ModifiedBlue Cross Blue Shield - OklahomaPolicy CPCPLAB052

Testing for Vector-Borne Infections

Defines BCBSOK laboratory reimbursement criteria for diagnostic testing of a range of vector-borne infections and indicates which tests may or may not be reimbursable for members across applicable products. Applies to providers submitting claims to Blue Cross Blue Shield of Oklahoma.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyTesting for Vector-Borne Infections

Policy CodePolicy CPCPLAB052

Change TypeRevisions and additions to pathogen-specific testing positions

Effective DateJan 15, 2025

Next Review Date

Key ActionProviders must submit accurate documentation and use valid HIPAA-approved code sets; follow specified testing modalities per suspected vector-borne infection when submitting claims.

SourceLink

POLICY UPDATE CHANGES

Reorganized and clarified reimbursement positions for relapsing fevers caused by Borrelia spp., specifying reimbursable tests for hard tick, louse-borne, and soft/tickborne relapsing fevers and that culture testing for Borrelia is not reimbursable.

Updated testing indications for Colorado tick fever to include PCR testing.

Expanded Zika testing language to remove 'non-pregnant' restriction and to align with CDC guidance that symptomatic individuals should be tested; updated multiple Zika NAAT/IgM reimbursement positions and timing windows.

Added that PCR testing may be reimbursable to confirm Plasmodium species in diagnosed malaria.

Clarified policy on use of IFA for rickettsial diseases: two tests occurring a minimum of two weeks apart may be reimbursable for IgG.

Added IFA for West Nile virus IgG or IgM and confirmatory plaque reduction neutralization test as potentially reimbursable; nucleic acid detection for WNV may be reimbursable for immunocompromised individuals.

20+distinct reimbursement rules for pathogens or test-types listed

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Zika up to 12wtime-bound reimbursement condition

Malaria ≤3x/3dallowed repeat testing condition

IFA IgMIFA IgM frequently non-reimbursable

PCR/NAATtests newly allowed or clarified (PCR/NAAT)

Pathogen- and Test-Specific Reimbursement Criteria

Pathogen-specific reimbursement criteria

Reimbursement determinations by pathogen and test type, including allowed and not-reimbursable tests and situational conditions.

ALL of the following

ANY of the following
- ALL of the following
  - Giemsa- or Wright-stained blood smear may be reimbursable.
  - Nucleic acid amplification testing (NAAT) may be reimbursable.
- ALL of the following
  - Either IgG or IgM indirect immunofluorescence antibody (IFA) assay for Babesia is not reimbursable.
ANY of the following
- ALL of the following
  - Culture testing for Borrelia is not reimbursable.
- ANY of the following
  - Serologic assays to detect Borrelia antibodies may be reimbursable for HTRF.
  - PCR testing to detect Borrelia miyamotoi may be reimbursable for HTRF.
- ANY of the following
  - Peripheral blood smear microscopy may be reimbursable for LBRF.
ANY of the following
- ALL of the following
  - Viral culture for diagnosis may be reimbursable.
  - NAAT for chikungunya in a serum sample may be reimbursable.
  - IFA assay for IgM antibodies during both the acute and convalescent phases may be reimbursable.
ANY of the following
- PCR testing may be reimbursable for CTF.
- IFA for CTF-specific IgM antibodies may be reimbursable.
ANY of the following
- ALL of the following
  - NAAT may be reimbursable for DENV detection.
  - IgM antibody capture ELISA (MAC-ELISA) may be reimbursable.
  - NS1 ELISA may be reimbursable.
  - Confirmatory plaque reduction neutralization test (PRNT) for DENV may be reimbursable.
- ALL of the following
  - IgG ELISA is not reimbursable for DENV.
ANY of the following
- ALL of the following
  - NAAT of whole blood may be reimbursable.
  - IFA assay for IgG antibodies may be reimbursable.
  - Microscopy for morulae detection may be reimbursable.
- ALL of the following
  - IFA assay for IgM antibodies is not reimbursable.
  - Standard blood culture is not reimbursable.
ANY of the following
- ALL of the following
  - Rapid immunochromatographic diagnostic tests may be reimbursable.
  - Smear microscopy to diagnose malaria, determine species, stage, and quantify parasitemia may be reimbursable; can be repeated up to three times within three days if initial microscopy is negative in suspected cases.
- PCR testing may be reimbursable to confirm Plasmodium species in an individual diagnosed with malaria.
- ALL of the following
  - IFA for Plasmodium antibodies is not reimbursable.
ANY of the following
- ALL of the following
  - IFA assay for IgG antibodies may be reimbursable limited to two tests occurring a minimum of two weeks apart.
- ALL of the following
  - Standard blood culture is not reimbursable.
  - IFA assay for IgM antibodies is not reimbursable.
ANY of the following
- ALL of the following
  - IFA for WNV-specific IgG or IgM antibodies in serum or CSF may be reimbursable.
  - Confirmatory plaque reduction neutralization test for WNV may be reimbursable.
- ALL of the following
  - Nucleic acid detection of WNV may be reimbursable to confirm infection in immunocompromised individuals.
- ALL of the following
  - NAAT for WNV is not reimbursable for immunocompetent individuals.
ANY of the following
- ALL of the following
  - NAAT for YFV may be reimbursable.
  - Serologic assays to detect virus-specific IgM and IgG antibodies may be reimbursable.
  - Confirmatory plaque reduction neutralization test for YFV may be reimbursable.
ANY of the following
- ALL of the following
  - NAAT may be reimbursable up to 12 weeks after onset of symptoms for symptomatic pregnant individuals with relevant travel/exposure history.
  - NAAT may be reimbursable for symptomatic non-pregnant individuals living in or with recent travel to an area with an active CDC Travel Health Notice when symptoms presented within the last seven days.
- ANY of the following
  - Testing reimbursable for pregnant individuals with fetal ultrasound findings consistent with congenital Zika virus infection.
  - Testing reimbursable for infants born to individuals who tested positive during pregnancy.

ALL of the following

See referenced Notes for symptom definitions and applicable clinical details.

Coverage criteria (summarized)

Selected coverage positions and criteria (summary of updated positions present in this document section):

ALL of the following

ALL of the following
- May be reimbursable for specified tests: HTRF — serologic assays or PCR for B. miyamotoi; LBRF — peripheral blood smear microscopy or PCR for B. recurrentis; STRF/TBRF — dark-field or Wright/Giemsa smear microscopy, PCR for Borrelia spp., or serologic assays for Borrelia antibodies; culture testing for Borrelia not reimbursable.
ALL of the following
- PCR testing may be reimbursable; testing indications updated to include PCR.
ALL of the following
- PCR may be reimbursable to confirm Plasmodium species in diagnosed malaria; IFA for Plasmodium antibodies is not reimbursable.

Procedure Codes, Test Modalities, and Timing Rules

Procedure codes guidancemixed

Procedure code list referenced but not exhaustive; inclusion of a code does not guarantee it is a covered service or eligible for reimbursement.

Test modality guidancemixed

Policy references specific test modalities (PCR/NAAT, IFA, serology, microscopy, culture not reimbursable for Borrelia). Exact CPT/HCPCS codes are not listed in this section of the document.

inv-05: IFA testing timing requirement

IFA IgG timing requirementTwo tests for IgG performed a minimum of two weeks apart may be reimbursable for rickettsial disease (replaces prior unit-limit language).

IFA IgM statusIFA IgM for rickettsial disease is listed as not reimbursable.

ScopeTiming-based requirement applies to IgG testing for rickettsial disease as described in the policy update (clarified from prior phrasing).

Provider Documentation and Reimbursement Guidance

Documentation Required

Provider documentation and coding expectations — Action required

If a conflict arises 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. If a conflict arises between this CPCP and any provider contract pursuant to which a provider participates in and/or provides Covered Services to eligible member(s) and/or plans, the provider contract will govern. 'Plan documents' include, but are not limited to, Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents. Blue Cross and Blue Shield of Oklahoma may use reasonable discretion interpreting and applying this policy to services being delivered in a particular case. BCBSOK has full and final discretionary authority for their interpretation and application to the extent provided under any applicable plan documents. Providers are responsible for submission of accurate documentation of services performed. Providers are expected to submit claims for services rendered using valid code combinations from HIPAA‑approved code sets and to code claims appropriately according to industry standard coding guidelines (for example, Uniform Billing Editor, AMA CPT resources, HCPCS, ICD‑10‑CM/PCS, NDCs, DRG guidance, CMS NCCI policies and table edits). Claim submissions are subject to code edit protocols and claim review including, but not limited to, plan benefit terms, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, providers should submit additional documentation to support medical necessity and coding.

Providers must submit accurate documentation and use valid HIPAA‑approved code sets.
Claims are subject to plan documents, provider contracts, medical and coding policies, and code edit protocols.

Policy Definitions and Lab Management Criteria

inv-08: Lab management reimbursement criteria

DefinitionLab management reimbursement criteria are payer-determined rules that specify when laboratory tests for vector-borne pathogens are reimbursable.

ApplicabilityNot all lab management requirements apply to every product; providers should review plan documents for eligible coverage.

EnforcementClaims are subject to plan terms, provider contract language, clinical payment and coding policies, and claim review processes.

inv-09: Plan documents

What 'Plan documents' includeCertificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.

Conflict resolutionIf a conflict exists between this Clinical Payment and Coding Policy and a member's plan document, the plan document governs.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyTesting for Vector-Borne Infections

Policy CodePolicy CPCPLAB052

Change TypeRevisions and additions to pathogen-specific testing positions

Effective DateJan 15, 2025

Next Review Date

Key ActionProviders must submit accurate documentation and use valid HIPAA-approved code sets; follow specified testing modalities per suspected vector-borne infection when submitting claims.

SourceLink

On This Page

PCR testing to detect Borrelia recurrentis may be reimbursable for LBRF.

ANY of the following

Dark-field microscopy of a peripheral blood smear may be reimbursable for STRF/TBRF.
Microscopy of a Wright- or Giemsa-stained blood smear may be reimbursable for STRF/TBRF.
PCR testing to detect Borrelia spp. may be reimbursable for STRF/TBRF.
Serologic assays to detect Borrelia antibodies may be reimbursable for STRF/TBRF.

Hemagglutination testing is not reimbursable for DENV.

Testing reimbursable for infants born with signs of congenital Zika syndrome whose birthing parent had possible exposure during pregnancy.

Testing reimbursable for symptomatic non-pregnant individuals with relevant travel when symptoms presented more than seven days prior to testing.

ALL of the following

NAAT and/or IgM testing for non-pregnant individuals who have not traveled outside the U.S. and its territories is not reimbursable.
Testing for listed pathogens during a general exam without abnormal findings is not reimbursable.

ALL of the following

IFA IgG may be reimbursable as two tests a minimum of two weeks apart (replaces prior unit-limit phrasing with timing-based requirement).

ALL of the following

IFA for WNV-specific IgG or IgM and confirmatory PRNT may be reimbursable; NAAT may be reimbursable for immunocompromised individuals and is not reimbursable for immunocompetent individuals.

ALL of the following

NAAT and IgM testing and confirmatory PRNT may be reimbursable in defined pregnant and symptomatic situations with timing windows (eg, up to 12 weeks for symptomatic pregnant individuals); NAAT/IgM not reimbursable for symptomatic non-pregnant individuals without travel/exposure.

Providers should provide additional documentation upon request.

Billing Rule

Provider reimbursement guidance — Billing/reimbursement note

BCBSOK has implemented laboratory management reimbursement criteria and reorganized reimbursement language for clarity. Providers should follow the specified testing modalities for suspected vector‑borne and relapsing fever infections per the updated reimbursement guidance. Examples of updated reimbursement positions include: for suspected relapsing fever due to Borrelia spp., reimbursable testing may include serology or PCR for Borrelia miyamotoi (hard tick relapsing fever), peripheral blood smear microscopy or PCR for Borrelia recurrentis (louse‑borne relapsing fever), and dark‑field microscopy, Wright/Giemsa blood smear microscopy, PCR, or serologic assays for soft‑tick/tick‑borne relapsing fever; culture testing for Borrelia is not reimbursable. Testing indications for certain infections (for example, Colorado tick fever, Zika/DENV) were clarified/expanded per CDC guidance. Not all requirements apply to every product — providers must review member plan documents for benefit eligibility before ordering/testing.

Reimbursement criteria apply variably by product — verify member coverage before testing.
Follow the specified testing modalities for suspected relapsing fevers: serology or PCR for HTRF; smear microscopy or PCR for LBRF; dark‑field or stained smear microscopy, PCR, or serology for STRF/TBRF. Culture for Borrelia is not reimbursable.
Updated testing indications (e.g., Colorado tick fever, Zika) reflect CDC guidance; providers should follow current public health recommendations and policy notes.

Provider responsibilitiesProviders must submit accurate documentation and use valid HIPAA-approved code sets; claims subject to code edit protocols and review.

inv-10: Policy notes and disease definitions

Renumbered notesNotes were renumbered and edited to define signs/symptoms and to distinguish relapsing fever types (HTRF, LBRF, STRF/TBRF).

Relapsing fever definitionsHTRF (hard tick relapsing fever), LBRF (louse-borne relapsing fever), and STRF/TBRF (soft tick/tickborne relapsing fever) are separately defined with associated recommended tests.

CDC updatesPolicy updated CDC classifications of Zika risk and aligned testing indications with CDC guidance (e.g., broadened symptomatic testing).

Policy editingMultiple notes edited for clarity/consistency and to update signs/symptoms referenced in position statements.