CurrentCentenePolicy N/A

CONCERT INFECTIOUS DISEASE: GENITOURINARY TESTING

Outpatient clinical policy that defines medical necessity criteria for targeted vaginitis/vaginosis pathogen testing, expanded multiplex vaginitis/vaginosis panels, urine culture for asymptomatic bacteriuria, and molecular/multiplex UTI panels, with coding implications and referenced example tests/labs.

Policy Summary

PayerCentene

PolicyCONCERT INFECTIOUS DISEASE: GENITOURINARY TESTING

Policy CodePolicy N/A

Change TypeRevised coding and coverage language; added examples

Effective Date

Next Review Date

Key ActionProviders must document at least one qualifying symptom (abnormal discharge, vulvovaginal itching/irritation/redness, dyspareunia, dysuria, or postcoital/contact bleeding) to justify medical necessity for targeted vaginitis/vaginosis pathogen testing.

SourceLink

POLICY UPDATE CHANGES

Changed policy statements from 'may be considered medically necessary' to 'are considered medically necessary' for Targeted Vaginitis/Vaginosis Pathogen Testing and for other sections.

Corrected CPT descriptions and removed several codes (87510, 87480, 87660, 0371U, 0372U, 0374U) in March 2024 revision and later restored/updated coding table.

Added Urinary Tract Infection Testing (NxGen MDx, LLC) to Policy Reference Table for Urine Culture for Asymptomatic Bacteriuria.

4Primary covered sections (Targeted vaginitis, Expanded multiplex, Urine culture ASB, Molecular UTI panels)

6Symptomatic criteria listed for targeted vaginitis

Coverage Summary

This outpatient policy defines medical necessity for targeted vaginitis/vaginosis pathogen testing and related genitourinary diagnostic testing. Targeted testing (direct probe, nucleic acid/PCR, or a multipathogen panel of six targets or fewer, with or without chlamydia and/or gonorrhea) is considered medically necessary for symptomatic members who have at least one qualifying symptom (abnormal vaginal discharge; vulvovaginal itching, irritation, or redness; dyspareunia; dysuria; or postcoital/contact bleeding). Expanded multiplex vaginitis/vaginosis panels with more than six targets are considered investigational. Urine culture for asymptomatic bacteriuria is medically necessary when the member is pregnant or will undergo an endoscopic urologic procedure with mucosal trauma; urine culture for other asymptomatic indications is investigational. Molecular/multiplex UTI panels are considered investigational for all indications.

Key policy statistics

Primary covered sections4

Symptomatic criteria count6

Maximum targets for targeted panels6

CPT/PLA codes referenced120+

Change in medical necessity wordingRevised to 'are considered medically necessary'

Medical Necessity Criteria

Coding (Referenced CPT / PLA Codes)

Referenced CPT / PLA Codesmixed

0321U	Infectious agent detection by nucleic acid (DNA or RNA), genitourinary pathogens, identification of 20 bacterial and fungal organisms and identification of 16 associated antibiotic-resistance genes, multiplex amplified probe technique
0330U	Infectious agent detection by nucleic acid (DNA or RNA); vaginal pathogen panel, identification of 27 organisms, amplified probe technique, vaginal swab
0371U	Infectious agent detection by nucleic acid (DNA or RNA), genitourinary pathogen, semiquantitative identification, DNA from 16 bacterial organisms and 1 fungal organism, multiplex amplified probe technique via qPCR, urine
0372U	Infectious disease (genitourinary pathogens), antibiotic-resistance gene detection, multiplex amplified probe technique, urine, reported as an antimicrobial stewardship risk score
0374U	Infectious agent detection by nucleic acid (DNA or RNA), genitourinary pathogens, identification of 21 bacterial and fungal organisms and identification of 21 associated antibiotic-resistance genes, multiplex amplified probe technique, urine
0504U	Infectious disease (urinary tract infection), identification of 17 pathologic organisms, urine, real-time PCR, reported as positive or negative for each organism
81513	Infectious disease, bacterial vaginosis, quantitative real-time amplification of RNA markers for Atopobium vaginae, Gardnerella vaginalis, and Lactobacillus species, vaginal-fluid specimens
81514	Infectious disease, bacterial vaginosis and vaginitis, quantitative real-time amplification of DNA markers... includes separate detection of Trichomonas vaginalis and/or Candida species
81515	Infectious disease, bacterial vaginosis and vaginitis, real-time PCR amplification... includes separate detection of Trichomonas vaginalis and Candida species; may report Candida glabrata/krusei
87086	Culture, bacterial; quantitative colony count, urine

1–10 of 60

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Provider Actions & Billing Impact

Documentation Required

Document symptomatic indication for targeted vaginitis testing

Providers must document at least one qualifying symptom (abnormal vaginal discharge, vulvovaginal itching/irritation/redness, dyspareunia, dysuria, or postcoital/contact bleeding) to justify medical necessity for targeted vaginitis/vaginosis pathogen testing.

Abnormal vaginal discharge
Vulvovaginal itching, irritation, or redness (e.g., pruritus, erythema, edema)
Painful sexual intercourse (dyspareunia)
Painful urination (dysuria)
Postcoital or contact bleeding

Documentation Required

Document pregnancy status or planned endoscopic urologic procedure for urine culture in asymptomatic patients

Background & Evidence

This policy aligns with recommendations from UpToDate, ACOG, USPSTF, and IDSA. It emphasizes targeted testing of symptomatic vaginitis (testing for BV, Candida species, and Trichomonas when symptomatic) and recognizes NAATs/NAATs as an appropriate diagnostic tool with sensitivity similar to or better than microscopy/culture. The USPSTF recommends against BV screening in pregnant individuals not at increased risk for preterm delivery and finds insufficient evidence for screening those at increased risk. The IDSA supports screening for asymptomatic bacteriuria in pregnant patients and in individuals undergoing endoscopic urologic procedures associated with mucosal trauma. The policy notes lack of professional guideline support for expanded multiplex vaginitis panels and for molecular/multiplex UTI panels and limits their use accordingly.

Label	Value
USPSTF 2020	Recommends against screening for bacterial vaginosis in pregnant patients who are not at increased risk for preterm labor; insufficient evidence for those at increased risk
IDSA 2019	Recommends screening for asymptomatic bacteriuria in pregnant individuals and in those undergoing endoscopic urologic procedures with mucosal trauma
UpToDate / ACOG	Support use of NAAT/NAATs for symptomatic vaginitis (including trichomoniasis); NAATs have similar or better sensitivity/specificity versus microscopy/culture; ACOG notes symptomatic findings (discharge, pruritus, dysuria, dyspareunia, postcoital bleeding)

Endoscopic urologic procedure with mucosal trauma: Examples include, but are not limited to, transurethral surgery of the prostate or bladder, ureteroscopy including lithotripsy, and percutaneous stone surgery.

Targeted multipathogen panel: A multipathogen panel of six targets or fewer (with or without chlamydia and/or gonorrhea) used for vaginitis/vaginosis pathogen testing.

Revision History

03/24coding_revision

Administrative/coding corrections: corrected CPT descriptions and removed several codes (87510, 87480, 87660, 0371U, 0372U, 0374U, 0416U).

11/24policy_revision

Annual review with minor rewording without clinical significance; added Urinary Tract Infection Testing (NxGen MDx, LLC) to Policy Reference Table; changed policy statements from 'may be considered medically necessary' to 'are considered medically necessary' for Targeted Vaginitis/Vaginosis Pathogen Testing and related sections; added multiple CPT/PLA codes to the coding table.

02/25administrative_updateLatest