Currentblue cross blue shield - tennesseePolicy N/A

Zika virus risk assessment and testing

Defines coverage criteria for laboratory testing (NAAT, IgM, PRNT) and specimen types related to Zika virus exposure, with emphasis on pregnant persons, fetuses, and infants; applies to benefit determinations for covered members.

Policy Summary

Payerblue cross blue shield - tennessee

PolicyZika virus risk assessment and testing

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2023

Next Review DateN/A

Key ActionOrder NAAT (RNA) testing of serum and urine for pregnant patients with exposure or fetal ultrasound findings and include specimen timing and source in documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2CPT/HCPCS codes listed

serum, urine, CSFSpecimen types cited

up to 12wNAAT time window

CDC, ACOG, WHOGuideline sources

7/1/2023Policy effective

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Covered Indications

Covered when ANY of the following are 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 — urine, serum, and CSF NAAT testing and IgM testing meet coverage.

From policy items 1a and 1b (III.1) and related CDC guidance

Maternal testing - fetal ultrasound findings: Pregnant individuals who have a fetus with prenatal ultrasound findings consistent with congenital Zika virus — maternal serum and urine NAAT testing meet coverage; maternal serum IgM testing also meets coverage when the fetus has ultrasound findings consistent with congenital Zika virus.

From policy items 2a and Reimbursement Policy item 3 (III.2, Reimbursement Policy 3)

Symptomatic pregnant individuals with exposure to Zika during pregnancy — maternal serum and urine NAAT testing meet coverage. When dengue is also possible, perform dengue and Zika NAAT on serum and Zika NAAT on urine; IgM testing for dengue only is recommended. Zika IgM is not recommended for symptomatic pregnant women.specimens collected up to 12 weeks after symptom onset

Policy item 2b and Updated Testing Guidance (chunks 18-19)

Asymptomatic pregnant travelers: Asymptomatic pregnant individuals who traveled to an area of Zika risk outside U.S. territories — NAAT testing of maternal serum and urine may meet coverage for up to 12 weeks post-travel; serologic (IgM) testing is not routinely recommended for asymptomatic pregnant women.up to 12 weeks post-travel

Policy item 2c (III.2c) and CDC/updated guidance (chunk 18)

Amniocentesis and tissue testing: When amniocentesis is performed as part of clinical care for pregnant women with possible exposure and fetal ultrasound findings, NAAT testing of amniotic fluid, and testing of placental and fetal tissues meet coverage.

Reimbursement Policy item 4 and CDC guidance on interpretation limitations (chunk 4, chunk 18)

Not Medically Necessary / Not Covered

Not covered when ANY of the following are present

Preconception screening: Zika urine and serum NAAT testing and Zika serum IgM testing do not meet coverage criteria.

Reimbursement Policy item 5 (chunk 4)

Non-pregnant late presenters: Non-pregnant individuals presenting ≥14 days after symptom onset: urine and serum NAAT testing and serum IgM testing do not meet coverage criteria.>= 14 days after symptom onset

Reimbursement Policy item 6 (chunk 4)

Other tests/specimens: All other tests for diagnosing Zika virus not mentioned above and testing of samples other than serum, urine, CSF, amniotic fluid, placental and fetal tissues do not meet coverage criteria due to lack of evidence.

Reimbursement Policy item 7 (chunk 4)

Covered Indications per CDC/ACOG

Covered when testing meets CDC/ACOG-guided clinical indications and specimen timing:

Symptomatic pregnant women with recent travel to areas with active dengue transmission and risk of Zika: Collect specimens as soon as possible after symptom onset, up to 12 weeks post-onset; perform dengue and Zika NAAT on serum, Zika NAAT on urine, and IgM testing for dengue only. Zika IgM testing is NOT recommended for symptomatic pregnant women. If a Zika NAAT is positive on a single specimen, repeat NAAT on newly extracted RNA from the same specimen to rule out false positives.<= 12 weeks

CDC/Updated Testing Guidance (chunks 18-19)

Symptomatic pregnant women with sexual exposure to someone from a Zika-risk area: Collect specimens as soon as possible after symptom onset, up to 12 weeks post-onset; perform Zika NAAT only. If Zika NAAT is positive on a single specimen, repeat NAAT on newly extracted RNA from the same specimen to rule out false positives.<= 12 weeks

CDC guidance cited in reimbursement policy (chunks 18-19)

Serologic IgM testing has important limitations for diagnosing Zika infection and is not routinely recommended for screening asymptomatic pregnant women. IgM antibodies can persist for months after infection and frequently cross-react with other flaviviruses, making interpretation difficult; this can prevent determining whether infection occurred before or during the current pregnancy. Policy language therefore restricts routine use of IgM in asymptomatic pregnant populations and recommends selective use tied to clinical indications (for example, maternal serum IgM when a fetus has ultrasound findings consistent with congenital infection).

Asymptomatic individuals without symptoms suggestive of Zika infection — including asymptomatic pregnant women who only traveled to Zika-affected areas and asymptomatic returned travelers who are trying to conceive — are generally not candidates for routine Zika testing per referenced public health guidance. The policy aligns with PHE and related guidance that testing should be reserved for persons with symptoms or specific clinical indications rather than travel alone.

Within the excerpt provided there are no additional explicit exclusions beyond the stated not-covered items (preconception screening, non-pregnant late presenters, and tests/samples not listed). The policy enumerates tests and specimen types that do not meet coverage criteria but does not list further named exclusions in this section.

The policy explicitly states that preconception screening is not covered: Zika urine and serum NAAT testing and Zika serum IgM testing for preconception screening DOES NOT MEET COVERAGE CRITERIA. Similarly, in non-pregnant individuals presenting ≥ 14 days after symptom onset, urine and serum NAAT and serum IgM testing do not meet coverage criteria.

External advisory bodies, including CATMAT, advise against routine testing of asymptomatic pregnant women because of the low prevalence of infection and the poor positive predictive value of serologic screening; a positive serologic result in low-prevalence settings is likely to be a false positive and carry significant adverse consequences.

In the provided excerpt there is no explicit statement phrased as 'not medically necessary' beyond the enumerated items that 'DOES NOT MEET COVERAGE CRITERIA.' The policy uses the formal language of coverage criteria and non-coverage rather than additional separate 'not medically necessary' declarations in this section.

Provider Actions, Billing & Documentation Requirements

Billing Rule

Billing codes for Zika testing

Use CPT codes 86794 (Zika virus IgM) and 87662 (Zika virus nucleic acid amplification/NAAT) on claims for Zika testing. Omitting these codes or using incorrect codes may result in claim denials.

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

Documentation Required

Claim documentation

When submitting claims for Zika testing, include supporting clinical documentation that demonstrates the indication for testing (e.g., pregnancy status, symptom onset date, travel or exposure history, fetal ultrasound findings, infant clinical findings, specimen source and collection timing). Failure to provide adequate documentation may lead to denials or requests for additional information.

Document specimen source (serum, urine, CSF, amniotic fluid, placental/fetal tissue) and timing relative to symptom onset or delivery.
Include maternal/infant clinical findings, pregnancy status, prenatal ultrasound results, and exposure/travel history.

Note

Government policy precedence

When government coverage policies (e.g., Medicare Local Coverage Determinations or National Coverage Determinations) conflict with this payer policy, the applicable government policy takes precedence. Verify and follow the most current Medicare or state Medicaid coverage rules for members subject to those programs.

LCDs and NCDs override payer policy when applicable.
Check CMS and state Medicaid websites for the latest determinations before finalizing coverage decisions.

Note

Testing sequence for symptomatic pregnant women

For symptomatic pregnant women with recent travel to or sexual contact linked to areas with Zika risk, prioritize molecular testing: perform dengue and Zika NAAT on a serum specimen and Zika NAAT on a urine specimen; perform dengue IgM testing (not Zika IgM). If Zika NAAT is positive on a single specimen, repeat the NAAT on newly extracted RNA from the same specimen to rule out false-positive results. If dengue NAAT or dengue IgM is positive, no further testing is indicated.

Collect specimens as soon as possible after symptom onset and up to 12 weeks post-onset.
Perform dengue and Zika NAAT on serum, Zika NAAT on urine, and dengue IgM testing.
Do NOT rely on Zika IgM for symptomatic pregnant women due to persistence and cross-reactivity.

Denial Risk

Repeat NAAT recommendation

If a Zika NAAT is positive on a single specimen, repeat the NAAT on newly extracted RNA from the same specimen to rule out false-positive NAAT results before reporting a confirmed positive.

Repeat NAAT on newly extracted RNA from the same specimen when an initial single-specimen NAAT is positive.

Definitions and Test Methodology

inv-27: NAAT — Nucleic acid amplification testing and specimen types

DefinitionNAAT (nucleic acid amplification testing) detects Zika virus RNA using methods such as rRT-PCR; used on serum, urine, whole blood, CSF, amniotic fluid, and tissues.

Primary clinical roleFirst-line test for symptomatic individuals early after symptom onset and for asymptomatic pregnant women with relevant travel/exposure (per CDC).

Specimen typesSerum and urine commonly used; whole blood, CSF, amniotic fluid, placental and fetal tissues also cited depending on clinical context.

inv-28: PRNT — Plaque reduction neutralization test definition and role

DefinitionPRNT (plaque reduction neutralization test) measures virus-specific neutralizing antibodies to Zika and other flaviviruses to help confirm serologic results.

Role in testing algorithmUsed to confirm presumptive positive, equivocal, or inconclusive IgM antibody results from MAC-ELISA due to cross-reactivity with other flaviviruses.

Laboratory requirementPRNT must be performed by the CDC or a laboratory qualified by the CDC.

inv-29: RNA NAT/RT-PCR — molecular test detecting Zika RNA and typical indications

DefinitionRNA NAT/RT-PCR: molecular testing that detects Zika virus RNA (e.g., rRT-PCR), definitive when positive.

IndicationsFor symptomatic individuals within the first two weeks after symptom onset and for asymptomatic pregnant women with travel to areas with active transmission; also indicated for pregnant women ≥2 weeks after exposure who are IgM positive.

InterpretationA positive RNA NAT confirms infection; a negative RNA NAT does not exclude infection and should be followed by IgM testing when appropriate.

inv-30: Zika MAC-ELISA and PRNT — IgM testing characteristics and need for PRNT confirmation

Test descriptionZika MAC-ELISA (IgM capture ELISA) detects Zika IgM antibodies in serum or CSF but is subject to cross-reactivity and nonspecific reactivity.

Timing and persistenceIgM typically becomes positive near day 4 post-onset and can remain detectable for up to ~12 weeks; timing affects interpretation.

Need for confirmationPositive, equivocal, or inconclusive IgM results must be confirmed by PRNT to distinguish Zika from other flavivirus infections.

inv-31: CPT/HCPCS code 86794 — Zika virus, IgM

Code86794

DescriptionZika virus, IgM

Usage noteInclude on claims when billing for Zika IgM serologic testing per policy coding guidance.

inv-32: CPT/HCPCS code 87662 — Zika virus RNA NAT (amplified probe technique)

Code87662

DescriptionInfectious agent detection by nucleic acid (DNA or RNA); Zika virus, amplified probe technique

Usage noteInclude on claims when billing for Zika RNA NAT testing per policy coding guidance.

OpenPayer

Zika virus risk assessment and testing

Coverage Criteria for Zika Virus Testing

Applicable Procedure and Billing Codes

Provider Actions, Billing & Documentation Requirements

Definitions and Test Methodology

Background on Zika Virus

Revision History

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