CurrentHumanaPolicy LAB2023053

Laboratory - Testing for Vector-Borne Infections

Medicare Advantage payment policy describing Humana claims payment positions for laboratory tests used to detect various vector-borne infections (e.g., Babesiosis, Borrelia, Dengue, Ehrlichiosis/Anaplasmosis, Malaria/Plasmodium, Rickettsiosis, West Nile, Zika) and applicability to Medicare Advantage products and providers.

Policy Summary

PayerHumana

PolicyLaboratory - Testing for Vector-Borne Infections

Policy CodePolicy LAB2023053

Change TypeNo material change

Effective Date07/2023

Next Review Date

Key ActionClaims payments require medical necessity and other Medicare Advantage plan requirements; testing for listed vector-borne pathogens in asymptomatic individuals is not reimbursable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

9+named pathogens

Asymptomaticgeneral exclusion

Medicare Advapplicability

>30references

Coverage Criteria for Vector-Borne Infection Testing

Ehrlichiosis/Anaplasmosis

Covered when ALL of the following are met:

ALL of the following

Member has one or more of the following symptoms: fever, gastrointestinal issues (nausea, vomiting, diarrhea), headache, insect bite, malaise, myalgia, shaking chills

Rickettsiosis

Covered with limits and conditions:

ALL of the following

Member has one or more of the following symptoms: abdominal pain, anorexia, chills, fever, headache, insect bite, malaise, myalgia, nausea, photophobia, skin rash, ulcerative lesion with regional lymphadenopathy (for Rickettsia species 364D), vomiting

Blood culture (CPT 87040) is NOT reimbursable for individuals with a diagnosis of typhus fever or Rickettsiosis

West Nile virus

Covered when ALL of the following are met:

ALL of the following

Member has one or more of the following symptoms: abdominal pain, altered level of consciousness, arthralgia, fatigue, fever, headache, insect bite, maculopapular rash, myalgia, nausea, neck stiffness, vision loss, vomiting, weakness

IFA assay for West Nile virus IgG (CPT 86789) is NOT reimbursable for individuals with a diagnosis of West Nile virus infection

Zika virus

Covered when ALL of the following are met:

ALL of the following

Member has one or more of the following: abnormal brain development, conjunctivitis, decreased joint movement, feeding problems, fever, headache, hearing loss, joint pain, microcephaly, muscle pain or stiffness, rash, seizures, suspected exposure to Zika virus, ultrasound findings consistent with congenital Zika virus, vision problems

Coverage references and absence of explicit criteria

References and notes:

The following section lists bibliographic references, guidance documents, and supporting literature relevant to diagnostic testing for vector-borne infections; these chunks do not contain additional explicit coverage criteria, codes, or prior authorization rules

Applicable Codes and Coding Notes

Applicable CPT/HCPCS/Proprietary codes listedmixed

86280	Hemagglutination inhibition test (HAI)
86619	Antibody; Borrelia (relapsing fever)
86666	Antibody; Ehrlichia
86750	Antibody; Plasmodium (malaria)
86753	Antibody; protozoa, not elsewhere specified
86757	Antibody; Rickettsia
86788	Antibody; West Nile virus, IgM
86789	Antibody; West Nile virus
86794	Antibody; Zika virus, IgM
87040	Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate)

1–10 of 17

1/2

Identifiers and coding absencemixed

No specific CPT/HCPCS/ICD codes listed in these document chunks.

inv-13: Rickettsia IFA repeat

Reimbursement frequencyIFA for Rickettsia IgG (CPT 86757) is reimbursable up to twice when at least two weeks has passed between tests

Indication requirementOnly reimbursable for individuals with listed symptoms (e.g., fever, headache, rash, insect bite, myalgia, nausea, vomiting, abdominal pain, anorexia, malaise, photophobia, skin rash, ulcerative lesion with regional lymphadenopathy for species 364D)

Non-reimbursable alternativeFor individuals with a diagnosis of typhus fever or Rickettsiosis, blood culture testing (CPT 87040) is not reimbursable

Related CPT codeCPT 86757 — Antibody; Rickettsia (IFA) (as referenced in policy)

inv-14: Diagnostic test examples referenced

Molecular NAAT/PCR examplesReferences include molecular PCR assays such as LCMAL Malaria, Molecular Detection, PCR (Test ID cited) and real-time PCR assays for Plasmodium species

Rapid diagnostic testsPolicy references potential limitations and false positives with rapid diagnostic tests (e.g., false positive malaria RDTs cited in literature)

Serology examplesSerologic methods referenced include immunofluorescence assays (IFA) and hemagglutination inhibition tests (e.g., CPT 86280 for dengue HAI)

Specific test identifiersTest ID cited: LCMAL Malaria, Molecular Detection, PCR, Varies (Mayo Clinic Labs)

Provider Actions, Claims and Policy Identifiers

Documentation Required

General Medicare Advantage claims requirements

As a Medicare Advantage plan, claims payments are subject to plan requirements including medical necessity and reasonableness determinations. Providers must ensure services meet the plan's medical necessity criteria and are reasonable in scope and frequency. Claims for services that have established criteria under Original Medicare Local Coverage Determinations (LCDs) will follow those LCD criteria when applicable.

Payments are subject to medical necessity and reasonableness.
Claims must comply with any applicable referrals or prior authorization requirements.
When an Original Medicare LCD exists for a procedure, the LCD criteria apply.

Note

Policy identification

This policy applies to Laboratory - Testing for Vector-Borne Infections. Reference the policy number when submitting inquiries or appeals.

Subject: Laboratory - Testing for Vector-Borne Infections
Policy Number: LAB2023053
Effective Date: 07/2023
Payer: Humana

Definitions and Example Tests

inv-17: NAAT (nucleic acid amplification test) including PCR

DefinitionNAAT: Nucleic Acid Amplification Test, including Polymerase Chain Reaction (PCR)

Example useCPT 87469 used for NAAT/PCR to detect Babesia microti (policy indicates NAAT/PCR is reimbursable with symptomatic indication)

Specimen contextNAAT/PCR testing referenced for whole blood specimens for organisms such as Anaplasma, Ehrlichia, Babesia and Plasmodium in policy examples

inv-18: IFA — Immunofluorescence assay for IgG or IgM antibodies

DefinitionIFA: Indirect immunofluorescence assay for detection of Immunoglobulin G (IgG) or Immunoglobulin M (IgM) antibodies

Clinical examplesIFA assays referenced include Babesia IFA (CPT 86753 — not reimbursable for individuals with a diagnosis) and Rickettsia IFA (CPT 86757 — reimbursable under conditions)

West Nile contextIFA for West Nile virus IgM (CPT 86788/86789) is reimbursable for symptomatic individuals; West Nile IgG (CPT 86789) is not reimbursable for individuals with a diagnosis

inv-19: Example laboratory test — LCMAL Malaria, Molecular Detection, PCR referenced

Example test IDLCMAL Malaria, Molecular Detection, PCR, Varies (Test ID cited from Mayo Clinic Labs)

ContextCited as an example molecular detection PCR test for Plasmodium (malaria) in policy references and test catalogs

Source link referencePolicy cites Mayo Clinic Labs test catalog entry for LCMAL Malaria Molecular Detection PCR

inv-20: Covered conditions (examples) — list of vector-borne infections referenced

Covered pathogen examplesPolicy references vector-borne infections including malaria (Plasmodium species), dengue virus, West Nile virus, rickettsial diseases, babesiosis, relapsing fever, chikungunya, yellow fever, and plague in supporting literature

Support sourcesMultiple bibliographic references and CDC guidance cited throughout policy for these conditions

Policy scopeThese conditions are the focus of laboratory testing guidance and reimbursement positions in the policy

Policy Summary

PayerHumana

PolicyLaboratory - Testing for Vector-Borne Infections

Policy CodePolicy LAB2023053

Change TypeNo material change

Effective Date07/2023

Next Review Date

Key ActionClaims payments require medical necessity and other Medicare Advantage plan requirements; testing for listed vector-borne pathogens in asymptomatic individuals is not reimbursable.

SourceLink

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