blue cross blue shield - tennessee STI testing Coverage

Syphilis antibody testing

Antibody testing for syphilis MEETS COVERAGE CRITERIA when any of the following are true:

Syphilis antibody testing indications: a) Asymptomatic person in a high-risk category: annual assessment using either a standard or reverse algorithm that includes initial and confirmatory tests (treponemal and nontreponemal). b) Diagnosis of a person presenting with signs and/or symptoms of syphilis. c) Every three months for HIV-positive men or men who have sex with men (MSM). d) Treponemal and nontreponemal testing once prior to transplant as part of pretransplant assessment in donors and recipients of allogeneic hematopoietic stem cell transplantation (allo‑HCT). e) When a nontreponemal test is used as a test of cure (TOC).

If treponemal test used first, reflex quantitative NTT (RPR/VDRL) to dilution >=1:8–1:16; if NTT used first, reflex treponemal test on same serum

Chlamydia NAAT

NAAT testing for chlamydia MEETS COVERAGE CRITERIA when any of the following are true:

Chlamydia NAAT indications: a) Annual assessment for asymptomatic persons in a high‑risk category. b) Diagnosis of symptomatic persons presenting with signs/symptoms of chlamydial infection. c) Diagnosis of suspected lymphogranuloma venereum (LGV). d) At least three months after initial diagnosis as a test of cure (TOC).

For asymptomatic individuals not in high‑risk groups, screening only as newborn screening

Gonorrhea NAAT and culture

NAAT testing for gonorrhea MEETS COVERAGE CRITERIA when any of the following are true:

Gonorrhea NAAT indications: a) Annual assessment for asymptomatic persons in a high‑risk category. b) Diagnosis of symptomatic persons presenting with signs/symptoms of gonorrheal infection. c) As a test of cure following treatment when indicated (timing per clinical guidance).

Culture for antimicrobial susceptibility meets coverage when initial treatment fails or when antimicrobial susceptibility testing is required

Trichomonas and M. genitalium testing

Trichomonas and Mycoplasma genitalium testing coverage:

Trichomonas NAAT: NAAT or PCR‑based testing for Trichomonas vaginalis meets coverage for symptomatic individuals and for asymptomatic individuals in high‑risk groups (concurrent STI, high‑prevalence settings, transactional sex). Enzyme immunoassay rapid identification does not meet coverage.

Mycoplasma genitalium NAAT: Testing for M. genitalium using NAAT meets coverage for symptomatic individuals (e.g., men with recurrent nongonococcal urethritis, women with recurrent cervicitis); screening asymptomatic individuals does not meet coverage. Resistance testing recommended if available.

Culture is impractical and not recommended for routine use

HSV and HPV testing

HSV and HPV testing coverage:

HSV NAAT and serology: NAAT for HSV‑1 or HSV‑2 meets coverage for individuals with active genital ulcers or mucocutaneous lesions. Type‑specific serologic testing for HSV‑2 (gG2) meets coverage for recurrent or atypical genital symptoms with negative PCR/culture, for clinical diagnosis without laboratory confirmation, or when a partner has genital herpes. Non‑type‑specific immunoassays and routine serologic screening of asymptomatic individuals do not meet coverage.

USPSTF recommends against routine serologic screening in asymptomatic persons due to high false‑positive rates

HPV testing meets coverage for diagnosis/assessment of cancer or cancer therapy (including p16 IHC or NAAT in tumor workup) and once every five years for women aged 30–65 as part of cervical screening. HPV testing does not meet coverage as part of general STI screening panels for asymptomatic individuals, for diagnosis of anogenital warts, or to screen for low‑risk HPV types.

See cervical screening policy AHS-G2002 for details

PrEP testing

PrEP-related testing that MEETS COVERAGE CRITERIA:

Preexposure prophylaxis (PrEP) initial and ongoing testing: Prior to PrEP: serum creatinine and estimated creatinine clearance, HIV antigen/antibody testing to confirm HIV‑negative status, hepatitis B and C screening, and pregnancy testing. During PrEP: HIV antibody testing every 3 months; renal function at 3 months then up to every 6 months; NAAT screening for gonorrhea and chlamydia by exposure site with intervals (every 3 months for MSM and persons of childbearing potential; nine months after initiation then every 6 months for sexually active individuals); syphilis testing every 3 months for MSM and persons of childbearing potential (with similar staggered schedule); pregnancy testing every 3 months.

Document HIV testing within 1 week before initiating or re‑initiating PrEP

Diagnostic standards and clinical testing context

Diagnostic methods and indications described in scientific background

Chlamydia/Gonorrhea diagnosis: Use NAAT as the preferred diagnostic test for chlamydia and gonorrhea; culture may be used for gonorrhea antimicrobial susceptibility testing and in situations such as suspected treatment failure or special forensic indications.NAAT preferred

NAAT recommended for appropriate specimen types including extragenital sites per product insert and CDC guidance

Syphilis diagnosis: Use two‑tier serologic testing (treponemal plus nontreponemal tests) as the standard diagnostic algorithm; NAAT/PCR for syphilis is not FDA‑approved for routine genital testing and has limited routine use; darkfield microscopy and direct detection remain gold standards for lesions when available.Two‑tier algorithm

Reflex quantitative NTT preferred when TT positive

HSV diagnosis:

CT/NG Screening (USPSTF)

USPSTF screening recommendations for chlamydia and gonorrhea:

USPSTF CT/NG screening: Screen sexually active females aged 24 years or younger and screen females 25 years or older only if at increased risk; screening should be performed using NAATs. Evidence insufficient to recommend routine screening in men except in high‑prevalence settings.age and risk factors as defined by USPSTF

Screening modality: NAAT preferred

HSV Serologic Screening

USPSTF stance on HSV serologic screening:

HSV serologic screening: Do not perform routine serologic screening for genital HSV in asymptomatic adolescents and adults, including pregnant persons, due to high false‑positive rates and potential psychosocial harms. Type‑specific serology may be used selectively in symptomatic or other targeted situations.asymptomatic status

Use serology only in indicated clinical scenarios

Assay selection and clinical utility

Test-performance considerations and utility:

Use of near‑patient NAAT vs POCT: Near‑patient NAATs yield high sensitivity (>95–98%) and high specificity and are acceptable for screening/diagnosis; antigen‑based POCTs have substantially lower sensitivity and should not be used alone for screening. Rapid NAATs (e.g., GeneXpert) can improve same‑visit management by enabling prompt treatment and reducing overtreatment or undertreatment.assay type

Consider throughput and turnaround (e.g., Cepheid Xpert throughput/time) when selecting assay

Syphilis Testing

Syphilis testing considerations:

Syphilis diagnostics: Serologic testing (two‑tier algorithms of treponemal plus nontreponemal tests) remains the primary approach for syphilis screening and diagnosis; PCR/TMA from mucosal/lesion sites may detect additional cases but generally adds limited value over serology in many settings. NAAT is not FDA‑approved for routine genital syphilis testing.test modality

Reflex quantitative NTT preferred when TT positive to at least 1:8–1:16 dilution

HPV Testing and Tumor Workup

HPV and cancer-related testing context:

HPV testing utility: HPV molecular testing is more sensitive than cytology alone for detecting CIN3+ and is recommended in screening and triage strategies; p16 IHC, PCR, and ISH are used in tumor workup to guide management. HPV testing is indicated in specific oncologic contexts and cervical screening per guideline age indications.clinical indication

Follow NCCN/CAP guidance for tumor workup modalities

Chlamydia and Gonorrhea Screening

Covered when aligned with guideline screening/testing indications:

Chlamydia/Gonorrhea screening: Screening using NAAT is recommended for sexually active females aged <=24 years and for older women at increased risk; screening of young men should be considered in high‑prevalence settings. NAAT of appropriate specimen types (first‑catch urine, endocervical/vaginal swabs, and extragenital swabs at exposure sites) is recommended.

USPSTF Grade B for females; follow CDC guidance for site‑specific testing and intervals

Syphilis Diagnosis and Confirmation

Covered diagnostic approach for syphilis:

Syphilis testing algorithm: Diagnosis requires both a nontreponemal test (RPR or VDRL, preferably quantitative) and a treponemal test (TPPA/TPHA/EIA/CLIA); perform reflex testing per algorithm: if TT used first, reflex quantitative NTT; if NTT used first, reflex TT. Direct detection (darkfield or PCR) is indicated for lesions and CSF‑VDRL when neurosyphilis suspected.

Quantitative NTT dilution target: at least 1:8 to 1:16 for reflex testing

Herpes Simplex Virus (HSV)

HSV testing recommendations:

HSV testing: HSV NAAT from lesions (most sensitive) meets coverage for persons with active lesions. Type‑specific serology (gG2) is indicated for recurrent or atypical presentations with negative PCR/culture, for clinical diagnosis without laboratory confirmation, or when partner has genital herpes. Routine serologic screening of asymptomatic persons, including pregnant women, does not meet coverage due to poor positive predictive value and potential harms.

Use type‑specific assays when indicated

Mycoplasma genitalium

M. genitalium testing recommendations:

M. genitalium testing: Test symptomatic men with recurrent nongonococcal urethritis and women with recurrent cervicitis using FDA‑cleared NAATs; consider testing in PID. Routine asymptomatic screening and extragenital testing are not recommended. Resistance testing should be performed if available.

Culture is impractical; NAATs cleared for urine and genital swabs

HPV Screening

HPV and other guideline notes:

HPV testing is recommended for cervical cancer screening in persons aged 30–65 per guideline intervals (HPV test alone every 5 years or cotest strategies); not recommended for routine STI screening in men or women <30, and not indicated for diagnosis of anogenital warts.

No approved routine HPV test for men; follow CDC and IUSTI guidance

Syphilis: Confirmatory and reflex testing

Recommended testing and reflex confirmatory steps for syphilis screening

Syphilis screening positive (treponemal test as primary): If a treponemal test (TT) is used first and is positive, perform a reflex quantitative non‑treponemal test (NTT) on the same serum reaching at least 1:8 to 1:16 dilution. If NTT is negative and very early syphilis is not suspected, repeat both tests after 1 month.quantitative NTT >=1:8 to 1:16

Confirmatory TT may be useful for counselling/notification but has limited impact on treatment

Syphilis screening positive (non‑treponemal test as primary): If an NTT alone is used as primary screening and is positive, reflex treponemal testing on the same serum is required; if quantitative NTT was not initially performed, repeat NTT quantitatively.quantitative NTT required if not done initially

Two‑test approach is standard

Both TT and NTT used in screening:

Preferred tests for other STIs

Preferred diagnostic methods for other common STIs

Chlamydia testing: Use NAATs (DNA or RNA) due to superior sensitivity and specificity; test symptomatic and asymptomatic sexually active individuals per guideline indications and retest 3 months after treatment when indicated.NAAT preferred

Consider extragenital NAAT at exposure sites and follow local lab validation for specimen types

Gonorrhea testing: Use NAATs for genital specimens; consider culture for antimicrobial susceptibility in symptomatic patients, treatment failures, or public health situations; test‑of‑cure timing varies by specimen site and clinical scenario.culture for susceptibility when needed

NAAT sensitivity superior to culture for many sites but culture required for susceptibility testing

LGV testing: Use commercial molecular NAAT platforms for C. trachomatis and confirm C. trachomatis‑positive specimens with LGV‑discriminatory NAAT (two‑step procedure) where LGV is suspected; serology cannot reliably distinguish past from current infection.

Guideline-based screening and retesting

Covered testing and recommended frequencies referenced from cited guidelines

General recommendations: Annual NAAT screening is recommended for at‑risk groups for chlamydia and gonorrhea; annual syphilis testing for at‑risk groups with 3–6 month testing for certain high‑risk populations; retesting 3 months after a positive test is recommended; NAATs preferred over culture where available; culture required for gonorrhea antimicrobial susceptibility testing.

Recommendations derived from multiple guideline sources (CDC, USPSTF, AAP, BASHH, Canadian guidelines, NICE)

This policy clarifies specific tests that do not meet coverage criteria and the contexts in which serologic or molecular assays are excluded. Examples include serology for Chlamydia/LGV, PCR/NAAT for routine genital syphilis, enzyme immunoassay rapid identification of Trichomonas, non-type-specific HSV immunoassays, HPV testing when used as a general STI screening panel in asymptomatic individuals, and nucleic acid quantification for organisms listed in this policy (C. trachomatis, N. gonorrhoeae, HSV-1/2, HPV, T. pallidum) which is specifically not supported by the available evidence described in the policy.

NAAT/PCR methods for Treponema pallidum are noted in the scientific background as having limited routine use; the policy states that NAAT has not been FDA-approved for routine genital syphilis testing and is not typically performed, and that serologic two‑tier algorithms (treponemal plus nontreponemal testing) remain the standard diagnostic approach.

The policy references USPSTF and CDC evidence showing that routine HSV serologic screening of asymptomatic adolescents and adults is not recommended because of high false‑positive rates and potential psychosocial harms; type‑specific serology (gG2) is reserved for targeted clinical situations (for example, recurrent atypical lesions or when PCR/culture are negative).

Routine serologic screening for genital HSV and routine NAAT screening for Mycoplasma genitalium in asymptomatic persons are discouraged. The CDC guidance supports M. genitalium NAAT only for symptomatic patients (e.g., men with recurrent NGU, women with recurrent cervicitis or PID), and advises against routine asymptomatic screening or extragenital testing for M. genitalium.

The policy documents that routine HSV serologic testing in asymptomatic patients is not recommended and that HPV testing is limited to specified indications (oncologic assessment and cervical screening per age-based guidance). HPV testing for diagnosing anogenital warts, for general STI panels in asymptomatic individuals, or routine oncogenic HPV testing in men is explicitly excluded.

If there is any conflict between this policy and an applicable government policy for a particular member (for example, Medicare Local or National Coverage Determinations or state Medicaid rules), the government policy will govern the coverage determination for that member.

Screening of asymptomatic individuals is limited to populations and intervals specified by guideline-based risk definitions. For example, USPSTF and CDC recommend annual NAAT screening for sexually active females aged ≤24 years and for older women only if at increased risk; screening asymptomatic low‑risk persons for chlamydia, gonorrhea, HSV, M. genitalium, or HPV (outside cervical screening) is not supported by the policy.

The excerpt does not present an explicit separate list labeled 'not medically necessary' for every test; rather, exclusions and not‑recommended practices are described within the policy language and scientific background without a standalone formalized NMN statement in this excerpt.

Antigen‑based point‑of‑care tests for Chlamydia trachomatis and Neisseria gonorrhoeae have substantially lower sensitivity compared with NAATs (pooled sensitivities around 53% for CT antigen POCTs versus >98% for near‑patient NAATs), and therefore antigen POCTs alone are not considered sufficient for screening where NAATs are available.

The policy states that screening asymptomatic adults for oral cancer and routine serologic HSV screening are not supported by USPSTF/CDC evidence summaries. In particular, no FDA‑approved test exists for oral HPV screening, and routine serologic screening for genital HSV in asymptomatic persons is discouraged due to low positive predictive value and potential harms.

HPV testing is covered for oncologic indications and for cervical cancer screening in women aged 30–65 per the referenced cervical screening policy, but HPV testing is not recommended for diagnosing anogenital warts or for routine screening in asymptomatic men; accordingly, such uses are excluded from coverage under general STI screening.

Procedure and Test Codes

Applicable CPT/HCPCS procedure codesmixed

No codes listed

Glossary / abbreviationsmixed

NA	Abbreviations and glossary entries (e.g., NAAT, PCR, CPT, HCPCS) listed in document glossary

Covered CPT Codesmixed

No codes listed

Covered CPT Codes, Not explicitly listed in this excerptmixed

No codes listed

General laboratory procedure codesCPT

82565	Creatinine; blood.
82575	Creatinine; clearance.
84702	Gonadotropin, chorionic (hCG); quantitative.
84703	Gonadotropin, chorionic (hCG); qualitative.

Serology, culture, and antigen detection codesCPTCovered

86592	Syphilis test, non-treponemal antibody; qualitative (e.g., VDRL, RPR, ART).
86593	Syphilis test, non-treponemal antibody; quantitative.
86631	Antibody; Chlamydia.
86632	Antibody; Chlamydia, IGM.
86694	Antibody; herpes simplex, non-specific type test.
86695	Antibody; herpes simplex, type 1.
86696	Antibody; herpes simplex, type 2.
86701	Antibody; HIV-1.
86702	Antibody; HIV-2.
86703	Antibody; HIV-1 and HIV-2, single result.

1–10 of 20

1/2

NAAT and nucleic acid detection codesCPTCovered

87490	Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique.
87491	Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique.
87529	Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, amplified probe technique.
87530	Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, quantification.
87590	Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, direct probe technique.
87591	Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique.
87592	Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, quantification.
87624	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types.
87625	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed.
87660	Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, direct probe technique.

1–10 of 15

1/2

Immunohistochemistry and proprietary test codesCPT | ProprietaryCovered

88341	Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure.
88342	Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure.
88344	Immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain procedure.
0064U	Antibody, Treponema pallidum, total and rapid plasma reagin (RPR), immunoassay, qualitative (Proprietary: BioPlex 2200 Syphilis Total & RPR Assay).
0065U	Syphilis test, non-treponemal antibody, immunoassay, qualitative (RPR) (Proprietary: BioPlex 2200 RPR Assay).
0096U	HPV, high-risk types, male urine (Proprietary: Molecular Testing Labs/Roche Cobas).
0167U	Gonadotropin, chorionic (hCG), immunoassay with direct optical observation, blood (Proprietary: ADEXUSDx hCG Test).
0210U	Syphilis test, non-treponemal antibody, immunoassay, quantitative (RPR) (Proprietary: BioPlex 2200 RPR Assay - Quantitative).

Additional proprietary and screening HCPCS/G-codesHCPCS | CPTCovered

0353U	Chlamydia trachomatis and Neisseria gonorrhoeae, multiplex amplified probe technique, urine/vaginal/pharyngeal/rectal (Xpert CT/NG).
0354U	HPV high-risk qualitative mRNA expression of E6/E7 by qPCR (PreTect HPV-Proofer' 7).
0402U	0402U detected or not detected (as listed).
0500T	HPV for five or more separately reported high-risk HPV types (genotyping).
G0432	Infectious agent antibody detection by EIA technique, HIV-1 and/or HIV-2, screening.
G0433	Infectious agent antibody detection by ELISA technique, HIV-1 and/or HIV-2, screening.
G0435	Infectious agent antibody detection by rapid antibody test, HIV-1 and/or HIV-2, screening.
G0472	Hepatitis C antibody screening, for individual at high risk and other covered indication(s).
G0499	Hepatitis B screening in non-pregnant, high risk individual includes HBsAg followed by confirmatory testing.
S3645	HIV-1 antibody testing of oral mucosal transudate.

Cepheid Xpert throughput / time

ThroughputProvides results for up to 96 specimens

Time to batch resultApproximately 90 minutes for up to 96 specimens

Specimen typesFemale and male urine, patient-collected vaginal swabs, clinician-collected endocervical, pharyngeal and rectal swabs

Abbott Alinity m time to first result

Assay formatFour-in-one multiplex RT-PCR detecting CT, TV, MG (RNA) and NG (DNA)

Time to first resultFirst result should appear in under 115 minutes

Validated specimen typesEndocervical, clinician- or self-collected vaginal swabs, ThinPrep, female and male urine

Quantitative NTT dilution

Recommended dilution for quantitative reflexPerform quantitative NTT to reach at least 1:8 to 1:16 dilution

When to performReflex quantitative NTT when treponemal test (TT) is positive on same serum

PurposeDetect prozone effect and provide baseline for follow-up and test-of-cure

Quantitative NTT dilution threshold

Dilution thresholdReach at least 1:8 to 1:16 dilution for quantitative NTT

ContextRequired when TT is positive or when NTT was not initially quantitative

Test typesApplies to RPR or VDRL performed quantitatively

Retest interval after positive result

Recommended retest intervalRetest at 3 months after a positive result (e.g., chlamydia/gonorrhea)

PurposeConfirm clearance or reinfection following treatment

Guideline basisConsistent with multiple guideline recommendations for retesting after treatment

Syphilis repeat testing in high-risk groups

Repeat testing interval (high-risk)3–6 months for certain high-risk populations (e.g., commercial sex workers, correctional inmates, persons who exchange sex for drugs)

Annual testingAnnual testing recommended for at-risk groups when not in highest-risk subgroups

Guideline sourcesRecommendations referenced from MTC, AAP, and other guideline groups

Provider Responsibilities and Billing Guidance

Documentation Required

Benefit verification required

Verify member benefits and eligibility prior to ordering tests. Application of coverage criteria depends on the individual's benefit coverage at the time of request; Medicare/Medicaid rules may override and are addressed in Applicable State and Federal Regulations.

Benefit verification required — confirm coverage and any plan-specific prior authorization or limits at time of request

Note

Preferred test modality

NAATs are the preferred modality for screening and diagnosis of chlamydia and gonorrhea and are recommended for extragenital sites when appropriate; culture is preferred when antimicrobial susceptibility testing is needed (e.g., treatment failure) or for certain pharyngeal/rectal specimens per laboratory validation.

Preferred test modality — NAAT preferred for CT/NG screening and diagnosis
Culture indicated to determine antimicrobial susceptibility for N. gonorrhoeae when treatment failure or resistance is suspected

Documentation Required

HIV testing before PrEP

Follow CDC guidance for HIV testing before initiating or re-initiating PrEP. Obtain antigen/antibody testing (blood) to confirm negative HIV status within one week before starting PrEP; do not use oral rapid tests for PrEP eligibility.

HIV testing before PrEP — antigen/antibody blood test within 7 days prior to initiating/reinitiating PrEP; point-of-care fingerstick FDA-approved blood tests acceptable; avoid oral rapid tests for PrEP screening

Documentation Required

PrEP monitoring documentation

For individuals on PrEP, document HIV testing, renal function monitoring, STI screening cadence, and pregnancy testing per CDC intervals: HIV and adherence every 3 months; serum creatinine at 3 months then every 6 months; NAAT screening for CT/NG by exposure site (every 3 months for MSM and persons with childbearing potential; other cadences per guidance).

PrEP monitoring documentation — document HIV test results, serum creatinine/creatinine clearance, NAAT STI screening results by anatomic site, pregnancy tests, and adherence counseling at recommended intervals

Prior Authorization

NAAT required for CT/NG screening

Use NAAT-based assays for chlamydia and gonorrhea screening based on anatomic site of exposure; NAAT is required/preferred where indicated and validated for the specimen type. Consult the test manufacturer's IFU and laboratory validation for specimen acceptability.

NAAT required for CT/NG screening — collect specimen types validated by the chosen NAAT (urine, endocervical, vaginal, urethral, rectal, pharyngeal as applicable)
Confirm NAAT is validated for pediatric, medico-legal, or other special populations before use

Denial Risk

Syphilis testing algorithm risk

Syphilis screening requires both treponemal and nontreponemal testing; use of only one serologic test is insufficient and may yield false-negative or false-positive results. When a treponemal test is used as the initial screen, reflex quantitative nontreponemal testing on the same serum is recommended; when NTT is primary, reflex TT is required.

Syphilis testing algorithm risk — do not rely on a single serologic test; perform recommended reflex/confirmatory testing to avoid false results
Syphilis reflex testing and documentation — document initial screening test, reflex quantitative NTT (or reflex TT as applicable), and follow-up testing timelines (1, 3, 6, 12 months for early disease; later intervals for late/neurologic disease)

Note

For individuals not responding to initial therapy

For individuals not responding to initial treatment for gonorrhea, perform culture and antimicrobial susceptibility testing to guide therapy; document the clinical indication and results.

Culture for susceptibility covered for treatment failures — submit culture to a laboratory with susceptibility capability and document treatment failure and prior therapy

Billing Rule

Affected procedure codes

Affected CPT/HCPCS procedure codes are provided for billing and coverage determinations. Verify code applicability to the performed test and specimen type; refer to the policy CPT/HCPCS list when submitting claims.

Affected procedure codes — include but not limited to: 82565, 82575, 84702, 84703, 86592-86593, 86631-86696, 86701-86704, 86780, 86803-86804, 87081, 87110, 87181, 87340, 87490-87491, 87529-87530, 87590-87592, 87624-87625, 87660-87661, 87797-87799, 87808, 88341-88344, 0064U, 0065U, 0096U, 0167U, 0210U, 0353U, 0354U, 0402U, 0500T, G0432-G0435, G0472, G0475, G0499

Note

No explicit authorization or denial criteria

No explicit prior authorization or denial criteria are specified in this section of the policy. Bibliographic entries and citations do not themselves set authorization requirements; follow payer-specific authorization processes and verify benefits.

No explicit authorization or denial criteria provided in this excerpt — check member benefits and prior authorization portals as required

Documentation Required

Coverage is dependent on member benefits and government policy

Coverage is dependent on the member's benefit plan and may be affected by government policies (LCDs/NCDs) which take precedence when applicable. If a conflict exists between this policy and applicable government policy, the government policy will be used.

Coverage is dependent on the member's benefit — verify plan, Medicare/Medicaid applicability, and local coverage determinations

Documentation Required

No documentation instructions are provided in citations

The policy provides no prescriptive documentation instructions beyond clinical indication and recommended reflex/confirmatory testing; providers should document clinical indication, specimen type, assay performed, test results, and any follow-up or confirmatory testing performed.

No documentation instructions are provided in bibliographic entries — document indication, specimen type, assay/manufacturer if relevant, reflex/confirmatory tests performed, and results

Definitions and Abbreviations

STI pathogens covered

Pathogens coveredChlamydia trachomatis

Pathogens coveredNeisseria gonorrhoeae

Pathogens coveredTreponema pallidum

Pathogens coveredHerpes simplex virus (HSV)

Pathogens coveredHuman papillomavirus (HPV)

NAAT — definition and gold-standard note

DefinitionNucleic acid amplification testing (NAAT): molecular methods for direct detection of pathogen nucleic acid

Clinical roleGold standard for chlamydia due to high sensitivity and specificity

Examples of methodsPCR, TMA, RT-PCR

Two-tier serologic testing (syphilis) — definition

DefinitionTwo-tier serologic testing: combination of treponemal and nontreponemal tests (e.g., EIA/TP plus RPR/VDRL)

PurposeStandard diagnostic algorithm for syphilis to improve accuracy and inform treatment/follow-up

Reflex actionsIf TT positive, reflex quantitative NTT; if NTT positive, reflex TT

Proprietary NAAT assays

ExamplesCepheid Xpert CT/NG and Abbott Alinity m STI cited as FDA-approved commercial NAATs

Specimen notesThese assays specify validated specimen types (e.g., urine, vaginal, endocervical, pharyngeal, rectal swabs)

Intended useMultiplex detection (e.g., Alinity m detects CT, TV, MG, NG); Xpert detects CT/NG including extragenital sites

NAAT — molecular assay definition

DefinitionMolecular assay that amplifies and detects specific nucleic acid targets (e.g., RT-PCR, TMA)

Performance noteNAATs have higher sensitivity and specificity than antigen-based POCTs and are preferred where available

Use casesUsed for CT, NG, LGV, and HSV lesion testing per guidelines

Serologic screening for HSV-2 — performance characteristics note

Test typeType-specific HSV-2 serologic assays (gG2) detect prior HSV-2 infection

PerformanceHigh sensitivity at manufacturer's cutpoint (pooled ~99%) but substantial false-positive rate lowering positive predictive value in general populations

Clinical implicationRoutine serologic screening in asymptomatic individuals is not recommended due to psychosocial harms from false positives

NTT — nontreponemal test definition

DefinitionNontreponemal test (NTT): tests such as RPR or VDRL used to detect reactivity to cardiolipin-based antigens

UsePrefer quantitative NTT for screening and follow-up to detect prozone and to monitor treatment response

ExamplesRPR and VDRL

TT — treponemal test definition

DefinitionTreponemal test (TT): assays such as TPHA, TPPA, EIA/ELISA/CLIA detecting treponemal antibodies

RoleOften used in reverse-sequence screening algorithms; more sensitive for early infection but can yield false positives in low-prevalence populations

ExamplesTPPA, TPHA, EIA/ELISA/CLIA

Treponemal test (TT) — short label

Short labelTreponemal test (TT)

Use noteUsed as part of two-tier serologic algorithm

Non-treponemal test (NTT) — short label

Short labelNon-treponemal test (NTT)

Use notePrefer quantitative NTT (e.g., RPR/VDRL) for screening follow-up

NAAT — additional NAAT definition for other pathogens

Definition (additional)NAAT: nucleic acid amplification tests for detection of CT, NG, LGV, and HSV DNA/RNA in lesions

RecommendationPreferred testing modality for lesion-based HSV and for chlamydia/gonorrhea where available

Specimen considerationsExtragenital specimen testing (pharyngeal/rectal) available on validated assays

NAAT — preferred sensitive and specific method (reiteration)

Preferred methodNAATs are a preferred, sensitive and specific method for detection of many STIs; recommended where available

ContrastNAATs outperform antigen-based POCTs and culture for many indications; culture still needed for gonorrhea susceptibility

Guideline supportSupported by BASHH and other guideline statements

LDT — laboratory-developed test definition and CLIA note

DefinitionLaboratory-developed test (LDT): tests developed and validated in-house, regulated under CLIA as high-complexity tests

Regulatory noteLDTs are not FDA-cleared/approved but are regulated by CMS/CLIA for clinical use

Validation requirementMust be validated and performed in-house per CLIA rules

Xpert CT/NG — brief device/test identifier

IdentifierXpert CT/NG (Cepheid GeneXpert system)

Intended targetsChlamydia trachomatis and Neisseria gonorrhoeae

Regulatory statusFDA-cleared NAAT (510(k) summaries cited)

Guideline sources

Guideline/ evidence sourcesUSPSTF (JAMA statement), CDC/MMWR, BASHH, Canadian (CPS), IUSTI, NICE, NCCN

Regulatory citationsFDA 510(k)/PMN summaries for assays (e.g., Xpert CT/NG, BD Onclarity) referenced

LiteraturePeer-reviewed studies and systematic reviews cited for assay performance and screening intervals

OpenPayer

Diagnostic Testing of Common Sexually Transmitted Infections

Coverage Criteria for STI Testing

Procedure and Test Codes

Provider Responsibilities and Billing Guidance

Definitions and Abbreviations

Background and Clinical Context

Policy Revision History