CurrentBlue KCPolicy POL-PP-312

Testing for Diagnosis of Active or Latent Tuberculosis

Defines reimbursement and coverage criteria for laboratory testing used to diagnose active tuberculosis (TB) and latent TB infection (LTBI) for Blue KC members and providers.

Policy Summary

PayerBlue KC

PolicyTesting for Diagnosis of Active or Latent Tuberculosis

Policy CodePolicy POL-PP-312

Change TypeNo material change

Effective DateOct 1, 2025

Next Review DateOct 1, 2026

Key ActionVerify member benefits and submit clinical justification when requesting IGRA, NAAT, culture, smear, or susceptibility testing to support reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

IGRA reimbursed for LTBIIGRA for LTBI

Not reimbursedIGRA in active TB

NAAT/Culture coveredStandard diagnostic tests

Not coveredAdvanced molecular/biomarkers

Professional & facilityProviders impacted

Policy Summary

PayerBlue KC

PolicyTesting for Diagnosis of Active or Latent Tuberculosis

Policy CodePolicy POL-PP-312

Change TypeNo material change

Effective DateOct 1, 2025

Next Review DateOct 1, 2026

Key ActionVerify member benefits and submit clinical justification when requesting IGRA, NAAT, culture, smear, or susceptibility testing to support reimbursement.

SourceLink

On This Page

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.

IGRA for latent TB

Covered when ANY of the following are met:

Individuals who are at risk for infection with Mycobacterium tuberculosis (Mtb).

Individuals who are unlikely to be infected with Mtb when screening is obliged by law.

Reimbursable tests for suspected TB infection

For all suspected TB infections, the following are reimbursable:

Acid fast bacilli (AFB) smear/stain.

Culture and culture-based drug susceptibility testing of Mycobacteria.

Qualitative nucleic acid amplification testing (NAAT) for Mycobacteria spp, M. tuberculosis and M. avium complex.

Molecular-based drug susceptibility testing

Molecular-based drug susceptibility testing may be reimbursed when ANY of the following are met:

The individual has been treated for TB in the past.

The individual was born in or has lived for at least 1 year in a foreign country with at least a moderate TB incidence (≥ 20 per 100,000) or a high primary multi-drug resistant (MDR)-TB prevalence (≥ 2%).

The individual is a contact of an individual with MDR-TB.

The individual is HIV infected.

Repeat drug susceptibility testing

Repeat drug susceptibility testing may be reimbursed when ANY of the following occur:

For individuals whose sputum cultures remain positive after 3 months of treatment.

When there is bacteriological reversion from negative to positive.

Extrapulmonary fluid testing

Fluid testing coverage for suspected extrapulmonary TB:

For individuals with pleural effusion, pericardial effusion, or ascites and suspected TB infection, cell counts, protein, glucose, and lactate dehydrogenase (LDH) concentrations of cerebrospinal, pleural, peritoneal, pericardial, and other fluids may be reimbursed.

Tests not meeting coverage

The following tests do not meet coverage criteria due to insufficient evidence:

Quantitative nucleic acid testing for Mycobacterium spp, M. tuberculosis, and M. avium complex may not be reimbursed.

Whole genome sequencing of Mycobacterium spp. for the detection of drug resistance may not be reimbursed.

Genotyping of Mycobacterium spp. may not be reimbursed.

Testing of adenosine deaminase (ADA) and interferon-gamma (IFN-γ) levels in cerebrospinal, pleural, peritoneal, pericardial, and other fluids for the diagnosis of extrapulmonary TB may not be reimbursed.

Testing of serum protein biomarkers or panels of biomarkers for the detection and diagnosis of TB may not be reimbursed.

Urine LAM testing in HIV

Covered when ALL of the following are met:

Individual is HIV-infected with CD4 cell count ≤ 100 cells/µL.

Individual has signs and symptoms of tuberculosis.

Urine-based detection of mycobacterial lipoarabinomannan (LAM) is intended to aid diagnosis in this clinical context.

Coding and Billing

Covered laboratory and pathology CPT/HCPCS codes (partial list)CPTCovered

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 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

1–10 of 14

1/2

Microbiology, smear, NAAT and susceptibility CPT codesCPTCovered

87150	Culture, typing; identification by nucleic acid probe
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, per enzyme
87186	Susceptibility studies; microdilution or agar dilution (MIC), each multi-antimicrobial, per plate
87187	Susceptibility studies; microdilution or agar dilution, MLC, each plate
87188	Susceptibility studies; macrobroth dilution method, each agent
87190	Susceptibility studies; mycobacteria, proportion method, each agent
87206	Smear, primary source with interpretation; fluorescent and/or acid fast stain

1–10 of 17

1/2

Proprietary/other molecular testHCPCS

0574U

Mycobacterium tuberculosis, culture filtrate protein - 10 - kDa (CFP-10), serum or plasma, LC-MSD (NanoDetect - TB)

Foreign country residence threshold

ThresholdLived ≥ 1 year in a foreign country with TB incidence ≥ 20 per 100,000 or primary MDR-TB prevalence ≥ 2%

ContextCriterion used to qualify for molecular-based drug susceptibility testing when sputum is AFB smear or NAAT positive

Duration specifiedAt least 1 year residence

HIV CD4 threshold for urine LAM

ThresholdHIV-infected individuals with CD4 ≤ 100 cells/µL

Test coveredUrine-based detection of lipoarabinomannan (LAM)

Clinical requirementSigns and symptoms of tuberculosis must be present

Persistent positive culture timeframe

TimeframeSputum cultures remain positive after 3 months of treatment

Action triggeredRepeat drug susceptibility testing may be reimbursed

Alternate triggerBacteriological reversion from negative to positive also qualifies for repeat DST

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization and Benefit Verification

Verify member benefits and prior authorization requirements before ordering tests. Standard laboratory tests described in this policy may be reimbursed when coverage criteria are met; prior authorization may be required depending on the member's plan.

Check eligibility and benefit coverage at time of request
Obtain prior authorization if required by the member's benefit plan

Step Therapy

No step therapy requirements are specified for TB diagnostic testing in this policy.

Documentation Required

Documentation Required for LTBI Screening or Suspected TB

Document clinical rationale: provide documentation of the individual's risk status for latent TB infection (LTBI) when requesting IGRA screening, or clinical evidence supporting suspected active TB when ordering diagnostic tests.

Risk factors (e.g., recent contact with TB case, birth or prolonged residence in high-incidence country, HIV infection, immunosuppression)
Clinical signs/symptoms or reason for suspected TB (e.g., prolonged cough, weight loss, night sweats, abnormal imaging)

Denial Risk

Denial Risk — Tests Not Covered

Claims for the following tests may be denied because they do not meet coverage criteria per this policy.

Quantitative NAAT for Mycobacterium spp, M. tuberculosis, and M. avium complex
Whole genome sequencing (WGS) of Mycobacterium spp. for detection of drug resistance
Genotyping of Mycobacterium spp.
Adenosine deaminase (ADA) and interferon-gamma (IFN-γ) testing in body fluids for extrapulmonary TB diagnosis
Serum protein biomarker panels for TB detection/diagnosis

Background

Infection with Mycobacterium tuberculosis exists on a spectrum from asymptomatic latent infection to active pulmonary or extrapulmonary disease. While culture remains the diagnostic gold standard and provides isolates for susceptibility testing, a range of laboratory methods are used in practice. Qualitative NAATs, acid-fast bacilli smear and stain, culture, and culture-based drug susceptibility testing are reimbursable when indicated; however, certain advanced molecular assays and fluid biomarker tests lack sufficient evidence and are excluded from reimbursement. Interferon-gamma release assays (IGRAs) are used to detect latent TB infection but are explicitly not reimbursed for diagnosing active tuberculosis.

Definitions

IGRA definition

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

PurposeUsed to diagnose or screen for latent TB infection (LTBI)

NoteNot intended for diagnosis of active tuberculosis (policy excludes IGRA reimbursement for active TB)

NAAT definition

DefinitionNucleic acid amplification test (NAAT): PCR-based methods for sensitive detection and identification of Mycobacterium species, including M. tuberculosis

Use caseQualitative NAAT for Mycobacteria spp., M. tuberculosis, and M. avium complex may be reimbursed for suspected TB infections

LimitationQuantitative NAAT is listed as not meeting coverage criteria

OpenPayer

Testing for Diagnosis of Active or Latent Tuberculosis

Coverage Criteria for TB Testing

Coding and Billing

Provider Actions and Prior Authorization

Background

Definitions

Revision History