CurrentHumanaPolicy LAB2023045

Laboratory - Identification of Select Microorganisms by Nucleic Acid Probes

Payment policy governing reimbursement for nucleic acid probe testing to identify select microorganisms for Humana Medicare Advantage products; affects providers submitting claims to Humana Medicare Advantage plans.

Policy Summary

PayerHumana

PolicyLaboratory - Identification of Select Microorganisms by Nucleic Acid Probes

Policy CodePolicy LAB2023045

Change TypeNo material changes

Effective Date

Next Review Date2026-03

Key ActionDo not bill for listed nucleic acid probe tests that are identified as not reimbursable for Medicare Advantage plans.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15distinct nucleic acid test codes enumerated

Medicare AdvantageApplies to plan type

≥12Specific tests not reimbursable

Coverage Criteria for Nucleic Acid Probe Testing

CPT Codes for Identification by Nucleic Acid Probe

Enumerated CPT codes for nucleic acid identificationCPT

87472	Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, quantification.
87485	Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, direct probe technique.
87487	Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, quantification.
87495	Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, direct probe technique.
87496	Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, amplified probe technique.
87497	Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, quantification.
87525	Infectious agent detection by nucleic acid (DNA or RNA); hepatitis G, direct probe technique.
87526	Infectious agent detection by nucleic acid (DNA or RNA); hepatitis G, amplified probe technique.
87527	Infectious agent detection by nucleic acid (DNA or RNA); hepatitis G, quantification.
87531	Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, direct probe technique.

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Provider Billing and Reimbursement Guidance

Policy Summary

PayerHumana

PolicyLaboratory - Identification of Select Microorganisms by Nucleic Acid Probes

Policy CodePolicy LAB2023045

Change TypeNo material changes

Effective Date

Next Review Date2026-03

Key ActionDo not bill for listed nucleic acid probe tests that are identified as not reimbursable for Medicare Advantage plans.

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.

Prior Authorization

Prior Authorization / Reimbursement Guidance for Nucleic Acid Probe Tests

Prior authorization and reimbursement requirements for certain nucleic acid probe and related tests. The following nucleic acid identification tests are NOT REIMBURSABLE for Medicare Advantage plans; do not submit for payment. Additionally, amplified probe testing for cytomegalovirus (CPT 87496) is NOT REIMBURSABLE when quantification testing for cytomegalovirus (CPT 87497) is performed on the same date of service.

Direct probe testing — Not reimbursable: CPT 87485 (Chlamydia pneumoniae); CPT 87495 (Cytomegalovirus); CPT 87525 (Hepatitis G); CPT 87531 (Herpes virus-6); CPT 87540 (Legionella pneumophila); CPT 87580 (Mycoplasma pneumoniae).
Amplified probe testing — Not reimbursable: CPT 87526 (Hepatitis G); CPT 87532 (Herpes virus-6).
Quantification testing — Not reimbursable: CPT 87472 (Bartonella henselae or quintana); CPT 87487 (Chlamydia pneumoniae); CPT 87527 (Hepatitis G); CPT 87542 (Legionella pneumophila); CPT 87582 (Mycoplasma pneumoniae).
Concurrent testing limitation — Amplified probe testing for cytomegalovirus (CPT 87496) is not reimbursable when CMV quantification (CPT 87497) is performed on the same date of service.

Definitions

Non-reimbursable — Definition of 'Non-reimbursable' for Medicare Advantage

DefinitionTests specifically listed as not reimbursable under this policy for Humana Medicare Advantage plans unless otherwise governed by applicable NCDs/LCDs or plan terms.

ScopeApplies to nucleic acid identification (direct probe, amplified probe, and quantification) for select organisms submitted to Humana Medicare Advantage plans.

Combination rule (most actionable)Amplified probe testing for cytomegalovirus (CPT 87496) is not reimbursable when quantification testing for cytomegalovirus (CPT 87497) is performed on the same date of service.

Examples of non-reimbursable direct probe testsCPT 87485 (Chlamydia pneumoniae); CPT 87495 (Cytomegalovirus); CPT 87525 (Hepatitis G); CPT 87531 (Herpes virus-6); CPT 87540 (Legionella pneumophila); CPT 87580 (Mycoplasma pneumoniae).

Examples of non-reimbursable amplified probe testsCPT 87526 (Hepatitis G); CPT 87532 (Herpes virus-6).

Examples of non-reimbursable quantification testsCPT 87472 (Bartonella henselae/quintana); CPT 87487 (Chlamydia pneumoniae); CPT 87527 (Hepatitis G); CPT 87542 (Legionella pneumophila); CPT 87582 (Mycoplasma pneumoniae).