 2).
- For diagnosis of any person presenting with signs and/or symptoms of a chlamydial infection (See Note 3).
- For diagnosis of any person with suspected lymphogranuloma venereum (LGV).
- As test of cure of treatment at least three months after initial chlamydial diagnosis.
ALL of the following
- Serology testing for chlamydia or lymphogranuloma venereum (LGV) is not reimbursable.

ALL of the following

ANY of the following
- Once a year assessment for any asymptomatic person in a high-risk category (See Notes 1 & 4).
- For diagnosis of any person presenting with signs and/or symptoms of a gonorrheal infection (See Note 4).
- As test of cure of treatment.
ALL of the following
- For an individual that does not respond to initial treatment, culture testing for N. gonorrhoeae to determine antimicrobial susceptibility may be reimbursable.

ALL of the following

ANY of the following
- Symptomatic individuals (See Note 5).
- Asymptomatic individuals belonging to a high-risk group, including concurrent STI or history of STIs; individuals in high-prevalence settings such as STI clinics; individuals who exchange sex for payment.
ALL of the following
- Rapid identification of Trichomonas by enzyme immunoassay is not reimbursable.

ALL of the following

ALL of the following
- For symptomatic individuals (See Note 6), testing for Mycoplasma genitalium using NAAT may be reimbursable.
ALL of the following
- For asymptomatic individuals (See Note 6), screening for M. genitalium using NAAT is not reimbursable.

ALL of the following

ANY of the following
- For individuals with active genital ulcers or mucocutaneous lesions, NAAT/NAAT-based testing for HSV-1 or HSV-2 may be reimbursable.
- Type-specific serologic testing for HSV-2 (gG2) may be reimbursable for recurrent or atypical genital symptoms or lesions with negative HSV PCR/culture, for clinical diagnosis when PCR/culture negative or without lab confirmation, or when an individual's partner has genital herpes.
ALL of the following
- Immunoassay testing for HSV-1 and/or non-type-specific HSV testing is not reimbursable; screening for HSV-1 or HSV-2 in asymptomatic individuals is not reimbursable.

ALL of the following

ALL of the following
- In the diagnosis and/or assessment of cancer or cancer therapy (p16 IHC or NAAT testing for high-risk HPV) may be reimbursable.
ALL of the following
- HPV testing as part of general asymptomatic STI panel is not reimbursable except as noted for cancer assessment.

ALL of the following

ALL of the following
- Nucleic acid testing to determine antimicrobial susceptibility to N. gonorrhoeae or macrolide resistance to M. genitalium is not reimbursable.
- Using nucleic acid testing to quantify organisms (C. trachomatis, N. gonorrhoeae, HSV-1, HSV-2, HPV, Treponema pallidum) is not reimbursable.

ALL of the following

ANY of the following
- As part of newborn screening.
- As part of follow-up of a victim of sexual assault.
- For sexually active individuals less than 18 years of age (annually).
ALL of the following
- PrEP-related testing guidance (baseline HIV antibody, renal function, HBV/HCV, pregnancy, and periodic STI screening) is addressed elsewhere in the policy.

ALL of the following

When an individual meets the conditions described above, multitarget PCR testing (targets limited to C. trachomatis, N. gonorrhoeae, T. vaginalis, and M. genitalium) may be reimbursable.

Reimbursement criteria (selected)

Summary of reimbursement positions from policy update history.

ALL of the following

Testing for Mycoplasma genitalium using NAAT may be reimbursable for symptomatic individuals (see Note 6).

ALL of the following

Screening for M. genitalium using NAAT is not reimbursable for asymptomatic individuals (see Note 6).

ALL of the following

When an individual meets the conditions for both chlamydia and gonorrhea, multitarget PCR limited to C. trachomatis and N. gonorrhoeae may be reimbursable.

ALL of the following

Procedure Codes and Coding Guidance

Selected procedure codes (not exhaustive)mixed

82565
87591
G0432
0064U

Codes added/removed in recent updatesmixed

87626	Added to code set (as listed in policy update history)
87563	Added to code set (as listed in policy update history)
0402U	Added proprietary code
0455U	Added proprietary code
0463U	Added proprietary code
0483U	Added proprietary code
0484U	Added proprietary code
0167U	Removed from code set
0353U	Removed from code set
0354U	Removed from code set

Chlamydia NAAT frequency for high‑risk asymptomatic

FrequencyOnce a year assessment for any asymptomatic person in a high-risk category

Other reimbursable situationsDiagnosis for persons with signs and/or symptoms of chlamydial infection

Test of cureAs test of cure at least three months after initial chlamydial diagnosis

Not reimbursableSerology testing for chlamydia or LGV is not reimbursable

PrEP monitoring — HIV antibody

HIV antibody monitoring frequency during PrEPA blood test once every three months to confirm a negative antibody result for HIV

Claims Submission, Provider Responsibilities, and Billing Rules

Documentation Required

Claims submission and documentation

Providers must submit accurate documentation of services performed and submit claims using valid HIPAA-approved code sets. Claims are subject to code edit protocols and may be reviewed against benefit coverage, provider contract language, medical policies, clinical payment and coding policies, coding software logic, and providers may be asked to submit additional documentation upon request.

Use industry-standard coding guidelines (CPT, HCPCS, ICD-10-CM/PCS, NDCs, CMS NCCI edits, DRG guidance).
Be prepared to provide additional documentation if requested during claim review.

Billing Rule

Multitarget PCR reimbursement (CT/GC only)

When an individual meets the conditions described for both chlamydia and gonorrhea, multitarget PCR testing limited to targets for C. trachomatis and N. gonorrhoeae may be reimbursable.

Definitions and Notes

NAAT — Definition

DefinitionNAAT = nucleic acid amplification tests for chlamydia and gonorrhea

Reimbursable uses (chlamydia)Once‑year assessment for asymptomatic high‑risk individuals; diagnosis of symptomatic individuals; suspected LGV; test of cure >=3 months

Reimbursable uses (gonorrhea)Once‑year assessment for asymptomatic high‑risk individuals; diagnosis of symptomatic individuals; test of cure

Multitarget PCR — Definition

ScopeMultitarget PCR testing is limited to C. trachomatis, N. gonorrhoeae, T. vaginalis, and M. genitalium

Reimbursement conditionWhen an individual meets the conditions described above, multitarget PCR testing for these targets may be reimbursable

Policy Updates and Change Log

2025-01-23effective_dateLatest

Policy effective date listed as 04/15/2025 with change: added code 87626 to the code set.

2024-10-30revision

Document updated with literature review and reimbursement information: added symptomatic and asymptomatic M. genitalium NAAT positions (Note 6), added T. vaginalis and M. genitalium to code list, added NAAT antimicrobial susceptibility non‑reimbursable position, and added and removed multiple CPT/HCPCS/proprietary codes.

2023-11-01revision