Cigna Nucleic Acid Pathogen Testing Coverage Update

Coverage Criteria

inv-01: Medically Necessary — Covered when ANY of the following are met (as described).

Covered when ANY of the following are met:

Asymptomatic high-risk or screening: Asymptomatic individual with any of: high-risk behavior (e.g., exposure to possible infected partner), high-risk condition (e.g., pregnancy, HIV infection), high-risk experience (e.g., assault), chlamydia screening in sexually active individuals, gonorrhea screening in sexually active individuals, or HPV cervical cancer screening.

Supports STD screening indications

Symptomatic consistent with suspected diagnosis: Symptomatic individual with signs/symptoms consistent with a suspected infectious diagnosis listed in the Coding Information section (see CPT/ICD-10 mappings for Candida, Chlamydia, Gardnerella, HSV, Gonorrhea, HPV, Trichomonas).

Provider should reference coding section for matching CPT/ICD-10

Panel testing medical necessity: Infectious pathogen detection by nucleic acid panel is considered medically necessary for: respiratory pathogens (subject to frequency limits), gastrointestinal pathogens (up to 11 targets), central nervous system pathogens (12–25 targets), and HSV/varicella‑zoster panels.respiratory: 1 per date of service; up to 12 tests per 12 rolling months (i.e., up to 11 targets)

Frequency limit applies to respiratory panels

inv-02: Not Covered or Reimbursable — 3 top-level nodes describing non-covered scenarios.

General not covered conditions: Nucleic acid pathogen testing (single or panel) performed in the outpatient setting when the above medical necessity criteria are not met is not covered or reimbursable.

Denial condition

Specific not covered outpatient indications: Outpatient nucleic acid pathogen testing for the diagnosis of: HPV low‑risk types (e.g., 6,11,42,43,44), syphilis, nail dystrophy, skin and/or nail fungal infections (e.g., tinea, onychomycosis), and urinary tract infections (pyelonephritis, cystitis, prostatitis) is not covered or reimbursable.

Listed as not covered for outpatient NAAT

Not covered quantification and resistance testing: Nucleic acid quantification to monitor disease progression or therapy outcomes for Gardnerella vaginalis, non‑invasive Candida, Neisseria gonorrhea, and HSV Types 1 & 2; and antibiotic resistance panel/genotyping via syndromic panels are not covered or reimbursable.

Quantification and resistance‑gene panels excluded

inv-03: Medically Necessary — Test with matching ICD-10: Covered when the test code is billed with one of the listed ICD-10 diagnosis/screening encounter codes and related clinical criteria.

Covered when the test code is billed with one of the listed ICD-10 diagnosis/screening encounter codes and related clinical criteria per Medical Coverage Policy: 0530

General requirement: Test is considered medically necessary when billed with an ICD‑10-CM diagnosis code listed in this policy (examples include screening encounters Z11.*, Z12.*, pregnancy and prenatal Z3A.*, exposures Z20.*, infectious disease codes such as A60.*, B20, N30.*) AND when the applicable clinical criteria in the policy are met.

See Coding Information sections for full ICD‑10 lists and matching CPT codes

inv-04: Medically Necessary — diagnosis-match requirement: Covered when criteria in the applicable policy statements listed above are met and the diagnosis is among the listed ICD-10 codes.

Covered when criteria in the applicable policy statements listed above are met and the diagnosis is among the listed ICD-10 codes

Diagnosis-match requirement: Test is considered medically necessary when the patient's documented diagnosis matches one of the ICD‑10 codes or ranges enumerated in the policy excerpts (see chunks 36–55) AND the applicable clinical criteria/policy statements are met.

Refer to listed ICD‑10 code ranges for permitted indications (CNS infections, pneumonia, conjunctivitis, keratitis, transplant infections, genital infections, urinary tract diagnoses, etc.).

inv-05: Medically Necessary — ICD-10 linked: Considered Medically Necessary when criteria in the applicable policy statements listed above are met.

Considered Medically Necessary when criteria in the applicable policy statements listed above are met

Medically necessary ICD-10 list: Testing is considered medically necessary when the submitted ICD‑10‑CM diagnosis code is among the 'Considered Medically Necessary' codes/ranges in the policy extract and the clinical criteria in the applicable policy statements are satisfied.

This extract contains partial code lists; consult the full policy for the complete ICD‑10 code set.

inv-06: Not Covered / Not Reimbursable — Lists codes and scenarios identified as not covered or not reimbursable.

Not Covered or Reimbursable

Not covered codes/tests: Services billed with ICD‑10‑CM diagnosis codes or CPT/HCPCS codes explicitly listed in the 'Not Covered or Reimbursable' sections are not payable under this policy (examples include CPT codes 87592, 87623 and unspecified molecular codes 87797–87799, and multiple ICD‑10 diagnosis ranges for dermatophyte and many urinary/bladder conditions).

Includes specific CPT codes and numerous ICD‑10 ranges shown in the Not Covered lists

inv-07: Medically Necessary Tests — Considered Medically Necessary when criteria in the applicable policy statements listed above are met.

Considered Medically Necessary when criteria in the applicable policy statements listed above are met:

General medical necessity and frequency: Tests (single‑pathogen NAATs and specified multiplex panels) are considered medically necessary when they meet the policy's clinical criteria and are within allowed frequency limits (not to exceed one test per date of service; up to 12 tests per 12 rolling months).1 per date of service; up to 12 per 12 rolling months

Applies to listed CPT/HCPCS and proprietary codes for respiratory, CNS, gastrointestinal, genitourinary, and vaginal pathogen NAATs.

inv-08: Not Medically Necessary / Not Covered Panels — Infectious Pathogen Detection by Nucleic Acid Panel Testing that does not meet the criteria in the above policy is Not Covered or Reimbursable.

Infectious Pathogen Detection by Nucleic Acid Panel Testing that does not meet the criteria in the above policy is Not Covered or Reimbursable:

Not covered panels: Listed high‑target‑count multiplex and NGS panel CPT/HCPCS/proprietary codes (examples: 87507, 87633, 0115U, 0152U, 0323U, 0480U, 0504U, 0531U, etc.) are not covered when they do not meet the policy clinical criteria.

Extensive enumerated list of panels considered not covered if criteria unmet.

inv-09: Coverage criteria / Not covered tests — Covered when testing meets policy clinical criteria; otherwise Not Covered or Not Reimbursable as listed below.

Covered when testing meets policy clinical criteria; otherwise Not Covered or Not Reimbursable as listed below.

Primary coverage rule: Tests must meet the clinical criteria (appropriate signs/symptoms or listed diagnoses and correct specimen site) and align with professional guidance (CDC/IDSA) to be covered; broad multiplex or mNGS panels that do not meet criteria are not covered.

See enumerated not‑covered CPT/HCPCS codes and clinical guidance notes.

Panel size guidance: Outpatient panels detecting up to 11 pathogens may be clinically useful for respiratory and gastrointestinal indications; panels up to 25 pathogens may be clinically useful for central nervous system testing.<=11 pathogens for GI/respiratory; <=25 for CNS

Clinical judgement and guideline alignment required.

mNGS stance: Metagenomic NGS (e.g., CSF or plasma mNGS) currently has insufficient established clinical utility for outpatient infectious pathogen identification; routine outpatient use is not supported.

inv-10: Metagenomic Next-Generation Sequencing (mNGS) — Policy stance on metagenomic NGS.

Policy stance on metagenomic NGS

mNGS coverage: Metagenomic next‑generation sequencing (mNGS) clinical utility to identify infectious pathogens in the outpatient setting has not been established; published professional society guidelines and randomized controlled trial evidence are lacking.

mNGS is listed as not covered for routine outpatient pathogen identification in this policy extract.

inv-11: Tinea (Dermatophyte) Testing — Policy stance on tinea/dermatophyte testing.

Policy stance on tinea/dermatophyte testing

Tinea testing coverage: Nucleic acid pathogen testing for tinea (dermatophyte skin/nail infections) is not established; guideline‑recommended diagnostics include fungal culture, calcofluor‑KOH preparation and histopathology.

IDSA guidance does not support NAAT for skin/subcutaneous dermatophyte infections.

inv-12: Urinary Tract Infection (UTI) Testing — Policy stance on urinary tract infection testing.

Policy stance on urinary tract infection testing

UTI testing coverage: Routine nucleic acid testing for urinary tract infections (cystitis, pyelonephritis, prostatitis, orchitis) is not supported by sufficient evidence; urinalysis and culture remain primary diagnostic tests. NAAT may be used selectively for specific viral agents (e.g., adenovirus) or for select circumstances per IDSA guidance.

For recurrent uncomplicated UTI in women, document prior positive urine cultures and obtain urinalysis and urine culture with sensitivity for each symptomatic episode prior to treatment.

inv-13: Antibiotic Resistance Genotyping — Policy stance on antibiotic resistance genotyping.

Policy stance on antibiotic resistance genotyping

Antibiotic resistance testing coverage: Antibiotic resistance genotyping via panel testing lacks proven clinical utility for routine outpatient use due to poor genotype–phenotype correlation, difficulty assigning resistance genes to specific pathogens in polymicrobial samples, and limited outcome data; therefore such testing is not supported absent established indications.

Policy notes limited guideline endorsement and scarce evidence of improved patient outcomes in outpatient settings.

Nucleic acid pathogen testing performed in the outpatient setting that does not meet the policy clinical criteria is Not Covered or Reimbursable. This includes metagenomic next-generation sequencing (mNGS) and use of broad antibiotic-resistance panel testing. Use of nonspecific "Not Otherwise Specified" molecular CPT codes 87797, 87798, and 87799 when a more specific CPT/HCPCS code exists is also designated Not Covered or Reimbursable. Providers should submit the most specific, applicable CPT/HCPCS code for the test ordered to avoid denial.

Claims billed with ICD-10-CM diagnosis codes that are not listed in the policy’s supported diagnosis lists are explicitly designated Not Covered or Reimbursable. The policy also identifies specific test codes that are not payable when submitted outside permitted indications; providers must ensure the submitted ICD-10 code matches one of the policy’s listed supporting diagnoses to be considered for coverage.

Quantitative testing for herpes simplex virus is excluded: CPT code 87530 (HSV quantification) is listed as Not Covered or Reimbursable in this policy excerpt. Nucleic acid quantification for monitoring disease progression or therapy outcomes is similarly not covered for specified pathogens.

The policy lists numerous ICD-10-CM diagnosis codes and ranges as examples of conditions that are designated Not Covered or Reimbursable for outpatient nucleic acid testing (e.g., dermatophytosis codes B35.0–B35.9, candidiasis of skin and nail B37.2, multiple urinary tract and cystitis codes N30.*, and related symptom codes such as R30.0 for dysuria). Refer to the Coding Information section for the full enumerated lists.

High-target-count multiplex assays and next‑generation sequencing panels that exceed the policy’s clinical thresholds or otherwise do not meet the stated criteria are explicitly listed as Not Covered or Reimbursable. Examples include large gastrointestinal and respiratory panels specified for 12–25 targets, CSF or plasma mNGS assays, and multi-organism panels with extensive pathogen and resistance‑gene content.

The policy enumerates many specific multiplex nucleic acid panel tests and proprietary or Category III codes that are not covered when policy criteria are unmet (for example, codes such as 0115U, 0152U, 0323U, 0480U, 0504U, 0528U, 0531U, 0556U, 0563U, 0564U). In addition, a broad set of tests that include multiple resistance‑gene targets (e.g., 0142U, 0321U, 0369U, 0370U, 0372U, 0373U, 0374U, 0600U) are listed as not covered or not reimbursable when the clinical criteria are not met.

Nucleic acid pathogen testing is not established or is specifically excluded for certain conditions in the outpatient setting. The policy identifies testing for tinea (dermatophyte) infections as not established and not supported by professional guidance for NAAT diagnosis; fungal culture, calcofluor‑KOH, and histopathology are the recommended methods. Routine molecular antibiotic resistance genotyping and broad NAAT applications intended to guide outpatient therapy are also not supported due to limited clinical utility and poor genotype–phenotype correlation.

Covered Indications and Clinical Context

Coding and Procedure Codes

Listed CPT/HCPCS codes (covered or referenced)mixed

81514	listed in document for Candida/Trichomoniasis etc.
87480	Infectious agent detection by nucleic acid (DNA or RNA); Candida species, direct probe technique
87481	Infectious agent detection by nucleic acid (DNA or RNA); Candida species, amplified probe technique
0352U	listed in document
81515	listed in document
0557U	listed in document
87490	Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique
87491	Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique
87492	Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, quantification
87510	listed in document

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ICD-10 codes referenced for medical necessityICD-10

A54.00-A54.9	Gonococcal infection
A55	Chlamydial lymphogranuloma (venereum)
A56.00-A56.8	Other sexually transmitted chlamydial diseases
B20	Human immunodeficiency virus [HIV] disease
B37.0-B37.9	Candidiasis codes (various sites)
N39.0	Urinary tract infection, site not specified
N76.0-N76.6	Vaginitis/vulvitis codes
Z11.4	Encounter for screening for HIV
Z20.6	Contact with and (suspected) exposure to HIV
Z21	Asymptomatic HIV infection status

Covered CPT/HCPCS Codes (select)CPTCovered

87494

Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis and Neisseria gonorrhoeae, multiplex amplified probe technique

Covered CPT/HCPCS Codes (vaginal infections)CPTCovered

81513	Infectious disease, bacterial vaginosis, quantitative real-time amplification of RNA markers for Atopobium vaginae, Gardnerella vaginalis, and Lactobacillus species
87510	Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, direct probe technique
87511	Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, amplified probe technique

Additional test codes mentionedCPTCovered

87512	Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, quantification
87528	Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, direct probe technique
87529	Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, amplified probe technique

Not Covered ICD-10-CM Codes (generic)ICD-10Not Covered

ICD-10-CM (all other codes)

All other ICD-10-CM codes not specifically listed are designated Not Covered or Reimbursable in sections

Covered molecular panel (example)HCPCSCovered

0527U

Herpes simplex virus (HSV) types 1 and 2 and Varicella zoster virus (VZV), amplified probe technique, each pathogen reported as detected or not detected

Not covered / reimbursableCPTNot Covered

87530

Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, quantification

Covered molecular tests (examples)CPTCovered

87590	Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, direct probe technique
87591	Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique

Covered HPV nucleic acid tests (when criteria met)CPTCovered

87624	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68)
87625	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed
87626	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), separately reported high-risk types and pooled results

Not Covered / Not Reimbursable procedure codesCPTNot Covered

87592	Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, quantification
87623	Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44)
87797	Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism
87798	Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism
87799	Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; quantification, each organism

Sample 'Considered Medically Necessary' ICD-10 codes and ranges (partial extract)ICD-10

J02.8	Acute pharyngitis due to other specified organisms
J02.9	Acute pharyngitis, unspecified
J31.2	Chronic pharyngitis
N39.0	Urinary tract infection, site not specified
N30.00-N30.21	Cystitis ranges listed
Z11.4	Encounter for screening for human immunodeficiency virus [HIV]
Z12.4	Encounter for screening for malignant neoplasm of cervix
Z21	Asymptomatic human immunodeficiency virus [HIV] infection status
B20	Human immunodeficiency virus [HIV] disease
C53.0-C53.9	Malignant neoplasm of cervix

Sample 'Not Covered or Reimbursable' ICD-10 codes (partial extract)ICD-10Not Covered

B35.0-B35.9	Dermatophytosis
B37.2	Candidiasis of skin and nail
N10	Acute pyelonephritis
N30.00-N30.01	Acute cystitis
R82.81-	Abnormal findings on cytological and histological examination of urine (range shown)

Not covered / general unspecified NAAT codesCPTNot Covered

87797	Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism.
87798	Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism.
87799	Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; quantification, each organism.

Covered / Considered medically necessary when criteria metmixedCovered

87631	Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus, multiplex amplified probe technique, multiple types or subtypes, 3-5 targets.
87636	Infectious agent detection by nucleic acid (DNA or RNA); SARS-CoV-2 and influenza A/B, multiplex amplified probe technique.
87637	Infectious agent detection by nucleic acid (DNA or RNA); SARS-CoV-2, influenza A/B, and RSV, multiplex amplified probe technique.
0240U	Pathogen-specific RNA, 3 targets (SARS-CoV-2, influenza A, influenza B), upper respiratory specimen.
0241U	Pathogen-specific RNA, 4 targets (SARS-CoV-2, influenza A, influenza B, RSV), upper respiratory specimen.
87483	CNS pathogen multiplex NAAT, 12-25 targets.
87505	Gastrointestinal pathogen NAAT, 3-5 targets.
87506	Gastrointestinal pathogen NAAT, 6-11 targets.
81514	Bacterial vaginosis and vaginitis panel with algorithm and separate detection of Trichomonas and Candida species.
81515	Bacterial vaginosis/vaginitis PCR panel with algorithm and separate detection of Trichomonas and Candida species.

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Not covered / Not reimbursable (panels not meeting policy criteria)mixedNot Covered

87507	Gastrointestinal pathogen NAAT, 12-25 targets.
87633	Respiratory virus NAAT, 12-25 targets.
0115U	Respiratory infectious agent detection, 18 viral types and subtypes and 2 bacterial targets.
0152U	Infectious disease (bacteria, fungi, parasites, and DNA viruses), DNA, PCR and NGS, plasma, detection of >1,000 organisms.
0140U	Fungal pathogen identification, DNA (15 fungal targets), blood culture.
0141U	Bacteria and fungi gram-positive identification and resistance gene detection, blood culture.
0202U	Respiratory pathogen-specific nucleic acid, 22 targets including SARS-CoV-2, RT-PCR, nasopharyngeal swab.
0223U	Respiratory pathogen-specific nucleic acid, 22 targets including SARS-CoV-2, RT-PCR, nasopharyngeal swab.
0225U	Respiratory pathogen-specific DNA and RNA, 21 targets including SARS-CoV-2, amplified probe technique.
0323U	CNS pathogen metagenomic NGS, CSF.

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Diagnosis codes referenced for medical necessity determinationICD-10

Various ICD-10-CM codes

Numerous ICD-10-CM diagnosis codes enumerated across genitourinary, pregnancy, sexual assault, screening, STIs, and other conditions

Not Covered or Not Reimbursable / Specific molecular codesCPT | HCPCS | mixedNot Covered

0441U	Semiquantitative biomechanical assessment, whole blood, algorithmic index
0442U	Myxovirus resistance protein A (MxA) and CRP fingerstick test
0463U	Oncology (cervix), mRNA gene expression profiling of 14 biomarkers (E6 and E7), NASBA
0480U	Infectious disease CSF metagenomic next-generation sequencing (DNA and RNA), bioinformatic analysis
0502U	HPV, E6/E7 markers for high-risk types, cervical cells
0504U	UTI identification of 17 pathologic organisms, urine, realtime PCR
0505U	Vaginal infection identification of 32 pathogenic organisms, swab, real-time PCR
0528U	Lower respiratory tract infectious agent detection, bacteria, viruses, and antimicrobial-resistance genes
0531U	Acid-fast bacteria and invasive fungi NGS, plasma (673 organisms)
0556U	Respiratory pathogen panel by real-time PCR, 12 targets

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Associated ICD-10 diagnosis codes mentionedICD-10

A54.00-A54.9	Gonococcal infection (ICD-10 range listed)
A55	Chlamydial lymphogranuloma (venereum)
A56.00-A56.8	Other sexually transmitted chlamydial diseases
A59.00-A59.9	Trichomoniasis
A60.00-A60.9	Anogenital herpesviral [herpes simplex] infections
A74.0-A74.9	Other diseases caused by chlamydiae
B00.1-B00.9	Herpesviral [herpes simplex] infections
O98.111-O98.13	Syphilis complicating pregnancy
O98.211-O98.23	Gonorrhea complicating pregnancy
Z11.51	Encounter for screening for human papillomavirus (HPV)

Updated/Added CodesCPT

87494	CPT code added (as listed in revision details)
0600U	HCPCS/CPT Category III code added (as listed in revision details)

inv-48: Respiratory panel frequency

Respiratory panel frequencyNot to exceed one test per date of service; up to 12 tests per 12 rolling months (i.e., up to 11 targets)

Applies toRespiratory nucleic acid pathogen panels billed in the outpatient setting

Limit period12 rolling months

Provider Actions and Billing Requirements

Billing Rule

Submission Requires Covered Codes and Proper Billing

Reimbursement will only be provided if requested services are submitted in accordance with the applicable Coverage Policy criteria and billed with covered diagnosis and/or procedure codes. Claims for services not accompanied by covered code(s) under this Coverage Policy will be denied as not covered. When billing, providers must use the most appropriate CPT/HCPCS and ICD-10-CM codes in effect on the date of service.

Submission requires covered codes — Services must be submitted with covered diagnosis and/or procedure codes that match the policy; otherwise claims will be denied.
Billing and coding documentation — Use the most appropriate CPT/HCPCS and ICD-10-CM codes as of the effective date of service; documentation must support the code(s) billed.

Prior Authorization

Prior Authorization Linkage and Potential Requirement

Frequency Limits

inv-103: Respiratory nucleic acid pathogen panel

Respiratory panel test capNot to exceed one respiratory panel test per date of service

12-month capUp to 12 tests per 12 rolling months (i.e., up to 11 targets) when applied across the period

Applies toRespiratory nucleic acid pathogen panels billed in outpatient setting

ReferenceMedical Coverage Policy: 0530 — frequency limits for respiratory panels

inv-104: Frequency limit placeholder

Frequency limit placeholderNo explicit additional frequency limits provided in this excerpt

Ordering Requirements

Note

Check benefit plan terms and submit with covered codes

Coverage depends on the terms of the member’s benefit plan; submit services with covered diagnosis/procedure codes and plan-specific prior authorization where required to ensure reimbursement.

Verify member benefit plan terms and any plan-specific utilization review processes before ordering tests.
Follow plan-specific prior authorization requirements if applicable.

Note

Order tests only when an applicable policy-listed ICD-10 diagnosis exists

The ordering clinician must ensure the test is supported by an applicable ICD-10 diagnosis from the policy’s lists (screening, exposure, pregnancy, symptomatic infection codes) before ordering.

Confirm the patient’s clinical indication corresponds to one of the policy’s listed ICD-10 codes.
Do not order outpatient NAATs for indications specifically listed as Not Covered.

Not Covered / Not Reimbursable

The policy’s Not Covered listing includes outpatient use of metagenomic next‑generation sequencing (mNGS), routine antibiotic resistance panel testing, outpatient nucleic acid testing for HPV low‑risk types, syphilis, nail dystrophy, skin/nail fungal infections, many urinary tract indications, and other enumerated exclusions. Use of nonspecific NOS molecular codes (87797–87799) when a specific CPT/HCPCS code is available is explicitly not reimbursable.

CPT code 87512 (Gardnerella vaginalis, quantification) is shown in the policy as Not Covered or Reimbursable when billed in contexts described in the Not Covered sections. Quantification uses are generally excluded for specified organisms unless otherwise supported by the policy.

The policy designates services billed with ICD‑10‑CM diagnosis codes that are not included in the policy’s listed supporting codes as Not Covered or Reimbursable. Providers must ensure the diagnosis code submitted corresponds to one of the policy’s permitted ICD‑10 codes for the requested nucleic acid test to be eligible for coverage.

CPT code 87530 (Herpes simplex virus quantification) is explicitly listed as Not Covered or Reimbursable in this policy excerpt. Quantitative HSV testing for monitoring or therapy response is not supported in the outpatient context per the policy exclusions.

The policy identifies several procedure codes as Not Covered or Reimbursable, including quantification codes such as 87592, the HPV low‑risk code 87623, and the nonspecific molecular codes 87797–87799. Multiple ICD‑10 diagnosis examples are also provided in the Not Covered lists to illustrate contexts where nucleic acid testing is not payable.

Background

Nucleic acid testing detects microbial DNA or RNA and is used to identify bacteria, viruses, parasites and fungi to inform diagnosis and treatment. This policy covers single‑pathogen NAATs and multi‑target panel testing in outpatient settings, while placing limits on panel size and excluding use of certain broad or investigational technologies (e.g., mNGS) that lack established outpatient clinical utility.

Definitions

inv-84: Panel testing definition

DefinitionPanel testing: when the test looks for more than one pathogen at the same time

ScopeIncludes multiplex NAAT panels for respiratory, gastrointestinal, CNS, genitourinary, and other specimen sources

ImplicationPanel testing allows simultaneous detection of multiple pathogens from a single specimen

inv-85: CPT/HCPCS code examples (87494 / 87510-87511 / 87528-87529 / 81513) for nucleic acid detection methods

Example CPT/HCPCS codes87494; 87510-87511; 87528-87529; 81513 (and related codes listed in coding sections)

UseThese codes represent nucleic acid or probe detection methods for various infectious agents (e.g., CT/NG multiplex, Gardnerella, HSV, bacterial vaginosis)

Revision History and Policy Changes

2026-02-15focused review — coding updateLatest

CPT coding update effective 01/01/2026 adding codes 87494 and 0600U.

2025-07-15annual review — material changes

Increased number of pathogens in gastrointestinal and respiratory infectious disease panels to 11 each and added a policy statement for metagenomic next-generation sequencing (mNGS); also added a herpes simplex/varicella-zoster panel bullet.

2025-10-15focused review — confirmation

Focused review noted no clinical policy statement changes.