Currentblue cross blue shield - tennesseePolicy N/A

ZIKA Virus Risk Assessment

Defines coverage criteria for Zika virus laboratory testing (NAAT, IgM, PRNT) in pregnant individuals, infants, and other populations and describes limitations and appropriate sample types. Applies to claims adjudication and clinical testing decisions for covered members.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyZIKA Virus Risk Assessment

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateJul 1, 2023

Next Review DateN/A

Key ActionOrder Zika NAAT and/or IgM testing only for covered clinical scenarios (pregnant persons with fetal ultrasound findings or exposure, symptomatic pregnant persons with exposure, and certain infant indications) and document specimen source and exposure history.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2CPT/HCPCS codes listed

5+Sample types referenced

12 weeksNAAT consideration window

7/1/2023Effective date

Coverage Criteria for Zika Virus Testing

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Covered Indications

Covered when the specific scenario below is met

Infant testing: Infants with clinical findings consistent with congenital Zika syndrome and possible maternal Zika exposure during pregnancy OR infants without clinical findings born to mothers with laboratory evidence of possible Zika virus infection during pregnancy

Zika urine, serum, and CSF NAAT and IgM testing meets coverage criteria

Maternal NAAT during pregnancy: Pregnant individuals who have a fetus with prenatal ultrasound findings consistent with congenital Zika virus OR symptomatic pregnant individuals with exposure during pregnancy OR asymptomatic pregnant individuals with travel exposure outside U.S. territories within 12 weeks post-travel<=12 weeks post-travel for asymptomatic pregnant individuals

Zika NAAT testing of maternal serum and urine meets coverage criteria

Maternal IgM for certain scenarios: Pregnant individuals with possible exposure AND who have a fetus with prenatal ultrasound findings consistent with congenital Zika virus

Maternal serum IgM meets coverage criteria in this scenario

Amniocentesis and tissue testing: Pregnant women with possible exposure and a fetus with prenatal ultrasound findings consistent with congenital Zika virus undergoing amniocentesis

NAAT testing of amniocentesis, placental, and fetal tissues meets coverage criteria

Not Medically Necessary / Not Covered

Not covered: preconception: Preconception screening: Zika urine and serum NAAT and Zika serum IgM testing does not meet coverage criteria

Not covered: delayed non-pregnant testing: All non-pregnant individuals presenting >=14 days after symptom onset: Zika urine and serum NAAT testing and Zika serum IgM testing does not meet coverage criteria>=14 days post-symptom onset

Not covered: unspecified tests/sample types: All other tests for diagnosing Zika virus not mentioned above and testing of samples other than serum, urine, CSF, amniocentesis, placental and fetal tissues do not meet coverage criteria

Due to lack of evidence

Symptomatic pregnant women

Covered when ALL of the following are met

Symptomatic pregnant women travel/sex exposure: Pregnant woman symptomatic with recent travel to or residence in an area with active dengue transmission and risk of Zika, or symptomatic after sex with someone who lives in or recently traveled to areas with risk of Zika; collect specimens as soon as possible up to 12 weeks after symptom onsetspecimen collection as soon as possible up to 12 weeks after symptom onset

Perform dengue and Zika NAAT on serum, Zika NAAT on urine; dengue IgM testing recommended; Zika IgM not recommended for symptomatic pregnant women; repeat positive NAAT on newly extracted RNA to confirm

Pregnant women with fetal findings or pregnancy travel

Covered when ALL of the following are met

Pregnant women with fetal ultrasound consistent with Zika or travel during pregnancy: Maternal NAAT and IgM on serum and NAAT on urine for pregnant women with prenatal ultrasound findings consistent with congenital Zika or who traveled during pregnancy to areas with risk; if NAAT negative and IgM positive, perform confirmatory PRNT for Zika and dengue; consider NAAT on amniotic fluid if amniocentesis is performed

Interpret amniotic fluid testing within known limitations; testing of placental and fetal tissues may be considered

Infants with congenital findings

Covered when ALL of the following are met

Infants with clinical findings consistent with congenital Zika syndrome: Infant born with clinical findings consistent with congenital Zika syndrome and possible maternal exposure during pregnancy

Test infant serum (RT-PCR), consider CSF for RNA and IgM especially if serum/urine negative; test placenta and tissues as indicated; initial samples preferably cord blood or infant within 2 days of birth

Infants of mothers with lab evidence

Covered when ALL of the following are met

Infants born to mothers with laboratory evidence of possible Zika infection: Infants without clinical findings but born to mothers with laboratory evidence of possible Zika virus infection during pregnancy should have Zika virus testing

Per CDC recommendations; include serum RT-PCR and IgM testing with confirmatory neutralizing antibody testing as indicated

Testing that is not specifically described in the covered scenarios is excluded from coverage. Specifically, Zika virus testing of specimen types other than serum, urine, cerebrospinal fluid (CSF), amniotic fluid obtained at amniocentesis, placental tissue, and fetal tissues does not meet coverage criteria. This policy also identifies that NAAT and IgM testing performed for indications not listed among the covered maternal, infant, or pregnancy-related scenarios are not supported due to insufficient evidence.

Routine testing of asymptomatic pregnant women who do not have ongoing exposure is not recommended. External guidance cited in the policy (e.g., CATMAT, PHE, and joint RCOG/RCM/PHE/HPS statements) advises against screening asymptomatic pregnant travelers because of the low population prevalence, poor positive predictive value of serologic screening, and the risk of false positives and unnecessary adverse consequences.

This policy aligns testing indications and interpretation with external guidance from authoritative sources (for example, ACOG and CDC) and references those sources for diagnostic and specimen‑handling recommendations. While the document cites and relies on external guidance for clinical decision-making, it does not list any additional explicit exclusions beyond those described in the coverage and not‑medically‑necessary sections.

Preconception screening with Zika urine and serum NAAT and Zika serum IgM testing does not meet coverage criteria. Likewise, Zika NAAT and IgM testing for non‑pregnant individuals presenting ≥ 14 days after symptom onset is not covered. These restrictions reflect limited clinical utility of testing in those contexts as stated in the policy.

Routine serologic testing of asymptomatic individuals, including asymptomatic pregnant women without ongoing exposure, is discouraged because serology has a low positive predictive value in low‑prevalence settings and a high risk of false‑positive results. The policy cites Public Health England and CATMAT guidance that testing availability and recommendations are restricted to symptomatic persons or specific exposure scenarios.

Provider Actions, Documentation, and Billing

Denial Risk

Coverage Limited to Specified Clinical Scenarios

Coverage for Zika testing is limited to the specific clinical scenarios described in the policy. Order testing only when the patient meets the indications (e.g., pregnant individuals with exposure or fetal ultrasound findings; infants with clinical findings of congenital Zika syndrome or maternal laboratory evidence). Testing for preconception screening, most asymptomatic individuals without exposure, and other unsupported indications may be denied.

Coverage limited to specified clinical scenarios per policy Sections III–Reimbursement Policy
Denials possible for NAAT and IgM testing for preconception screening and asymptomatic individuals without exposure

Billing Rule

Referenced Procedure Codes

Use the following CPT codes as the billing references for Zika testing. Include correct codes on claims to reduce risk of reimbursement denials.

CPT 87662 — Infectious agent detection by nucleic acid (RNA NAT); Zika virus, amplified probe technique
CPT 86794 — Zika virus, IgM

Note

Procedure Code Reference

Procedure codes listed in this policy are provided as general billing references and do not imply prior authorization requirements. Verify member benefit coverage and any applicable prior authorization requirements separately.

Codes serve as billing reference only; check benefit for prior auth requirements

Denial Risk

Coding-Related Denial Risk

Ensure correct CPT coding (87662 and 86794) when submitting claims. Incorrect or missing codes increase the likelihood of claim denials or improper reimbursement.

Include CPT 87662 for Zika RNA NAT claims
Include CPT 86794 for Zika IgM claims

Documentation Required

Confirmatory Testing and Interpretation

If a Zika NAAT is positive on a single specimen, repeat the NAAT on newly extracted RNA from the same specimen to help rule out false-positive results. Interpret single-specimen positive results with caution and follow CDC confirmatory guidance (including neutralizing antibody testing when indicated).

Repeat NAAT on newly extracted RNA for positive single-specimen NAATs
Use PRNT or neutralizing antibody testing for confirmatory serology interpretation when recommended

Documentation Required

Specimen and Exposure Documentation

Document specimen source(s) and detailed exposure history on the request and in the medical record. For infants or when maternal testing is performed because of fetal abnormalities, clearly document timing of exposure, maternal symptoms, travel history, and specimen collection details.

Record specimen source (serum, urine, CSF, amniotic fluid, placental/fetal tissue) on all requests
Document exposure history, travel, sexual contact exposures, symptom onset dates, and maternal-fetal findings

Documentation Required

Clinical Indication and Guideline Alignment

When ordering testing, align clinical indications with cited guidelines (ACOG, CDC, PHE, RCOG) and the policy's coverage criteria. Document how the patient meets those guidelines (e.g., symptomatic pregnant with exposure, fetal ultrasound findings, infant with congenital findings).

Document which guideline-based indication applies when ordering (e.g., CDC testing guidance for pregnant women and infants)
Testing unsupported by these guidelines or policy criteria may be denied

Note

Sequential Testing

Follow sequential testing recommendations: if RNA NAT is negative on serum and urine, perform IgM serology for Zika, dengue, and chikungunya as recommended. For symptomatic pregnant individuals, collect specimens promptly and consider concurrent dengue testing when dengue is a co-circulating risk.

If RNA NAT negative on serum and urine, perform serum IgM testing for Zika, dengue, and chikungunya
Pregnant symptomatic patients: collect specimens as soon as possible and perform concurrent dengue and Zika NAAT on serum and Zika NAAT on urine

Definitions and Test Descriptions

NAAT definition — nucleic acid amplification testing for Zika virus RNA

Definition: NAATNucleic acid amplification testing (NAAT) detects Zika virus RNA (includes RT-PCR, rRT-PCR, qRT-PCR) in serum, urine, or whole blood

Use caseConfirms infection when positive and is most informative in the early symptomatic period (first 1–2 weeks)

Analytical validity noteReal-time RT-PCR (rRT-PCR) is the definitive method for detecting Zika virus RNA per analytical validity descriptions

IgM definition — immunoglobulin M antibody testing and limitations

Definition: IgMImmunoglobulin M (IgM) antibody testing detects recent or prior Zika virus infection via serology (eg, MAC-ELISA)

Timing and persistenceIgM typically appears near day 4 post-onset and can persist for up to about 12 weeks

LimitationsIgM assays are subject to cross-reactivity with other flaviviruses and nonspecific reactivity; positive or equivocal results may require PRNT confirmation

PRNT definition — plaque reduction neutralization test for flavivirus-specific antibodies

Definition: PRNTPlaque reduction neutralization test (PRNT) measures virus-specific neutralizing antibodies to Zika and other flaviviruses

RoleUsed to confirm presumptive positive, equivocal, or inconclusive IgM results when serology is not definitive

Laboratory requirementPRNT must be conducted by CDC or a laboratory qualified by the CDC

RNA NAT / RT-PCR — molecular testing most informative early after symptom onset

Definition: RNA NAT / RT-PCRMolecular nucleic acid testing (RNA NAT/RT-PCR) to detect Zika virus RNA; confirms infection when positive and is most informative within the first two weeks after symptom onset

Specimen typesDetects RNA in serum, urine, and whole blood; Trioplex rRT-PCR can detect Zika, dengue, and chikungunya RNA

Follow-upA negative RNA NAT does not exclude infection and should be followed by IgM serologic testing per CDC guidance

Zika MAC-ELISA — IgM antibody capture ELISA subject to cross-reactivity and may require PRNT confirmation

Definition: Zika MAC-ELISAIgM antibody capture ELISA (MAC-ELISA) for qualitative detection of Zika virus IgM in serum or CSF

Interpretation limitationsResults may be difficult to interpret due to cross-reaction with other flaviviruses and possible nonspecific reactivity

ConfirmationPositive, equivocal, or inconclusive MAC-ELISA results should be confirmed by PRNT

PRNT (repeat) — confirmatory test to measure virus-specific neutralizing antibodies when serology is inconclusive

Definition: PRNT (confirmatory)PRNT is the confirmatory assay to measure virus-specific neutralizing antibodies when IgM serology is presumptive, equivocal, or inconclusive

When to usePerform PRNT to distinguish Zika from other endemic flavivirus infections after a presumptive positive or equivocal IgM

Performance notePRNT must be performed by CDC or CDC-qualified laboratories

Zika IgM — serologic assay detecting IgM (CPT 86794)

Test: Zika IgM (CPT 86794)Serologic assay detecting IgM antibodies to Zika virus; listed CPT code 86794

Specimen typesIgM detected in serum or CSF; used when RNA NAT is negative or when testing later after symptom onset

InterpretationDue to cross-reactivity with other flaviviruses, positive IgM often requires PRNT confirmation

Zika nucleic acid test (NAAT) — molecular assay for Zika RNA (CPT 87662)

Test: Zika NAAT (CPT 87662)Nucleic acid amplification test for detection of Zika virus RNA; listed CPT code 87662

Clinical useUsed to confirm infection when performed on appropriate specimens (serum, urine, whole blood) early after symptom onset

Coding noteInclude appropriate CPT code (87662) on claims to support reimbursement

OpenPayer

ZIKA Virus Risk Assessment

Coverage Criteria for Zika Virus Testing

Procedure Codes and Timing for Testing

Provider Actions, Documentation, and Billing

Background on Zika Virus

Definitions and Test Descriptions

86794	Zika virus, IgM
87662	Infectious agent detection by nucleic acid (DNA or RNA); Zika virus, amplified probe technique

86794	Zika virus, IgM.
87662	Infectious agent detection by nucleic acid (DNA or RNA); Zika virus, amplified probe technique