CurrentHumanaPolicy LAB2023048

Laboratory - Onychomycosis Testing

This Medicare Advantage claims payment policy explains Humana's reimbursement stance for laboratory tests used to diagnose onychomycosis (tinea unguium) and which procedures are reimbursable or not for Humana Medicare Advantage members.

Policy Summary

PayerHumana

PolicyLaboratory - Onychomycosis Testing

Policy CodePolicy LAB2023048

Change TypeNo material changes

Effective DateJul 1, 2023

Next Review Date

Key ActionReimburse NAAT for Candida (CPT 87480, 87481) only when onychomycosis is resistant to antifungal drug therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

87480/87481NAAT reimbursable (specific)

MultipleNAAT codes not reimbursable

88749ATR-FTIR excluded

82542Sterol testing excluded

Medicare AdvantageProduct applicability

Coverage determinations and exclusions

Coverage criteria and exclusions for laboratory tests related to onychomycosis

Coverage determinations and exclusions for laboratory tests related to onychomycosis:

Covered when ALL of the following are met:

ALL of the following

The patient has onychomycosis (tinea unguium) that is resistant to antifungal drug therapy.
Nucleic acid amplification testing (NAAT) for Candida (CPT 87480, CPT 87481) is being ordered to evaluate the resistant infection.

Not reimbursable (EXCLUSIONS)

NAAT and related nucleic acid detection codes 87149, 87150, 87153, 87482, 87798, 87801 are NOT reimbursable for onychomycosis or disorders of the toenail (e.g., onycholysis, nail dystrophy, Beau's lines, yellowing of the nail).

Policy Summary

PayerHumana

PolicyLaboratory - Onychomycosis Testing

Policy CodePolicy LAB2023048

Change TypeNo material changes

Effective DateJul 1, 2023

Next Review Date

Key ActionReimburse NAAT for Candida (CPT 87480, 87481) only when onychomycosis is resistant to antifungal drug therapy.

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.

CPT and related codes

Specified CPT codes and descriptionsCPT

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
87482	Infectious agent detection by nucleic acid (DNA or RNA); Candida species, quantification
87149	Culture, typing; identification by nucleic acid (DNA or RNA) probe, direct probe technique, per culture or isolate, each organism probed
87150	Culture, typing; identification by nucleic acid (DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed
87153	Culture, typing; identification by nucleic acid sequencing method, each isolate (e.g., sequencing of the 16S rRNA gene)
87798	Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism
87801	Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique
82542	Column chromatography, includes mass spectrometry, if performed (e.g., HPLC, LC, LC/MS, LC/MS-MS, GC, GC/MS-MS, GC/MS, HPLC/MS), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen
88749	Unlisted in vivo (e.g., transcutaneous) laboratory service

Provider actions, billing, and denial risks

Prior Authorization

Prior authorization / coverage note for Candida NAAT

For individuals with onychomycosis (Tinea unguium) that is resistant to antifungal drug therapy, nucleic acid amplification testing (NAAT) for Candida is reimbursable when used to evaluate persistent or treatment‑resistant infection.

Affected codes: CPT 87480, CPT 87481

Denial Risk

Denial risk for specified NAAT codes

NAAT and related nucleic acid detection codes are listed as not reimbursable for onychomycosis and certain non‑infectious nail disorders. Claims for these codes may be denied when submitted for the listed conditions.

Not reimbursable for onychomycosis and disorders of the toenail (e.g., onycholysis, nail dystrophy, Beau's lines, yellowing of the nail): CPT 87149, CPT 87150, CPT 87153, CPT 87482, CPT 87798, CPT 87801

Documentation Required

Billing and documentation warning for excluded tests

Certain laboratory methods are specifically excluded for the diagnosis of onychomycosis and will not be reimbursed. Submitters should not bill these tests for onychomycosis diagnosis; include supporting clinical documentation when submitting alternative, covered tests.

Excluded/non‑reimbursable for diagnosis of onychomycosis: CPT 88749 (ATR‑FTIR spectroscopy / unlisted in vivo laboratory service), CPT 82542 (fungal‑derived sterol testing)

Terminology and test descriptions

inv-06: Nucleic acid amplification testing (NAAT) for fungal organisms used to detect Candida and other agents

DefinitionNucleic acid amplification testing (NAAT) for fungal organisms used to detect Candida and other agents; includes CPT 87480 (direct probe) and 87481 (amplified probe).

Reimbursable conditionNAAT (CPT 87480, 87481) IS REIMBURSABLE when the patient has onychomycosis (tinea unguium) that is resistant to antifungal drug therapy.

Not reimbursable codesNAAT-related codes 87149, 87150, 87153, 87482, 87798, 87801 are listed as NOT REIMBURSABLE for onychomycosis and disorders of the toenail.

Related guidanceOriginal Medicare LCDs/MolDX policies list many of these procedure codes and should be consulted for applicability (see MolDX LCD listings).

inv-07: Attenuated total reflectance Fourier-transform infrared spectroscopy (laboratory method listed under CPT 88749)

DefinitionAttenuated total reflectance Fourier-transform infrared (ATR-FTIR) spectroscopy — laboratory method listed under CPT 88749 (unlisted in vivo/transcutaneous laboratory service).

Coverage stanceFor the diagnosis of onychomycosis, ATR-FTIR spectroscopy (CPT 88749) IS NOT REIMBURSABLE.

Billing noteClaims for ATR-FTIR testing for onychomycosis are excluded and subject to other plan requirements including medical necessity, referral, and authorization rules.

inv-08: Testing for fungal-derived sterols (example CPT 82542) sometimes used to detect fungal components in nails

DefinitionTesting for fungal-derived sterols (example CPT 82542) — column chromatography including mass spectrometry, qualitative or quantitative, per specimen.

Coverage stanceFor the diagnosis of onychomycosis, testing for the presence of fungal-derived sterols (CPT 82542) IS NOT REIMBURSABLE.

Code descriptionCPT 82542: Column chromatography, includes mass spectrometry if performed (e.g., HPLC, LC, LC/MS), non-drug analyte(s), qualitative or quantitative, each specimen.