ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLAB059

Diagnosis of Vaginitis

Lab management reimbursement criteria for diagnostic testing of vaginitis (BV, VVC, trichomoniasis) and related molecular assays; applies to providers submitting claims to Blue Cross Blue Shield of Oklahoma.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyDiagnosis of Vaginitis

Policy CodePolicy CPCPLAB059

Change TypeRevised with code additions/removals and reimbursement clarifications

Effective Dateas written

Next Review Date

Key ActionProviders must submit accurate documentation and be prepared to provide additional documentation upon request; claims are subject to code edits and benefit/contract review.

SourceLink

POLICY UPDATE CHANGES

Document updated with literature review and Reimbursement Information modified (removed statements #4, #5, #10; added 'qualitative' to define NAAT for Candida; limited testing frequency; added exclusions for quantitative NAAT).

Added 'measurement of sialidase activity' to reimbursement criteria and changed reagent language from 'hydrogen peroxide' to 'potassium hydroxide'; added code 81515 and deleted 0352U.

Added code 0505U on 10/30/2024.

Revised stance on NAAT panel testing (may be reimbursable) and changed title to Diagnosis of Vaginitis Including Multi-target PCR Testing.

New policy established on 11/01/2022.

7specific reimbursable testing scenarios listed

3explicitly non-reimbursable test categories listed

25+procedure and CPT/HCPCS/other codes listed

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyDiagnosis of Vaginitis

Policy CodePolicy CPCPLAB059

Change TypeRevised with code additions/removals and reimbursement clarifications

Effective Dateas written

Next Review Date

Key ActionProviders must submit accurate documentation and be prepared to provide additional documentation upon request; claims are subject to code edits and benefit/contract review.

SourceLink

On This Page

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Vaginitis Testing Coverage Criteria

Vaginitis testing reimbursement criteria

Reimbursement determined by clinical presentation (symptomatic vs asymptomatic) and specific test type.

ALL of the following

Symptomatic testing (one or more):
- Testing of pH, testing for the presence of amines, measurement of sialidase activity, saline wet mount, potassium hydroxide/KOH wet mount, and microscopic examination of vaginal fluids may be reimbursable.
- Direct probe DNA-based identification of Gardnerella, Trichomonas, and Candida (e.g., BD Affirm VPIII) may be reimbursable.
- If wet-mount preparations are negative and pH is normal, vaginal cultures for Candida species for diagnosis of vulvovaginal candidiasis may be reimbursable.
- For complicated vulvovaginal candidiasis/VVC, qualitative PCR-based identification of Candida to confirm clinical diagnosis and identify non-albicans Candida may be reimbursable.
- For signs and symptoms of bacterial vaginosis/BV, NAAT specific to BV (e.g., Aptima BV, OneSwab BV Panel PCR with Lactobacillus Profiling by qPCR; SureSwab Advanced BV, TMA) and single or multitarget PCR testing for BV may be reimbursable.
- NAAT panel testing designed to detect more than one type of vaginitis (VVC, BV, and/or trichomoniasis; e.g., BD MAX Vaginal Panel, NuSwab VG, Xpert Xpress MVP) may be reimbursable, limited to no more than one test every seven days.
  Frequency limit: no more than one test every seven days (see Note 1).
ALL of the following
- Screening of asymptomatic individuals, including asymptomatic pregnant individuals at average or high risk for premature labor, for trichomoniasis and bacterial vaginosis is not reimbursable.
- Explicit exclusions:
  - NAAT testing for Candida (e.g., quantitative NAAT testing) in situations not described above is not reimbursable.
  - Molecular-based panel testing for microorganisms involved in vaginal flora imbalance and/or infertility is not reimbursable.
  - Broad molecular panels designed to concurrently test for vaginitis and various other STIs not specifically addressed above are not reimbursable.

Reimbursement criteria and limitations

Summarized reimbursement positions and restrictions from the update history:

ALL of the following

Qualitative NAAT testing for Candida is defined and permitted for the clinical situations described in the policy (added language specifying 'qualitative').
Quantitative NAAT testing for Candida is explicitly not reimbursable for situations not described in the policy (new exclusion).
NAAT panel testing designed to detect more than one type of vaginitis (e.g., BD MAX Vaginal Panel, NuSwab VG, Xpert Xpress MVP) may be reimbursable (policy revised 03/15/2024).
Testing frequency for NAAT panel testing is limited to no more than one test every seven days (frequency restriction added).
See Note 1 referenced in policy update history.

Procedure Codes and Coding Limits

Listed procedure codesmixedCovered

81513
81514
81515
82120
83986
87070
87149
87150
87210
87480

1–10 of 27

1/3

Policy-specified laboratory codes added or removedmixed

0068U	Added to policy (specific assay unspecified in this excerpt)
0557U	Added to policy (specific assay unspecified in this excerpt)
81515	Added to policy
0505U	Added to policy
87661	Removed from policy
87808	Removed from policy
0352U	Deleted from policy

NAAT panel frequency limit (inv-05)

Frequency limitNAAT panel testing designed to detect more than one type of vaginitis is limited to no more than one test every seven days.

Applies toNAAT panel testing for combined detection of VVC, BV, and/or trichomoniasis (e.g., BD MAX Vaginal Panel, NuSwab VG, Xpert Xpress MVP).

ContextLimit referenced in the reimbursement information under item #6; see Note 1 for related details.

Testing frequency limit (inv-06)

Testing frequency policyTesting frequency limited to no more than one test every seven days for the specified NAAT panel item (now #6).

Reference to update

Documentation, Claims, and Provider Notices

Documentation Required

Documentation and claims review

Providers must submit accurate documentation of services performed and code claims using valid, industry-standard code sets. Claims are subject to code edit protocols and review against benefit coverage, provider contracts, medical policies, and coding software logic; upon request, providers should submit additional documentation.

Submit claims using valid HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, etc.).
Be prepared to provide additional documentation upon request for claim review.

Billing Rule

Reimbursement and coding updates; testing frequency and type limitations

The policy history documents additions and removals of laboratory procedure codes and clarifies which NAAT test types and frequencies are reimbursable; testing is limited to no more than one NAAT panel test every seven days and qualitative NAAT for Candida is identified as the permitted type while quantitative NAAT for Candida is explicitly not reimbursable for situations not described in the policy.

Definitions and Plan Documents

Plan documents (inv-09)

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

Governing roleIf a conflict exists between this policy and a plan document, the plan document governs.

ApplicabilityBCBSOK may interpret and apply this policy using reasonable discretion, subject to applicable plan documents and provider contracts.

Qualitative NAAT for Candida (inv-10)

Permitted useQualitative NAAT may be reimbursable to confirm diagnosis of complicated VVC and to identify non-albicans species when described in the reimbursement criteria.

DistinctionQualitative NAAT reports presence/identification of Candida rather than providing a numeric organism load (contrast with quantitative NAAT).