Harvard Pilgrim STI testing Coverage Update

Coverage Criteria for STI Testing

Syphilis antibody testing (covered situations)

Antibody testing for syphilis infection MEETS COVERAGE CRITERIA in the following situations:

Syphilis antibody testing: high-risk asymptomatic: 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 tests for any initial positive test (e.g., treponemal and nontreponemal tests)annual

Includes treponemal and nontreponemal testing

Syphilis antibody testing: other covered indications

Diagnosis of any person presenting with signs and/or symptoms of syphilis
See Note 3 for symptom details
Once every three months for HIV-positive men or men who have sex with men (MSM)
Treponemal and nontreponemal testing once prior to allogeneic hematopoietic stem cell transplant (allo-HCT) in both donors and recipients as part of pre-transplant assessment
When a nontreponemal test is used as a test of cure (TOC) for a previously positive syphilis infection
TOC use

Syphilis antibody testing (other covered)

Additional covered indications for syphilis antibody testing:

Asymptomatic, not high-risk: limited covered uses

As part of newborn screening
As part of follow-up in a victim of sexual assault
For sexually active individuals under 18 years of age (annual screening)

Documentation requirement for positive tests: For any initial positive syphilis antibody test, documentation must include confirmatory testing using treponemal and nontreponemal tests per standard or reverse algorithm

See policy documentation requirements

Syphilis NAAT/PCR (not covered)

Syphilis NAAT/PCR coverage stance:

Syphilis NAAT/PCR: Polymerase chain reaction (PCR) testing and nucleic acid amplification testing (NAAT) for syphilis DO NOT MEET COVERAGE CRITERIAnot applicable

Explicit non-coverage

Trichomonas NAAT (covered)

Trichomonas NAAT testing MEETS COVERAGE CRITERIA in the following situations:

Trichomonas NAAT indications

For symptomatic individuals
Follow-up testing a minimum of three months after initial trichomoniasis diagnosis>= 3 months
Annual screening for asymptomatic individuals in high-risk groups (including high-prevalence settings and persons who exchange sex for payment)
Concurrent STI or history of STIs; annual screening for asymptomatic persons with HIV
As part of follow-up in a victim of sexual assault

Herpes simplex virus testing (covered with limits)

HSV testing coverage and limitations:

HSV NAAT and serology indications

Qualitative NAAT for HSV-1 or HSV-2 meets coverage for individuals with active genital ulcers or mucocutaneous lesions
Type-specific serologic testing for HSV-2 (gG2) meets coverage for recurrent or atypical genital symptoms with negative PCR/culture; for clinical diagnosis without laboratory confirmation; or when a partner has genital herpes
Immunoassay testing for HSV-1 and non-type-specific herpes simplex tests do NOT MEET COVERAGE CRITERIA

HPV testing (oncologic indications covered)

HPV testing coverage stance:

HPV testing indications

Testing for high-risk HPV meets coverage when used in the diagnosis and/or assessment of cancer or cancer therapy (e.g., p16 immunohistochemistry or NAAT for HR-HPV)
Testing for HPV does NOT MEET COVERAGE CRITERIA for general STI screening of asymptomatic individuals, as part of routine STI panels, for low-risk HPV types, or for diagnosis of anogenital warts

PrEP-related STI testing (covered)

Preexposure prophylaxis (PrEP) related testing that meets coverage:

PrEP baseline and monitoring: Prior to and during PrEP, covered tests include: baseline and repeat HIV antibody testing every 3 months; serum creatinine and estimated creatinine clearance baseline and monitoring; hepatitis B screening (HBsAg, anti-HBs, anti-HBc); pregnancy testing; and qualitative NAAT screening for gonorrhea and chlamydia by anatomic site at recommended intervals (every 3 months for MSM and individuals with child-bearing potential; nine months after initiation then every six months for sexually active individuals)baseline and periodic monitoring

See policy for exact intervals per population

Nucleic acid testing performed to determine antimicrobial susceptibility in Neisseria gonorrhoeae or to detect macrolide resistance in Mycoplasma genitalium does not meet coverage criteria. Such tests are specifically excluded due to a lack of published evidence demonstrating clinical utility for routine diagnosis or treatment decisions and may be denied when billed for these indications.

Direct probe detection or quantitative NAAT (i.e., assays that report organism load/quantity rather than a qualitative positive/negative) for the listed organisms — Chlamydia trachomatis, Neisseria gonorrhoeae, Herpes simplex virus‑1 and ‑2, Human papillomavirus, and Treponema pallidum — does not meet coverage criteria and may be denied.

Immunoassay-based and/or non–type-specific herpes simplex antibody tests (including HSV‑1 immunoassays and non‑type‑specific herpes antibody assays) do not meet coverage criteria. Type‑specific serologic testing for HSV‑2 (gG2) is covered only in limited clinical situations (see covered criteria for recurrent/atypical symptoms, clinical diagnosis without laboratory confirmation, or when a partner has genital herpes).

Human papillomavirus (HPV) testing by NAAT or other methods meets coverage criteria only for oncologic indications — for example, testing used in diagnosis or assessment of cancer (p16 immunohistochemistry or NAAT for high‑risk HPV) or in the context of cancer therapy. HPV testing does not meet coverage criteria when used for general STI screening of asymptomatic individuals, as part of routine STI panels, for screening low‑risk HPV types, or to diagnose anogenital warts.

Procedure codes listed in this policy are provided solely as a general reference tool and may not be all‑inclusive. Providers must verify the correct and complete coding for services rendered with the most current CPT/HCPCS guidance and member benefit rules.

No additional coverage exceptions or exclusions are specified in the provided excerpt.

The following items are considered not medically necessary under the criteria in this policy and may be denied: screening asymptomatic individuals for HSV‑1 or HSV‑2; routine population screening for HPV as part of general STI panels or for asymptomatic individuals; screening asymptomatic persons for Mycoplasma genitalium; and using PCR/NAAT methods for diagnosis of syphilis. These services are not supported by the policy's stated clinical indications and evidence base.

No additional entries are included in this excerpt.

Applicable Procedure and Test Codes

Applicable CPT/HCPCS Procedure Codesmixed

Procedure codes appearing in policy documents are included only as a general reference tool

Reference statement — specific CPT/HCPCS codes not listed in this section of the document

General laboratory CPT/serology/culture codesmixed

82565	Creatinine; blood.
82575	Creatinine; clearance.
84702	Gonadotropin, chorionic (hCG); quantitative.
84703	Gonadotropin, chorionic (hCG); qualitative.
86592	Syphilis test, non-treponemal antibody; qualitative (e.g., VDRL, RPR, ART).
86593	Syphilis test, non-treponemal antibody; quantitative.
86631	Antibody; Chlamydia.
86632	Antibody; Chlamydia, IGM.
86694	Antibody; herpes simplex, non-specific type test.
86695	Antibody; herpes simplex, type 1.

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NAAT and antigen detection codesCPT

87181	Susceptibility studies, antimicrobial agent; agar dilution method, per agent (e.g., antibiotic gradient strip).
87340	Infectious agent antigen detection by immunoassay technique; hepatitis B surface antigen (HBsAg).
87490	Infectious agent detection by nucleic acid; Chlamydia trachomatis, direct probe.
87491	Infectious agent detection by nucleic acid; Chlamydia trachomatis, amplified probe.
87492	Infectious agent detection by nucleic acid; Chlamydia trachomatis, quantification.
87528	Infectious agent detection by nucleic acid; Herpes simplex virus, direct probe.
87529	Infectious agent detection by nucleic acid; Herpes simplex virus, amplified probe.
87530	Infectious agent detection by nucleic acid; Herpes simplex virus, quantification.
87563	Infectious agent detection by nucleic acid; Mycoplasma genitalium, amplified probe technique.
87590	Infectious agent detection by nucleic acid; Neisseria gonorrhoeae, direct probe.

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Proprietary assays, multiplex panels, and miscellaneous HCPCS/CPT/HCPCS G/S codesmixed

88341	Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure.
88342	Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure.
88344	Immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain procedure.
0064U	Antibody, Treponema pallidum, total and rapid plasma reagin (RPR), immunoassay, qualitative (BioPlex 2200 Syphilis Total & RPR Assay).
0065U	Syphilis test, non-treponemal antibody, immunoassay, qualitative (RPR) (BioPlex 2200 RPR Assay).
0096U	HPV, high-risk types, male urine proprietary test.
0210U	Syphilis test, non-treponemal antibody, immunoassay, quantitative (BioPlex 2200 RPR Assay - Quantitative).
0402U	Multiplex amplified probe for CT, NG, TV, MG — each pathogen reported (Abbott Alinity m STI Assay).
0455U	Multiplex amplified probe for CT, NG, TV (Abbott Alinity m STI Assay) for multiple specimen types.
0463U	Oncology (cervix), mRNA gene expression profiling of 14 biomarkers (Proofer '7 HPV mRNA E6 and E7 Biomarker Test).

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Coding grid updates (removed and added codes)mixed

82565	removed
82575	removed
84702	removed
84703	removed
86701	removed
86702	removed
86703	removed
86705	removed
86803	removed
86804	removed

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inv-24: Effective date for select CPT updates

Effective dateCodes 87626 and 87800 effective for dates of service beginning June 1, 2026

Affected codes87626, 87800

ScopeApplies to coding grid entries for HPV and multi-organism NAATs as listed in policy coding section

inv-25: coding change effective date

Effective DOSDates of service on or after June 1, 2026

Change description

Provider Billing, Authorization, and Documentation Actions

Prior Authorization

Prior Authorization — verify with payer

Verify member benefits and prior authorization requirements with the payer before performing or billing for tests. Procedure codes in this policy are provided for reference only and do not guarantee coverage; using codes outside their intended clinical context may result in claim denials.

Check member eligibility and specific plan benefits on the date of service.
Confirm whether prior authorization (PA) or referral is required for the requested STI tests and specimens.
Obtain and document any required prior authorization number on the claim when applicable.

Prior Authorization

Confirm prior authorization and benefits for updated STI test codes

Confirm prior authorization and benefit coverage for updated or proprietary STI test codes (including CPT/HCPCS and recent PLA/U-codes) prior to ordering or performing testing. New multiplex and proprietary assays listed in coding (e.g., 0402U, 0455U, 0463U, 0483U) may have different PA or coverage rules.

Verify whether the payer covers the specific multiplex or manufacturer-specific assay and under what conditions.

Background

Sexually transmitted infections (STIs) encompass both bacterial and viral pathogens transmitted predominantly via sexual contact and can result in significant complications if untreated, including pelvic inflammatory disease, infertility, neurologic and cardiac manifestations (notably with syphilis), and malignancies associated with oncogenic human papillomavirus. Many STIs are asymptomatic; recognized risk factors include multiple sexual partners, men who have sex with men (MSM), HIV infection, incarceration, sex work, and younger age. This policy focuses on aligning testing methods with clinical use‑cases for common STIs and specifying which tests meet coverage based on diagnostic utility and evidence.

Definitions and Key Terms

inv-40: High-risk — Define high-risk groups and related note

High-risk — definitionIndividuals with behavioral or demographic risks such as multiple sex partners, working in sex trade, inconsistent condom use, men who have sex with men (MSM), prior STI diagnosis, admission to correctional facilities, and lower socioeconomic status

Implication for screeningAnnual antibody screening for syphilis and annual NAAT screening for certain STIs recommended for asymptomatic high-risk individuals

Settings noted as higher prevalenceCorrectional facilities and STI clinics are examples of high-prevalence settings referenced elsewhere in policy

inv-41: TOC (Test of Cure) — Definition and context

TOC definitionTest of cure (TOC): use of a nontreponemal test for syphilis or NAAT at least three months after initial diagnosis for certain infections to document cure

OpenPayer

Diagnostic testing for common sexually transmitted infections (STIs)

Coverage Criteria for STI Testing

Applicable Procedure and Test Codes

Provider Billing, Authorization, and Documentation Actions

Background

Definitions and Key Terms