CurrentBlue Cross Blue Shield - TexasPolicy CPCPLABO27

Testing for Diagnosis of Active or Latent Tuberculosis

Defines lab reimbursement criteria for tests used to diagnose or screen for latent and active tuberculosis for Blue Cross and Blue Shield of Texas products; applicability may vary by product and is subject to plan documents and provider contracts.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyTesting for Diagnosis of Active or Latent Tuberculosis

Policy CodePolicy CPCPLABO27

Change TypeCode list updateliterature review (no change to reimbursement stance)

Effective DateMay 15, 2025

Next Review Date

Key ActionProviders must submit accurate documentation and use valid HIPAA-approved code sets; review plan documents for product-specific reimbursement requirements.

SourceLink

POLICY UPDATE CHANGES

Added code 87564 to the procedure codes list.

Document updated with literature review; reimbursement information unchanged.

1.0policy version

1 addedcode list update

2025-02-05approval date

Coverage and Reimbursement Criteria

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 when the following requirements and exclusions are applied as specified below.

ALL of the following

IGRA for latent TB
- IGRA may be reimbursable to diagnose or screen for latent tuberculosis (TB) infection; applicability is subject to product-specific plan documents.
IGRA exclusion
- IGRA is not reimbursable for individuals with active tuberculosis.
Culture and related testing
- Culture and culture-based drug susceptibility testing of Mycobacteria species may be reimbursable for suspected TB infections.
- Acid-fast bacilli (AFB) smear/stain may be reimbursable.
- Direct probe or amplified nucleic acid–based testing, including PCR, may be reimbursable for M. tuberculosis, Mycobacteria species, and M. avium intracellulare.
Molecular-based susceptibility testing (AFB smear or MTD positive sputum)
- Molecular-based susceptibility testing may be reimbursable for individuals whose sputum is AFB smear positive or Hologic Amplified MTD positive when ONE of the following epidemiologic or clinical criteria is met:
- ANY of the following
  - The individual was born in or has lived for at least 1 year in a foreign country with at least a moderate TB incidence (≥220 per 100,000) or a high primary MDR-TB prevalence (≥22%).
  - The individual has been treated for TB in the past.
  - The individual is a contact of an individual with MDR-TB.
  - The individual is HIV infected.
Repeat susceptibility testing
- Repeat susceptibility testing may be reimbursable for individuals whose sputum cultures remain positive after 3 months of treatment.
- Repeat susceptibility testing may be reimbursable when there is bacteriological reversion from negative to positive.
Extrapulmonary fluid testing
- For suspected extrapulmonary TB with pleural effusion, pericardial effusion, or ascites, testing of cell counts, protein, glucose, and lactate dehydrogenase (LDH) concentrations of cerebrospinal, pleural, peritoneal, pericardial, and other relevant fluids may be reimbursable.
Urine LAM in advanced HIV
- Urine-based detection of lipoarabinomannan (LAM) may be reimbursable in HIV-infected individuals with CD4 cell counts <100 cells/µL who have signs and symptoms of tuberculosis.
Not reimbursable – simultaneous/quantitative tests
- Simultaneous ordering of combination of direct probe, amplified probe, and/or quantification for the same organism in a single encounter is not reimbursable.
- Quantitative nucleic acid testing for Mycobacterium species, M. tuberculosis, and M. avium intracellulare is not reimbursable.
Not reimbursable – fluid biomarkers and serum panels
- Testing of adenosine deaminase (ADA) and interferon-gamma levels in cerebrospinal, pleural, peritoneal, pericardial, and other fluids for diagnosis of extrapulmonary TB is not reimbursable.
- Testing of serum protein biomarkers or panels of biomarkers for detection and diagnosis of TB is not reimbursable.

Procedure Codes and Coding Rules

Listed procedure codesCPT

87149
87150
87153
87181
87184
87185
87186
87187
87188
87190

1–10 of 21

1/3

AFB smear positive criteria for susceptibility testing

Reimbursable test typeMolecular-based susceptibility testing for AFB smear–positive or Hologic Amplified MTD–positive sputum

Prior TB treatmentReimbursable when the individual has been treated for TB in the past

Residence in high‑incidence areaReimbursable when the individual was born in or has lived ≥1 year in a country with ≥220 cases per 100,000 or high MDR‑TB prevalence (22%)

Known contact with MDR‑TBReimbursable when the individual is a contact of an individual with MDR‑TB

HIV infectionReimbursable when the individual is HIV infected

Documentation and Provider Requirements

Documentation Required

Provider documentation, coding, and product-specific reimbursement

Submit accurate documentation of services performed and code claims using valid HIPAA‑approved code sets; code according to industry standard coding guidelines. Review applicable plan documents because reimbursement requirements vary by product and, when plan documents conflict with this policy, the plan document will govern.

Providers are responsible for submission of accurate documentation of services performed.
Claims must use valid code combinations from HIPAA‑approved code sets and be coded per industry standards (eg, CPT, HCPCS, ICD‑10).
Not all requirements apply to every product — providers should review Plan documents for coverage and eligibility.
If a conflict exists, the plan document governs over this policy.

Definitions and Test Scope

Plan documents

Plan documents govern conflictsIf a conflict exists between this policy and a plan document, the plan document will govern (e.g., Certificates of Benefits, Summary Plan Descriptions)

Provider responsibilityProviders must submit accurate documentation of services performed and use valid HIPAA‑approved code sets when filing claims

Product variabilityNot all requirements apply to every product; providers should review applicable plan documents for coverage eligibility

IGRA

IGRA reimbursableIGRA (interferon gamma release assay) may be reimbursable to diagnose or screen for latent TB infection

IGRA not reimbursable for active TBIGRA is not reimbursable for individuals with active tuberculosis

Apply per productReimbursement for IGRA is applied per product; providers should consult plan documents