Blue KC STI Diagnostic Testing Coverage Update

Coverage Criteria for STI Diagnostic Testing

Syphilis antibody testing - covered indications

Covered when any of the following are met

Syphilis antibody testing indications: For any asymptomatic person in a high-risk category: once-a-year assessment using either a standard or reverse algorithm that includes initial and confirmatory testing (treponemal and nontreponemal tests, e.g., treponemal Ig and nontreponemal Ig).

See Notes 1 & 2 for definitions of high-risk.

Symptomatic individuals: Diagnosis of any person presenting with signs and/or symptoms of syphilis infection.

See Note 3 for signs/symptoms.

Increased-frequency screening for MSM/HIV+ men: Once every three months for HIV-positive men or men who have sex with men (MSM).

Pre-transplant assessment: Treponemal and nontreponemal testing (once prior to transplant) as part of pre-transplant assessment in both donors and recipients of allogeneic hematopoietic stem cell transplantation (allo-HCT).

Test of cure: When a nontreponemal test is used as a test of cure (TOC) for a previously positive syphilis infection.

Asymptomatic, non-high-risk exceptions: For asymptomatic individuals NOT in a high-risk category, antibody screening may be reimbursed only as part of newborn screening, follow-up in a victim of sexual assault, or annually for sexually active individuals under age 18.

Syphilis molecular testing - not covered

Not covered

Syphilis PCR/NAAT: Polymerase chain reaction (PCR) testing and nucleic acid amplification testing (NAAT) for syphilis may not be reimbursed.

Chlamydia NAAT - covered indications

Covered when any of the following are met

Chlamydia NAAT indications: Once-a-year assessment for any asymptomatic person in a high-risk category. Diagnosis of any person presenting with signs or symptoms of chlamydial infection. Diagnosis of suspected lymphogranuloma venereum (LGV). At least three months after initial chlamydial diagnosis when used as a test of cure (TOC).

For asymptomatic individuals not in a high-risk category, screening reimbursable only for newborn screening, sexual assault follow-up, or sexually active individuals <18 years annually.

Chlamydia serology - not covered

Not covered

Chlamydia serology: Serology testing for Chlamydia trachomatis or lymphogranuloma venereum (LGV) may not be reimbursed.

Gonorrhea NAAT and culture

Covered when any of the following are met

Gonorrhea NAAT indications: Once-a-year assessment for any asymptomatic person in a high-risk category. Diagnosis of any person presenting with signs or symptoms of gonorrheal infection. Use as a test of cure (TOC) following treatment. For individuals not responding to initial treatment, culture for Neisseria gonorrhoeae to determine antimicrobial susceptibility may be reimbursed.

For asymptomatic non-high-risk individuals, NAAT screening reimbursable only for newborn screening, sexual assault follow-up, or sexually active individuals <18 years annually.

Trichomonas testing

Covered when any of the following are met

Trichomonas NAAT indications: Symptomatic individuals. Follow-up testing a minimum of three months after initial trichomoniasis diagnosis. Annual screening for symptomatic individuals in high-risk groups. Annual screening for asymptomatic individuals with HIV. As part of follow-up in a victim of sexual assault.

Rapid enzyme immunoassay identification for Trichomonas may not be reimbursed.

Mycoplasma genitalium testing

Covered when condition met

M. genitalium NAAT indications: Qualitative NAAT testing for Mycoplasma genitalium may be reimbursed for symptomatic individuals. Screening asymptomatic individuals for M. genitalium using NAAT may not be reimbursed.

See Note 9 for signs and symptoms that support testing (eg, dysuria, urethral pruritus, purulent or mucopurulent discharge in men; vaginal discharge, itching, dysuria, pelvic discomfort in women).

HSV testing

Covered when condition met

HSV NAAT and serology: Qualitative NAAT for HSV-1 or HSV-2 may be covered for individuals with active genital ulcers or mucocutaneous lesions. Type-specific serologic testing for HSV-2 (glycoprotein G2) may be reimbursed for recurrent/atypical genital symptoms with negative PCR/culture, for clinical diagnosis when PCR/culture are negative or absent, or when an individual's partner has genital herpes. Immunoassay testing for HSV-1 or non-type-specific herpes serology for asymptomatic screening may not be reimbursed.

HPV testing - coverage stance

Covered when specific indications met

HPV testing indications: NAAT testing for high-risk HPV may be reimbursed in the diagnosis and/or assessment of cancer or cancer therapy (for example, p16 immunohistochemistry or HR-HPV testing).

HPV testing is not reimbursed as part of general STI screening panels for asymptomatic individuals, for anogenital wart diagnosis, or for low-risk HPV types.

PrEP-related STI screening

Covered when following schedule applied

PrEP initiation/monitoring testing: Prior to starting PrEP: hepatitis B screening panel (HBsAg, anti-HBs, anti-HBc) may be reimbursed. For PrEP monitoring: qualitative NAAT screening for gonorrhea and chlamydia once every 3 months for MSM and individuals with child-bearing potential, once every 6 months for sexually active individuals; blood testing for syphilis once every 3 months for MSM and once every 6 months for sexually active individuals.

Multitarget PCR panels

Covered when condition met

Multitarget PCR (limited targets): When an individual meets covered conditions for testing (eg, symptomatic or meeting screening criteria), multitarget PCR panels limited to Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and Mycoplasma genitalium may be reimbursed.

Recognized diagnostic tests - covered diagnostic tests and proprietary assays listed

Covered diagnostic tests and proprietary assays listed

Listed tests: Recognized CPT/HCPCS and proprietary test codes are enumerated for STI diagnostics, including NAATs for CT, NG, TV, MG and molecular resistance tests (eg, 0402U, 0455U multiplex assays; 0483U gyrA S91F ciprofloxacin resistance for N. gonorrhoeae; 0484U 23S rRNA macrolide resistance for M. genitalium). Coverage applies to these listed codes when clinical indications in the policy are met.

Check payer-specific prior authorization or benefit coverage rules for proprietary assay codes.

The policy states that direct probe detection and/or quantitative NAAT for several organisms may not be reimbursed due to insufficient evidence. Specifically, direct probe detection and/or quantitative NAAT for Chlamydia trachomatis, Neisseria gonorrhoeae, Herpes simplex virus‑1, Herpes simplex virus‑2, Human papillomavirus, and Treponema pallidum are listed as not meeting coverage criteria. This limitation applies even where NAAT methods are discussed elsewhere for specific clinical indications; providers should confirm that the requested NAAT method and code align with the policy’s recognized covered NAAT indications and codes before submitting claims.

Within the cited material there are no additional explicit exclusions beyond those enumerated in the policy text. Providers should rely on the listed non‑coverage items (e.g., specific direct probe/quantitative NAAT exclusions) and the coverage criteria for individual tests; operational exceptions or payer‑specific rules should be checked with the benefit administrator.

The policy specifies that immunoassay testing for HSV-1 and non‑type‑specific herpes serology is generally not reimbursed, and that type‑specific HSV-2 serology (gG2) may be reimbursed only for defined clinical situations (recurrent/atypical symptoms with negative PCR/culture, clinical diagnosis when PCR/culture are negative or absent, or when a partner has genital herpes). For HPV, NAAT testing for high‑risk types is reimbursable when used in the diagnosis or assessment of cancer or cancer therapy (for example, p16 immunohistochemistry or HR‑HPV testing), but HPV testing is not reimbursed as part of general STI screening panels for asymptomatic individuals or for low‑risk/type testing or anogenital wart diagnosis.

The reviewed chunks do not list any additional conditions explicitly labeled as not medically necessary beyond the immunoassay and panel exclusions described elsewhere. Where 'not reimbursed' or 'does not meet coverage criteria' is used in the policy, treat those as the operational non‑coverage positions; if clarification is needed for a specific clinical scenario, contact the payer or review benefit plan language.

Coding and Frequency Guidance

Enumerated laboratory CPT codesCPT

86704	Hepatitis B core antibody (HBcAb); total
86706	Hepatitis B surface antibody (HBsAb)
86780	Antibody; Treponema pallidum
87081	Culture, presumptive, pathogenic organisms, screening only
87110	Culture, Chlamydia, any source
87181	Susceptibility studies, antimicrobial agent; agar dilution method, per agent
87340	Infectious agent antigen detection by immunoassay technique; hepatitis B surface antigen (HBsAg)
87490	Infectious agent detection by nucleic acid; Chlamydia trachomatis, direct probe technique
87491	Infectious agent detection by nucleic acid; Chlamydia trachomatis, amplified probe technique
87492	Infectious agent detection by nucleic acid; Chlamydia trachomatis, quantification

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Recognized CPT/HCPCS/proprietary test codesmixed

86704	Hepatitis B core antibody (HBcAb); total
86706	Hepatitis B surface antibody (HBsAb)
86780	Antibody; Treponema pallidum
87081	Culture, presumptive, pathogenic organisms, screening only
87110	Culture, Chlamydia, any source
87181	Susceptibility studies, antimicrobial agent; agar dilution method, per agent
87340	Infectious agent antigen detection by immunoassay; hepatitis B surface antigen (HBsAg)
87490	Infectious agent detection by nucleic acid; Chlamydia trachomatis, direct probe
87491	Chlamydia trachomatis, amplified probe technique
87492	Chlamydia trachomatis, quantification

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Screening frequency examples

Syphilis screening frequencyOnce yearly for any asymptomatic person in a high‑risk category; once every 3 months for HIV‑positive men or men who have sex with men (MSM).

Syphilis testing when symptomaticAt presentation for any person with signs or symptoms of syphilis (diagnostic testing).

Syphilis pre‑transplantTreponemal and nontreponemal testing once prior to allogeneic HCT for donors and recipients as part of pre‑transplant assessment.

Syphilis test of cure (TOC)Nontreponemal testing may be used as a test of cure following treatment.

Resistance mutation

N. gonorrhoeae resistance marker

Provider Actions, Documentation, and Authorization

Prior Authorization

Prior Authorization May Apply for Proprietary/Multiplex STI Assays

Prior authorization may be required for certain proprietary or multiplex STI assay codes. Coverage is determined by the member's benefit at the time of request; confirm prior authorization requirements with the payer before ordering proprietary multiplex panels (examples include Abbott Alinity m STI Assay and other listed proprietary tests).

Examples of proprietary/multiplex assays that may require prior authorization: 0402U (Bio-Rad multiplex: C. trachomatis, N. gonorrhoeae, T. vaginalis, M. genitalium), 0455U and Abbott Alinity m STI Assay, other proprietary codes listed (e.g., 0463U, 0483U, 0484U).
Verify member benefit and obtain prior authorization when required before sending proprietary/multiplex STI panels.

Billing Rule

Nonreimbursable Molecular Tests

Background

Sexually transmitted infections (STIs) are caused by bacteria, viruses, and other organisms transmitted through sexual contact and can lead to significant sequelae. Examples and potential complications highlighted in the policy include pelvic inflammatory disease and infertility (commonly associated with chlamydia and gonorrhea), neurologic and cardiac disease related to syphilis, and oncogenic risk from certain high‑risk human papillomavirus (HPV) types. Risk factors referenced include multiple sexual partners, men who have sex with men (MSM), prior STI history, incarceration, and socioeconomic factors; these risk designations are used in the policy to define screening frequency and covered testing indications.

Definitions

STI — definition and examples

DefinitionSexually transmitted infections (STIs) are infections caused by bacteria, viruses, or other microorganisms transmitted through sexual contact. Examples include Chlamydia trachomatis, Neisseria gonorrhoeae, Treponema pallidum (syphilis), Trichomonas vaginalis, Mycoplasma genitalium, HPV, and HSV.

Clinical impactUntreated STIs can cause pelvic inflammatory disease, infertility, pregnancy complications, neurologic and cardiac disease (syphilis), and cancers (HPV).

Risk factorsMultiple sex partners, MSM, prior STI, correctional facility admission, and lower socioeconomic status increase risk.

NAAT — nucleic acid amplification test

NAAT definitionNucleic acid amplification test (NAAT): a molecular test detecting DNA or RNA of infectious agents (eg, amplified probe techniques for C. trachomatis, N. gonorrhoeae, T. vaginalis, M. genitalium).

OpenPayer

Diagnostic Testing of Common Sexually Transmitted Infections

Coverage Criteria for STI Diagnostic Testing

Coding and Frequency Guidance

Provider Actions, Documentation, and Authorization

Background

Definitions