CurrentColorado Rocky Mountain Health PlansPolicy 2025R8011B

Reimbursement for onychomycosis diagnostic testing

Governs reimbursement methodology for diagnostic tests billed on CMS-1500/UB04 related to onychomycosis for UnitedHealthcare Commercial and Individual Exchange plans and affects all network and non-network providers submitting such claims.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyReimbursement for onychomycosis diagnostic testing

Policy CodePolicy 2025R8011B

Change TypeNo material change

Effective Date

Next Review Date

Key ActionReimbursement is considered for NAAT when prior antifungal therapy has failed to resolve onychomycosis.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Procedure codes listed

NAAT reimbursedNAAT coverage condition

ATR-FTIRExcluded method

All productsPlan applicability

Coverage Determinations

Onychomycosis diagnostic testing coverage

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyReimbursement for onychomycosis diagnostic testing

Policy CodePolicy 2025R8011B

Change TypeNo material change

Effective Date

Next Review Date

Key ActionReimbursement is considered for NAAT when prior antifungal therapy has failed to resolve onychomycosis.

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.

ALL of the following

ALL of the following
- Clinical diagnosis of onychomycosis (documented in the medical record)
- Documentation that antifungal therapy was administered and failed to resolve the infection
ALL of the following
- NAAT procedure codes: CPT 87480 or CPT 87481

ALL of the following

Attenuated total-reflectance Fourier transform infrared (ATR-FTIR) spectroscopy (CPT 88749) is not covered for screening, determining, or confirming onychomycosis.

Provider Billing and Reimbursement Guidance

Prior Authorization

NAAT reimbursed only after failed antifungal therapy

Reimbursement will be considered for nucleic acid amplification testing (NAAT) for individuals with onychomycosis when antifungal therapy has failed to resolve the infection.

Applicable procedure codes: 87480, 87481 (see Coding section).
Document prior antifungal therapy and lack of clinical resolution when submitting claims.

Denial Risk

ATR-FTIR (CPT 88749) is not reimbursable for onychomycosis

UnitedHealthcare will not consider reimbursement of attenuated total-reflectance Fourier transform infrared (ATR-FTIR) spectroscopy to screen for, determine, or confirm onychomycosis.

Do not bill CPT 88749 for onychomycosis screening, diagnosis, or confirmation — it is not reimbursed.

Key Definitions

NAAT — Nucleic acid amplification testing

TermNucleic acid amplification testing (NAAT)

DefinitionA molecular diagnostic method that amplifies and detects fungal nucleic acids to diagnose onychomycosis.

Reimbursement conditionUnitedHealthcare will consider reimbursement for NAAT for individuals with onychomycosis when antifungal therapy has failed to resolve the infection.

Relevant CPT codes87480, 87481 (see Procedure Code(s) section)

Documentation requiredClinical diagnosis of onychomycosis and documentation of prior antifungal therapy with lack of resolution.

ATR-FTIR — Attenuated total-reflectance fourier transform infrared spectroscopy

TermAttenuated total-reflectance Fourier transform infrared (ATR-FTIR) spectroscopy

DefinitionA spectroscopic diagnostic method intended to analyze nail samples for onychomycosis using ATR-FTIR technology.

Reimbursement stanceUnitedHealthcare will not consider reimbursement of ATR-FTIR spectroscopy to screen for, determine, or confirm onychomycosis.

Relevant CPT code88749 (listed as not reimbursed)

Implication for providersClaims for ATR-FTIR testing for onychomycosis are not eligible for reimbursement under this policy.

OpenPayer

Reimbursement for onychomycosis diagnostic testing

Coverage Determinations

CPT / Procedure Codes and Coverage Status

Provider Billing and Reimbursement Guidance

Key Definitions