ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLAB052

Testing for Vector-Borne Infections

Describes reimbursement criteria for laboratory testing of various vector-borne infections and which tests may or may not be reimbursable; applies to providers submitting claims to Blue Cross and Blue Shield of Oklahoma.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyTesting for Vector-Borne Infections

Policy CodePolicy CPCPLAB052

Change TypeMultiple material additions and revisions (IFA additions, NAAT terminology broadened, Zika criteria updated)

Effective DateSep 26, 2025

Next Review Date

Key ActionSubmit claims with documentation supporting use of Giemsa/Wright-stained blood smear, NAAT, or IgG/IgM IFA for babesiosis with confirmatory IFA testing at least two weeks after initial test.

SourceLink

POLICY UPDATE CHANGES

Added 'IgG or IgM indirect immunofluorescence antibody (IFA) assay for Babesia (initial testing and confirmatory testing should occur a minimum of two weeks apart)' to reimbursable testing for babesiosis.

Replaced 'PCR testing' with 'NAAT testing' in multiple policy items (#2, #5, and #11).

Added NAAT (PCR) may be reimbursable to confirm Plasmodium species in malaria.

Updated Zika testing reimbursement criteria including NAAT and IgM timing and expanded situations (pregnant symptomatic up to 12 weeks; symptomatic non-pregnant within 7 days, etc.).

New reimbursable option: nucleic acid detection of West Nile virus for immunocompromised individuals to confirm infection.

Manylisted procedure and lab codes referenced

Multiple

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pathogen-specific testing entries updated

WindowsZika NAAT/IgM timing specified

Repeats x3malaria microscopy repeat limit

Reimbursement and Coverage Criteria for Vector-Borne Testing

Select pathogen-specific reimbursement notes

Reimbursable tests for specific suspected infections (summary of items 1–5):

For individuals suspected of having babesiosis: Giemsa- or Wright-stained blood smear, nucleic acid amplification testing (NAAT), or IgG or IgM indirect immunofluorescence antibody (IFA) assay; initial and confirmatory IFA testing should occur a minimum of two weeks apart.

For individuals suspected of having a relapsing fever caused by a Borrelia spp.: testing varies by syndrome — HTRF: serologic assays to detect Borrelia antibodies or NAAT to detect Borrelia miyamotoi; LBRF: peripheral blood smear microscopy or NAAT to detect Borrelia recurrentis; STRF/TBRF: dark-field microscopy, Wright- or Giemsa-stained smear microscopy, NAAT to detect Borrelia spp., or serologic assays to detect Borrelia antibodies.

Culture testing for Borrelia in suspected relapsing fever is not reimbursable.

For individuals suspected of having chikungunya: viral culture, NAAT on a blood sample, or IFA assay for IgM antibodies during both acute and convalescent phases may be reimbursable.

For individuals suspected of having Colorado tick fever (CTF): NAAT testing or IFA for CTF-specific IgM antibodies may be reimbursable.

Arboviral testing (Dengue, Zika)

Dengue, Zika, and related testing rules:

For detection of dengue virus (DENV): NAAT, IgM antibody capture ELISA (MAC-ELISA), NS1 ELISA, and confirmatory plaque reduction neutralization test may be reimbursable for individuals suspected of DENV or for individuals who are symptomatic for Zika virus infection.

For suspected DENV, IgG ELISA or hemagglutination testing is not reimbursable.

Zika NAAT reimbursement windows

Symptomatic pregnant individuals: NAAT may be reimbursable up to 12 weeks after symptom onset if during pregnancy they lived in or traveled to areas with current or past Zika transmission or had sexual exposure to someone with relevant travel/exposure.
Symptomatic non-pregnant individuals with living in or recent travel to an area with an active CDC Zika Travel Health Notice or area with current/past Zika transmission: NAAT reimbursable when symptoms presented within the last 7 days (or in some specified scenarios more than 7 days as detailed below).

Other vector-borne pathogens

West Nile, yellow fever, ehrlichiosis/anaplasmosis, malaria, and rickettsial disease testing:

For ehrlichiosis and/or anaplasmosis: NAAT of whole blood, IFA assay for IgG antibodies, or microscopy for morulae detection may be reimbursable.

For ehrlichiosis/anaplasmosis: IFA for IgM antibodies or standard blood culture is not reimbursable.

For malaria: rapid immunochromatographic diagnostic test or smear microscopy may be reimbursable to diagnose malaria, determine Plasmodium species, identify life‑cycle stage, and/or quantify parasitemia; microscopy can be repeated up to three times within three days if initial microscopy is negative in suspected cases.

To confirm Plasmodium species in a diagnosed malaria case, NAAT testing may be reimbursable; IFA for Plasmodium antibodies is not reimbursable.

For rickettsial disease: IFA assay for IgG antibodies (initial and confirmatory testing should occur a minimum of two weeks apart) may be reimbursable; standard blood culture, NAAT, or IFA for IgM are not reimbursable.

Reimbursable testing criteria (selected)

Summarized reimbursable testing rules and notable restrictions (selected from updated items in this document portion):

For suspected babesiosis: Giemsa- or Wright-stained blood smear, NAAT, or IgG/IgM IFA assay may be reimbursable; IFA initial and confirmatory testing should occur a minimum of two weeks apart.

For suspected relapsing fevers caused by Borrelia spp.: reimbursable tests vary by syndrome (HTRF: serology or NAAT for B. miyamotoi; LBRF: peripheral blood smear microscopy or NAAT for B. recurrentis; STRF/TBRF: dark-field microscopy, Wright/Giemsa smear, NAAT, or serology); culture for Borrelia is not reimbursable.

For malaria: NAAT may be reimbursable to confirm Plasmodium species; IFA for Plasmodium antibodies is not reimbursable.

For rickettsial diseases: IFA assay for IgG antibodies with initial and confirmatory testing separated by a minimum of two weeks may be reimbursable; NAAT and IFA IgM and standard blood culture are not reimbursable for these infections.

For West Nile virus: IFA for WNV-specific IgG or IgM and confirmatory plaque reduction neutralization test may be reimbursable; nucleic acid detection (NAAT) may be reimbursable to confirm infection in immunocompromised individuals but NAAT is not reimbursable for immunocompetent individuals.

Asymptomatic/general exam testing

Screening / asymptomatic testing rules

For asymptomatic individuals undergoing a general exam without abnormal findings, testing for babesiosis, chikungunya virus, CTF, DENV, ehrlichiosis/anaplasmosis, malaria, rickettsial disease, TBRF, WNV, YFV, or Zika virus is not reimbursable.

Procedure and Laboratory Codes

Example listed laboratory procedure codesCPT

86280
86750
87207
87478
0043U

Newly added/mentioned codesCPT

87164

Code referenced as added in update history (document does not enumerate full code list in this chunk).

Malaria microscopy repeat limit

LimitMicroscopy for malaria may be repeated up to three times within three days if the initial smear is negative in suspected cases of malaria.

Applicable testSmear microscopy (Giemsa- or Wright-stained) or rapid immunochromatographic diagnostic test may be used to diagnose malaria, determine species, life-cycle stage, and quantify parasitemia.

PurposeRepeat microscopy intended to improve diagnostic sensitivity when initial microscopy is negative but clinical suspicion remains.

IFA testing interval

Interval requirementIndirect immunofluorescence antibody (IFA) testing requires paired tests occurring a minimum of two weeks apart for initial and confirmatory IgG testing in rickettsial disease and similar uses.

Provider Responsibilities and Billing Guidance

Documentation Required

Documentation responsibility

Providers are responsible for submission of accurate documentation of services performed. Upon request, providers should submit any additional documentation to support medical necessity, coding, and claims processing. Claims must be coded using valid HIPAA-approved code sets (eg, CPT, HCPCS, ICD-10-CM/PCS, NDC) and adhere to industry standard coding guidelines and payer/provider contract terms. Claims are subject to code edit protocols and claim review, including review against benefit coverage, provider contract language, medical and clinical payment policies, and coding software logic.

Submit documentation on request to support claim review and payment.
Use appropriate, industry-standard code sets and combinations.
Claims are subject to coding edits, benefit and contract review.

Billing Rule

Policy Definitions and Governing Documents

Plan documents

DefinitionPlan documents include Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.

Governing priorityIf a conflict exists between this Clinical Payment and Coding Policy and any plan document under which a member is entitled to Covered Services, the plan document will govern.

Provider contractsIf a conflict arises between this CPCP and any provider contract, the provider contract will govern.

NAAT

Term updateNAAT — terminology in the policy was broadened from 'PCR testing' to 'nucleic acid amplification testing (NAAT)' to encompass broader nucleic acid detection methods.

ScopeNAAT language replaces prior 'PCR' wording in multiple policy items to allow broader nucleic acid testing approaches (e.g., for Babesia, Plasmodium species confirmation, and other indications where NAAT may be reimbursable).

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyTesting for Vector-Borne Infections

Policy CodePolicy CPCPLAB052

Change TypeMultiple material additions and revisions (IFA additions, NAAT terminology broadened, Zika criteria updated)

Effective DateSep 26, 2025

Next Review Date

SourceLink

On This Page

Zika virus NAAT and IgM testing and confirmatory PRNT may be reimbursable in specified situations: symptomatic pregnant individuals up to 12 weeks post‑onset with relevant exposure; pregnant individuals with fetal ultrasound findings consistent with congenital Zika; infants born to individuals who tested positive for Zika during pregnancy; infants with signs of congenital Zika syndrome born to a parent with possible exposure; and certain symptomatic non‑pregnant individuals with travel/exposure history (timing criteria apply).

For non‑pregnant individuals who have not traveled outside the United States and its territories and who are symptomatic for Zika, NAAT and/or IgM testing is not reimbursable.

West Nile virus testing

IFA for WNV-specific IgG or IgM in serum or CSF with confirmatory plaque reduction neutralization test may be reimbursable.
For immunocompromised individuals, nucleic acid detection (NAAT) to confirm WNV infection may be reimbursable.
For immunocompetent individuals suspected of WNV, NAAT for WNV is not reimbursable.

For Zika virus: NAAT and IgM testing with confirmatory PRNT may be reimbursable in specified scenarios including symptomatic pregnant individuals up to 12 weeks post-symptom onset with relevant exposure, infants with congenital findings or born to infected parents, and certain symptomatic non-pregnant individuals with travel/exposure history; NAAT/IgM not reimbursable for symptomatic non-pregnant individuals without travel/exposure history.

Operational/terminology updates from 09/26/2025: 'PCR testing' terminology replaced with 'NAAT testing' in multiple items; 'serum sample' language was replaced with 'blood sample' in at least one item; IFA testing interval guidance clarified as two tests a minimum of two weeks apart.

IFA assays for IgG (and where noted IgM/IgG for some pathogens) require initial and confirmatory testing separated by the minimum interval.

ExamplesPolicy explicitly applies the two-week minimum interval to IFA testing for rickettsial diseases and the updated Babesia guidance (initial and confirmatory testing should occur a minimum of two weeks apart).

Reimbursement actions and testing modalities

Reimbursement may vary by testing modality and clinical scenario. For Babesia: Giemsa- or Wright-stained blood smear, NAAT, or IgG or IgM indirect immunofluorescence antibody (IFA) assay may be reimbursable for individuals suspected of having babesiosis; when IFA is used, initial and confirmatory testing should occur a minimum of two weeks apart. Note that language throughout the policy replaces prior references to PCR with NAAT and clarifies sample type as blood sample where applicable. Providers should bill using the appropriate CPT/HCPCS codes and be prepared to supply clinical documentation supporting the selected testing modality.

Babesia testing modalities reimbursable: Giemsa/Wright-stained blood smear; NAAT; IgG or IgM IFA (initial and confirmatory ≥2 weeks apart).
Policy language updated: PCR → NAAT; 'serum sample' → 'blood sample'.
Bill with appropriate CPT/HCPCS codes and retain clinical documentation supporting test selection.

Billing Rule

Zika testing reimbursement criteria

Zika virus testing reimbursement criteria refined per CDC-based policy updates. NAAT may be reimbursable in symptomatic pregnant individuals up to 12 weeks after symptom onset when there is relevant travel/exposure history or sexual exposure. Zika NAAT and IgM testing (with confirmatory plaque reduction neutralization test when indicated) may be reimbursable in specified clinical scenarios including symptomatic pregnant individuals within 12 weeks, pregnant individuals with fetal ultrasound findings suggestive of congenital Zika, infants born to persons who tested positive during pregnancy, infants with signs of congenital Zika syndrome whose birthing parent had possible exposure, and symptomatic non-pregnant individuals with relevant travel/exposure when presentation exceeds seven days. NAAT/IgM testing is not reimbursable for symptomatic non-pregnant individuals without travel/exposure history.

NAAT reimbursable up to 12 weeks after symptom onset for symptomatic pregnant individuals with relevant exposure/travel or sexual exposure.
Zika NAAT and IgM (± confirmatory PRNT) reimbursable for: symptomatic pregnant individuals up to 12 weeks; pregnant individuals with fetal ultrasound findings consistent with congenital Zika; infants born to persons who tested positive; infants with congenital Zika signs with parental exposure; symptomatic non-pregnant individuals with relevant travel/exposure when >7 days since symptom onset.
NAAT/IgM not reimbursable for symptomatic non-pregnant individuals without travel/exposure history.

ImplicationNAAT may be reimbursable in specific scenarios described (see individual pathogen rules), including species confirmation and for immunocompromised WNV cases as noted elsewhere in the policy.

IFA (indirect immunofluorescence antibody assay)

Assay descriptionIFA — indirect immunofluorescence antibody assay used to detect IgG and/or IgM antibodies for specified vector-borne infections.

Paired testing requirementFor certain infections (e.g., Babesia and rickettsial diseases) IFA initial and confirmatory testing should occur a minimum of two weeks apart.

Use casesPolicy allows IFA IgG for rickettsial diseases and IFA IgG/IgM for Babesia as reimbursable when performed according to the paired-testing interval; IFA for Plasmodium antibodies is not reimbursable.