CurrentHumanaPolicy LAB2O24004

Laboratory Onychomycosis Testing

Payment and claims policy describing Humana's reimbursement stance for laboratory tests used to diagnose onychomycosis for Medicare Advantage products, including which NAAT and ATR-FTIR tests are reimbursable or not.

Policy Summary

PayerHumana

PolicyLaboratory Onychomycosis Testing

Policy CodePolicy LAB2O24004

Change TypeNo material change

Effective DateJul 1, 2023

Next Review DateN/A

Key ActionReimburse NAAT for Candida (CPT 87480, 87481) only when onychomycosis is resistant to antifungal therapy; do not reimburse listed NAAT variants or ATR-FTIR (CPT 88749) for diagnosis.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

NAAT reimbursableNAAT reimbursable when resistant

Several not reimbursedMany NAAT codes not reimbursable

ATR-FTIR excludedATR-FTIR not reimbursed

Medicare AdvantageProduct applicability

Specific CPT listCodes enumerated

Coverage criteria for onychomycosis laboratory testing

Reimbursement and non-reimbursement rules for laboratory tests used to diagnose onychomycosis.

Covered when ALL of the following are met:

ALL of the following

NAAT for Candida (CPT 87480, CPT 87481) is reimbursable when used for individuals with an onychomycosis (tinea unguium) infection that is resistant to anti-fungal drug therapy.

Not reimbursable tests

ANY of the following codes when submitted for onychomycosis or related toenail disorders are not reimbursable:
- CPT 87149 — Culture, typing; identification by nucleic acid probe, direct probe technique (not reimbursable for onychomycosis or related toenail disorders).

Policy Summary

PayerHumana

PolicyLaboratory Onychomycosis Testing

Policy CodePolicy LAB2O24004

Change TypeNo material change

Effective DateJul 1, 2023

Next Review DateN/A

Key ActionReimburse NAAT for Candida (CPT 87480, 87481) only when onychomycosis is resistant to antifungal therapy; do not reimburse listed NAAT variants or ATR-FTIR (CPT 88749) for diagnosis.

SourceLink

On This Page

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Applicable CPT and procedure codes

Applicable CPT codesCPT

82542	Column chromatography, includes mass spectrometry, non-drug analyte(s), qualitative or quantitative
87149	Culture, typing; identification by nucleic acid probe, direct probe technique
87150	Culture, typing; identification by nucleic acid probe, amplified probe technique
87153	Culture; typing; identification by nucleic acid sequencing method
87480	Infectious agent detection by nucleic acid; Candida species, direct probe technique
87481	Infectious agent detection by nucleic acid; Candida species, amplified probe technique
87482	Infectious agent detection by nucleic acid; Candida species, quantification
87798	Infectious agent detection by nucleic acid, not otherwise specified; amplified probe technique
87801	Infectious agent detection by nucleic acid, multiple organisms; amplified probe technique
88749	Unlisted in vivo (transcutaneous) laboratory service (ATR-FTIR spectroscopy)

Reimbursement authorization and provider guidance

Billing Rule

Reimbursement and coding rules for NAAT and ATR-FTIR in onychomycosis

NAAT for Candida (CPT 87480, 87481) is reimbursable only for individuals with onychomycosis (tinea unguium) that is resistant to antifungal drug therapy. NAAT codes 87149, 87150, 87153, 87482, 87798, and 87801 are not reimbursable when submitted for individuals with onychomycosis or related toenail disorders (e.g., onycholysis, nail dystrophy, Beau's lines, yellowing of the nail). ATR-FTIR spectroscopy (CPT 88749) is not reimbursable for the diagnosis of onychomycosis.

Reimbursable NAAT: CPT 87480, CPT 87481 — only for infection resistant to antifungal therapy.
Not reimbursable NAAT codes for onychomycosis or related toenail disorders: CPT 87149, 87150, 87153, 87482, 87798, 87801.
ATR-FTIR spectroscopy (CPT 88749) is not reimbursable for onychomycosis diagnosis.
Claims remain subject to medical necessity, reasonableness, and applicable plan referral/authorization requirements.

Testing method definitions and coverage notes

inv-04: Nucleic acid amplification testing (NAAT) for Candida and other pathogens; specific CPT codes listed in policy

NAAT reimbursable (highlight)Nucleic acid amplification testing (NAAT) for Candida (CPT 87480, 87481) is reimbursable for individuals with onychomycosis that is resistant to antifungal drug therapy.

NAAT not reimbursable — listed codesNAAT codes CPT 87149, CPT 87150, CPT 87153, CPT 87482, CPT 87798, and CPT 87801 are not reimbursable when submitted for individuals with onychomycosis or related toenail disorders (e.g., onycholysis, nail dystrophy, Beau's lines, yellowing).

NAAT code descriptionsCPT 87480: Infectious agent detection by nucleic acid; Candida species, direct probe technique; CPT 87481: Infectious agent detection by nucleic acid; Candida species, amplified probe technique; CPT 87482: Infectious agent detection by nucleic acid; Candida species, quantification; CPT 87149/87150/87153: culture/typing identification by nucleic acid probe or sequencing; CPT 87798/CPT 87801: infectious agent detection by nucleic acid, not otherwise specified/multiple organisms, amplified probe technique.

ApplicabilityPayment criteria apply to Medicare Advantage plans as described in the policy and reference Original Medicare LCDs where applicable.

inv-05: Attenuated total reflectance Fourier-transform infrared spectroscopy (CPT 88749), listed as not reimbursable for onychomycosis diagnosis

ATR-FTIR not reimbursable (highlight)Attenuated total reflectance Fourier-transform infrared (ATR-FTIR) spectroscopy (CPT 88749) is not reimbursable for the diagnosis of onychomycosis.

CPT code listedCPT 88749 is described as an unlisted in vivo (transcutaneous) laboratory service (ATR-FTIR spectroscopy) in the policy's applicable procedures list.

Related claim considerationsClaims remain subject to medical necessity, reasonableness, and other Medicare Advantage plan processing rules as noted in the policy introduction.