Blue Cross Blue Shield TN TB Testing Coverage

Coverage Criteria for Tuberculosis Testing

inv-01: IGRA for Latent TB Screening

IGRA meets coverage criteria in the following situations:

IGRA coverage conditions

Risk or legal requirement: (a) Individuals who are at risk for infection with M. tuberculosis OR (b) Individuals who are unlikely to be infected when screening is obliged by law.
Policy II.1 a-b

inv-02: Testing for Suspected Active TB

For suspected active TB infections, the following meet coverage criteria when clinically indicated:

Core tests for suspected TB: At minimum, the following meet coverage criteria: (a) Acid-fast bacilli (AFB) smear/stain; and (b) Culture and culture-based drug susceptibility testing of Mycobacteria spp.

Policy II.2 a-b

NAAT coverage: Direct probe or amplified probe nucleic acid-based testing (including PCR) meets coverage criteria for: (a) Mycobacteria spp.; (b) M. tuberculosis; and (c) M. avium intracellulare.

Policy II.3 a-c

inv-03: Molecular-based Drug Susceptibility Testing

Molecular drug susceptibility testing meets coverage criteria for AFB smear positive or Amplified MTD positive sputum when any of the listed risk criteria are met:

Eligibility for molecular DST: Covered when the individual's sputum is AFB smear positive or Hologic Amplified MTD positive AND any of the following: (a) prior treatment for TB; (b) born in or lived ≥1 year in a country with TB incidence ≥20 per 100,000 or with primary MDR-TB prevalence ≥2%; (c) contact of an individual with MDR-TB; or (d) HIV infection.High TB incidence ≥20/100,000; High MDR prevalence ≥2%

Reimbursement 4 a-d

inv-04: Repeat Drug Susceptibility Testing

Repeat DST meets coverage criteria in the following situations:

Repeat DST triggers: Repeat drug susceptibility testing is covered when: (a) sputum cultures remain positive after 3 months of treatment; OR (b) there is bacteriological reversion from negative to positive.3 months

Reimbursement 5 a-b

inv-05: Fluid Analysis in Suspected Extrapulmonary TB

For suspected TB in pleural, pericardial, or peritoneal sites:

Fluid studies covered: When TB is suspected in individuals with pleural effusion, pericardial effusion, or ascites, analysis of cerebrospinal, pleural, peritoneal, pericardial, and other fluids for cell counts, protein, glucose, and lactate dehydrogenase (LDH) meets coverage criteria.

Reimbursement 6

inv-06: Urine LAM Testing in HIV

Point-of-care urine LAM testing meets coverage criteria for a defined subgroup:

Urine LAM coverage: Urine-based detection of mycobacterial lipoarabinomannan (LAM) is covered for HIV-infected individuals with CD4 cell counts ≤100 cells/microL who have signs and symptoms of tuberculosis.CD4 ≤100 cells/microL

Reimbursement 7

inv-07: Not Covered / Not Meeting Coverage Criteria

The following tests are explicitly listed as not meeting coverage criteria:

Excluded tests: IGRA for individuals with active tuberculosis; quantitative nucleic acid testing for Mycobacterium spp., M. tuberculosis, and M. avium intracellulare; whole genome sequencing of Mycobacterium spp. for detection of drug resistance; genotyping of Mycobacterium spp.; testing of adenosine deaminase (ADA) and interferon-gamma (IFNγ) levels in cerebrospinal, pleural, peritoneal, pericardial, and other fluids for extrapulmonary TB diagnosis; and testing of serum protein biomarkers or biomarker panels for TB detection.

Policy II.8 and Reimbursement 10-14

IGRA (interferon-gamma release assay) is explicitly listed as not meeting coverage criteria for individuals with active tuberculosis. This policy therefore supports use of IGRA for screening or diagnosis of latent TB infection but excludes IGRA as a diagnostic test in the setting of known active TB disease. Additionally, the policy calls out advanced molecular techniques — including quantitative nucleic acid testing, whole genome sequencing, and genotyping of Mycobacterium species — as tests that do not meet coverage criteria and are considered not covered due to insufficient published evidence.

Several bibliographic entries and reference-only items are included in the policy literature list (for example, reports of emerging diagnostic technologies and recent immunologic biomarker research), but these reference-only chunks do not themselves state explicit coverage exclusions or procedural limitations. They are provided to support clinical context and literature review rather than to define coverage rules.

The policy lists a set of specific tests that do not meet coverage criteria: quantitative NAATs for Mycobacterium spp., M. tuberculosis, and M. avium-intracellulare; whole genome sequencing of Mycobacterium spp.; genotyping of Mycobacterium spp.; measurement of adenosine deaminase (ADA) and interferon-gamma (IFNγ) levels in body fluids to diagnose extrapulmonary TB; and testing of serum protein biomarkers or biomarker panels for TB detection. These items are identified as not meeting coverage criteria because currently available published scientific literature does not confirm they are required and beneficial for diagnosis or treatment.

Some bibliographic items cited in the policy (for example, reports on emerging diagnostics and biomarker research) are included for reference and context only; those citation entries do not themselves specify any items as not medically necessary or provide explicit exclusion language.

Applicable Procedure and Laboratory Codes

General and immunologic/microbiology CPT codesCPT

81099	Unlisted urinalysis procedure
81425	Genome sequence analysis
81426	Genome sequence analysis, each comparator genome
81479	Unlisted molecular pathology procedure
82945	Glucose, body fluid, other than blood
83520	Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative
83615	Lactate dehydrogenase (LD), (LDH)
84157	Protein, total, except by refractometry; other source (eg, synovial fluid, cerebrospinal fluid)
84311	Spectrophotometry, analyte not elsewhere specified
86480	Tuberculosis test, cell mediated immunity antigen response measurement; gamma interferon

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Culture, identification, and susceptibility CPT codesCPTCovered

87077	Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate
87116	Culture, tubercle or other acid-fast bacilli any source, with isolation and presumptive identification of isolates
87149	Culture, typing; identification by nucleic acid probe, direct probe technique
87150	Culture, typing; identification by nucleic acid probe, amplified probe technique
87153	Culture, typing; identification by nucleic acid sequencing method, each isolate
87181	Susceptibility studies; agar dilution method, per agent
87184	Susceptibility studies; disk method, per plate
87185	Susceptibility studies; enzyme detection (eg, beta lactamase)
87186	Susceptibility studies; microdilution or agar dilution (MIC), each multi-antimicrobial, per plate
87187	Susceptibility studies; microdilution or agar dilution, minimum lethal concentration (MLC), each plate

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Nucleic acid detection CPT codes (direct, amplified, quantification)CPT

87550	Infectious agent detection by nucleic acid; Mycobacteria species, direct probe technique
87551	Infectious agent detection by nucleic acid; Mycobacteria species, amplified probe technique
87552	Infectious agent detection by nucleic acid; Mycobacteria species, quantification
87555	Infectious agent detection by nucleic acid; Mycobacteria tuberculosis, direct probe technique
87556	Infectious agent detection by nucleic acid; Mycobacteria tuberculosis, amplified probe technique
87557	Infectious agent detection by nucleic acid; mycobacteria tuberculosis, quantification
87560	Infectious agent detection by nucleic acid; mycobacteria avium-intracellulare, direct probe technique
87561	Infectious agent detection by nucleic acid; mycobacteria avium-intracellulare, amplified probe technique
87562	Infectious agent detection by nucleic acid; mycobacteria avium-intracellulare, quantification

High TB incidence country threshold — numeric threshold used in risk assessment

High TB incidence country threshold≥20 per 100,000 population (used to define residence ≥1 year in a country with at least moderate TB incidence)

Context of useApplied when determining eligibility for molecular-based drug susceptibility testing for individuals born in or who lived ≥1 year in such countries

Source policy locationReimbursement Policy section item 4(b)

High primary MDR-TB prevalence threshold — numeric threshold used in risk assessment

High primary MDR-TB prevalence threshold≥2% (used to define high primary multi-drug resistant TB prevalence)

Provider Documentation, Ordering, and Billing Guidance

Documentation Required

Coverage for IGRA, culture, and NAAT when indicated

IGRA, mycobacterial culture (including AFB smear/stain and culture-based susceptibility), and nucleic acid amplification testing (NAAT/PCR) meet coverage criteria when clinically indicated for diagnosis or management of tuberculosis (TB). Document the clinical indication or suspected diagnosis (e.g., screening for latent TB, evaluation of active TB, suspected extrapulmonary TB), relevant risk factors (HIV status, prior TB treatment, country of origin, known exposure to MDR-TB), and specimen source when ordering these tests.

IGRA: Covered for diagnosing/screening latent TB in at-risk individuals; NOT covered for active TB evaluation.
AFB smear/stain and culture (including culture-based drug susceptibility): Covered for suspected TB infections.
NAAT/amplified probe/PCR: Covered for Mycobacteria spp., M. tuberculosis, and M. avium complex when indicated.
Molecular-based drug susceptibility testing: Covered when criteria met (e.g., prior TB treatment, residence in high TB/MDR-TB region, MDR contact, HIV infection).
Repeat drug susceptibility testing: Covered for persistent culture positivity after 3 months or bacteriological reversion from negative to positive.

Medical Background on Tuberculosis and Testing

Mycobacterium tuberculosis infection exists on a spectrum from latent infection (asymptomatic, immunologic evidence of prior exposure) to active disease in pulmonary or extrapulmonary sites. Culture remains the diagnostic gold standard because it provides organism isolation for species identification and drug susceptibility testing; AFB smear and culture-based methods are foundational in the evaluation of suspected TB. Nucleic acid amplification tests (NAATs), including direct probe and amplified probe techniques, offer more rapid and sensitive detection of mycobacterial DNA and are covered when clinically indicated. Interferon-gamma release assays (IGRAs) detect T-cell release of interferon-gamma after stimulation with M. tuberculosis–specific antigens and are used primarily to detect latent TB infection, while urine lipoarabinomannan (LAM) testing is supported in a defined subgroup (HIV-infected individuals with CD4 ≤100 cells/μL) who present with signs and symptoms of tuberculosis.

Definitions and Test Descriptions

IGRA definition — interferon-gamma release assay description

DefinitionInterferon-gamma release assay (IGRA): a blood test measuring T‑cell release of interferon‑gamma after stimulation by M. tuberculosis‑specific antigens, used to detect latent tuberculosis infection.

Clinical roleUsed for LTBI screening in individuals at risk or when screening is legally required; not indicated for diagnosis of active TB per policy exclusions.

Supporting referenceClinical description and use cited in policy description and Pai et al. 2014

NAAT definition — nucleic acid amplification test description

DefinitionNucleic acid amplification test (NAAT): molecular assays (eg, PCR) for detection and identification of Mycobacteria species, enabling sensitive detection of low‑density infections.

Clinical role

OpenPayer

Testing for Diagnosis of Active or Latent Tuberculosis

Coverage Criteria for Tuberculosis Testing

Applicable Procedure and Laboratory Codes

Provider Documentation, Ordering, and Billing Guidance

Medical Background on Tuberculosis and Testing

Definitions and Test Descriptions