ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLAB051

Diagnostic Testing of Common Sexually Transmitted Infections

Reimbursement and coding criteria for laboratory testing of selected sexually transmitted infections (STIs) for Blue Cross Blue Shield - Oklahoma members; outlines when specific tests (NAAT, PCR, serology, culture) for pathogens such as C. trachomatis, N. gonorrhoeae, T. vaginalis, HSV, HPV, T. pallidum, and M. genitalium are reimbursable and any explicit exclusions.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyDiagnostic Testing of Common Sexually Transmitted Infections

Policy CodePolicy CPCPLAB051

Change TypeClarifications and additions to reimbursement criterianew/removed codes

Effective DateApr 24, 2026

Next Review DateN/A

Key ActionSubmit claims with accurate documentation and valid HIPAA-approved code combinations; BCBSOK may review claims and apply policy discretion.

SourceLink

POLICY UPDATE CHANGES

Added code 87494.

Clarified wording to add 'qualitative' to 'qualitative NAAT' in multiple reimbursement items and added NAAT to other items; revised reimbursement criteria related to T. vaginalis and PrEP testing frequency.

Added code 87800 and removed several older codes (including 82565, 82575, 84702, 84703, 86701-86705, 86803, 86804, 87660, 0500T, G0432, G0433).

Added reimbursement positions for Mycoplasma genitalium NAAT testing for symptomatic individuals and not reimbursable for asymptomatic screening.

Added multitarget PCR testing for chlamydia and gonorrhea may be reimbursable when conditions for both are met.

6primary pathogens covered

PrEP

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PrEP screening guidance included

~7policy updates referenced

Coverage and Reimbursement Criteria by Pathogen and Scenario

Gonorrhea testing — 1 top-level node

Reimbursement Information: This policy is limited to testing for C. trachomatis, N. gonorrhoeae, T. pallidum, T. vaginalis (for guidance on T. vaginalis in vaginitis, see CPCPLAB059 Diagnosis of Vaginitis Including Multi-Target PCR Testing), HSV, and HPV. See related policies: Human Immunodeficiency Virus (CPCPLAB065); Hepatitis B and C (CPCPLAB015); Pediatric Preventive Screening (CPCPLAB016); Cervical Cancer Screening (CPCPLAB002); Pathogen Panel Testing (CPCPLAB045). For STI screening in pregnant individuals, see CPCPLAB014 Prenatal Screening (Nongenetic).

title":"Chlamydia testing — reimbursable and non-reimbursable testing criteria by pathogen and clinical scenario","type":"criteria_group"},{

inv-02: Gonorrhea testing — 1 top-level node

ALL of the following

Gonorrhea (N. gonorrhoeae) - Qualitative NAATs may be reimbursable when ANY of the following apply:
ANY of the following
- Once-a-year screening for any asymptomatic person in a high-risk category (see Notes 1 & 4).
- Diagnosis of any person presenting with signs and/or symptoms of gonorrheal infection (see Note 4).
- Test-of-cure after treatment.
For individuals not responding to initial treatment, culture testing to determine antimicrobial susceptibility may be reimbursable.
For asymptomatic individuals NOT in a high-risk category, screening for gonorrhea may be reimbursable ONLY when ANY of the following apply:
ANY of the following
- As part of newborn screening.
- As part of follow-up of a victim of sexual assault.
- Sexually active individuals < 18 years of age (annually).
Nucleic acid testing to determine antimicrobial susceptibility for N. gonorrhoeae is not reimbursable.

inv-03: Trichomonas testing — 1 top-level node

ALL of the following

Trichomonas (T. vaginalis) - Qualitative NAAT/PCR testing may be reimbursable when ANY of the following apply:
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.
- Follow-up testing a minimum of three months after initial trichomoniasis diagnosis (per policy update).
- Annual screening for asymptomatic individuals in high-risk groups and for asymptomatic individuals with HIV infection (per policy update).

inv-04: HSV testing — 1 top-level node

ALL of the following

Herpes Simplex Virus (HSV-1, HSV-2) - NAAT for HSV-1 or HSV-2 may be reimbursable for individuals with active genital ulcers or mucocutaneous lesions.
Non-type-specific immunoassay testing for HSV is not reimbursable.
Type-specific serologic testing for HSV-2 (gG2) may be reimbursable when ANY of the following apply:
ANY of the following
- Recurrent or atypical genital symptoms or lesions in individuals with a negative HSV PCR or culture result.
- Clinical diagnosis of genital herpes in individuals with a negative PCR or culture result or without laboratory confirmation.

inv-06: Mycoplasma genitalium testing — 1 top-level node

ALL of the following

Mycoplasma genitalium - NAAT testing may be reimbursable for symptomatic individuals (see Note 6).
Screening asymptomatic individuals for M. genitalium using NAAT is not reimbursable.
Nucleic acid testing to determine macrolide resistance in M. genitalium is not reimbursable.
When an individual meets the conditions described above for chlamydia, gonorrhea, trichomonas, and M. genitalium, multitarget PCR testing (targets limited to C. trachomatis, N. gonorrhoeae, T. vaginalis, and M. genitalium) may be reimbursable.

inv-07: Syphilis testing — 1 top-level node

ALL of the following

Syphilis (Treponema pallidum) - Blood testing to screen for syphilis may be reimbursable; see PrEP-related frequency guidance for MSM and individuals with childbearing potential or sexually active individuals on PrEP.

inv-08: PrEP-related testing — Testing guidance related to Preexposure prophylaxis (PrEP)

ALL of the following

Preexposure prophylaxis (PrEP) related testing - Prior to initiating PrEP, the following may be reimbursable:
ANY of the following
- Serum creatinine and estimated creatinine clearance to determine baseline renal function.
- Antibody testing to confirm baseline negative HIV status.
- Hepatitis B (triple panel: HBsAg, anti-HBs, total anti-HBc) and/or Hepatitis C screening to identify positive individuals.
- Pregnancy testing.

inv-09: COVERAGE CRITERIA — additional top-level coverage node

ALL of the following

Additional coverage notes and limitations:
ANY of the following
- Qualitative NAAT is specified for chlamydia, gonorrhea, and trichomonas per policy clarifications; 'qualitative' was added for clarity in policy updates.
- Direct probe detection and/or quantitative NAAT to quantify microorganisms (Chlamydia trachomatis, Neisseria gonorrhoeae, HSV-1, HSV-2, HPV, Treponema pallidum) is not reimbursable.
- Rapid enzyme immunoassay identification for Trichomonas is not reimbursable.
- Immunoassay testing for HSV-1 or non-type-specific HSV tests are not reimbursable; type-specific HSV-2 (gG2) serology reimbursable only per criteria above.

Procedure Codes, Frequency Guidance, and Recent Code Changes

Procedure code guidancemixed

Procedure codes list is not an all-encompassing code list. The inclusion of a code does not guarantee that it is a covered service or eligible for reimbursement.

Recently added/updated codesmixed

87494	Code added to policy (description not present in this window)
87800	Code added to policy (description not present in this window)

Chlamydia NAAT frequency for high-risk asymptomatic individuals

FrequencyOnce a year

Applicable populationAsymptomatic persons in a high-risk category (see policy notes)

Related situationsAlso reimbursable for diagnosis of symptomatic individuals, suspected LGV, and test-of-cure ≥3 months after diagnosis

Gonorrhea NAAT frequency for high-risk asymptomatic individuals

FrequencyOnce a year

Applicable populationAsymptomatic persons in a high-risk category (see policy notes)

Documentation, Billing Responsibilities, and Provider-Facing Notices

Documentation Required

Documentation and claim submission responsibilities

Providers are responsible for submission of accurate documentation of services performed and must submit claims using valid HIPAA-approved code combinations. Claims should be coded according to industry-standard coding guidelines (e.g., Uniform Billing Editor, American Medical Association CPT, HCPCS, ICD-10-CM/PCS, NDCs, DRG guidelines, CMS NCCI policy manual and table edits). Claims are subject to code edit protocols and review against benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers should submit additional documentation to support the claim.

Submit claims using valid HIPAA-approved code sets and appropriate code combinations.
Claims are subject to review and code edit protocols; additional documentation may be requested.

Billing Rule

Key Terms and Test Types

Nucleic acid amplification test (NAAT)

TermNucleic acid amplification test (NAAT)

DefinitionMolecular test that detects nucleic acids of pathogens (policy refers to NAATs for chlamydia and gonorrhea reimbursement criteria)

Reimbursement contextNAATs may be reimbursable for specified screening, diagnostic, and test-of-cure situations per policy criteria

HSV-2 gG2 serology

TestHSV-2 gG2 serology (glycoprotein G2)

IndicationsReimbursable for recurrent or atypical genital symptoms/lesions in individuals with negative HSV PCR or culture results

Limitations

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyDiagnostic Testing of Common Sexually Transmitted Infections

Policy CodePolicy CPCPLAB051

Change TypeClarifications and additions to reimbursement criterianew/removed codes

Effective DateApr 24, 2026

Next Review DateN/A

Key ActionSubmit claims with accurate documentation and valid HIPAA-approved code combinations; BCBSOK may review claims and apply policy discretion.

SourceLink

On This Page

Rapid identification of Trichomonas by enzyme immunoassay is not reimbursable.

When an individual's partner has genital herpes.

Screening for HSV-1 or HSV-2 in asymptomatic individuals is not reimbursable.

Baseline qualitative NAAT screening for gonorrhea and chlamydia and other STI screening per CDC guidelines.

While on PrEP, reimbursable tests may include:

ANY of the following

HIV antibody testing every three months to confirm negative status.
Serum creatinine and estimated creatinine clearance three months after initiation and up to one time every six months thereafter.
NAAT screening for gonorrhea and chlamydia by anatomic site: once every three months for MSM and individuals with child-bearing potential; nine months after PrEP initiation and once every six months thereafter for sexually active individuals (policy update); alternative phrasing in some updates: once every three months for MSM and once every six months for sexually active individuals.
Blood testing to screen for syphilis: once every three months in MSM and individuals with childbearing potential; nine months after PrEP initiation and once every six months thereafter for sexually active individuals.
Pregnancy testing once every three months.

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

Use of serology for chlamydia or LGV is not reimbursable.

When criteria for both chlamydia and gonorrhea are met, multitarget PCR testing limited to C. trachomatis and N. gonorrhoeae may be reimbursable; when conditions above (including M. genitalium and T. vaginalis criteria) are met, multitarget PCR testing limited to C. trachomatis, N. gonorrhoeae, T. vaginalis, and M. genitalium may be reimbursable.

Related situationsAlso reimbursable for diagnosis of symptomatic individuals and as test-of-cure

PrEP and screening frequency

PrEP NAAT screening intervals (chlamydia & gonorrhea)Qualitative NAAT: once every 3 months for MSM; once every 6 months for sexually active individuals (per policy update)

Syphilis monitoringBlood testing to screen for syphilis at the same intervals as NAAT screening during PrEP

Baseline and other PrEP testsPrior to or during PrEP: triple panel hepatitis B testing may be reimbursable (HBsAg, anti-HBs, anti-HBc); HIV and pregnancy testing per baseline recommendations

Coding changes and reimbursement list updates

Coding and reimbursement changes are recorded in the Policy Update History. Recent updates include additions and removals of procedure and molecular testing codes (for example, addition of 87494; additions of 87563, 0402U, 0455U, 0463U, 0483U, 0484U; and removals of codes such as 82565, 82575, 84702, 84703, 0167U, 0353U, 0354U and others listed in the policy history). Providers should review the Policy Update History for the complete, current list of added or removed codes and ensure billing systems and claim submissions reflect these changes.

Refer to Policy Update History for code additions (e.g., 87494, 87563, 0402U, 0455U, 0463U, 0483U, 0484U) and removals (e.g., 82565, 82575, 84702, 84703, 0167U, 0353U, 0354U and others).
Update billing systems and claim submissions to reflect current code lists and effective dates.

Denial Risk

Reimbursement criteria for M. genitalium and antimicrobial susceptibility testing

Reimbursement positions for Mycoplasma genitalium and antimicrobial susceptibility testing: Qualitative NAAT testing for M. genitalium may be reimbursable for symptomatic individuals as specified in the policy (see Note on signs and symptoms). Screening for M. genitalium by NAAT in asymptomatic individuals is not reimbursable. Nucleic acid testing to determine antimicrobial susceptibility in N. gonorrhoeae or macrolide resistance in M. genitalium is not reimbursable. Providers must follow the policy criteria for when testing is covered and document clinical indications (e.g., symptoms) to support reimbursement.

Mycoplasma genitalium NAAT may be reimbursable for symptomatic individuals only.
Screening (NAAT) for M. genitalium in asymptomatic individuals is not reimbursable.
Nucleic acid testing for antimicrobial susceptibility in N. gonorrhoeae or for macrolide resistance in M. genitalium is not reimbursable.
Document clinical signs/symptoms when ordering M. genitalium testing to support reimbursement.

Used as type-specific serologic testing for HSV-2; non-specific HSV immunoassays are not reimbursable

Qualitative NAAT

TermQualitative NAAT

Policy emphasisPolicy language clarified to specify 'qualitative NAAT' for certain reimbursement items (e.g., chlamydia, gonorrhea, T. vaginalis) in update history

Use in guidanceQualitative NAAT referenced for screening and diagnostic use in PrEP monitoring and STI reimbursement criteria

Multitarget PCR

DefinitionMultitarget PCR testing limited to C. trachomatis and N. gonorrhoeae may be reimbursable when an individual meets conditions for both infections

ScopePolicy notes indicate multitarget PCR may be reimbursable when conditions for both chlamydia and gonorrhea testing are met

Policy historyAdded as a reimbursable option in the 11/01/2023 update and reiterated in later updates