CurrentHumanaPolicy LAB2023053

Laboratory - Testing for Vector-Borne Infections

Payment policy for laboratory tests used to detect various vector-borne infections for Humana Medicare Advantage products; specifies reimbursable and non-reimbursable tests and symptomatic criteria for reimbursement.

Policy Summary

PayerHumana

PolicyLaboratory - Testing for Vector-Borne Infections

Policy CodePolicy LAB2023053

Change TypeNo material change

Effective Date07/2023

Next Review Date

Key ActionDo not bill or expect reimbursement for listed vector-borne infection tests when performed in asymptomatic individuals; ensure claims meet medical necessity and any referral/authorization requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

LAB2023053Policy identifier

MultipleCovered diseases

AsymptomaticNot reimbursable

Medicare AdvApplies to

Coverage Criteria for Vector-Borne Infection Testing

Patient is symptomatic (one or more of: body aches, chills, fatigue, fever, hemolytic anemia, hepatomegaly, insect bite, jaundice, splenomegaly, weakness)

NAAT/PCR testing for Babesia microti (CPT 87469) is ordered

Testing is not an IFA IgG/IgM assay for Babesia (CPT 86753) for the purpose of confirming an established diagnosis

IFA (CPT 86753) is not reimbursable for individuals with a diagnosis of Babesiosis

Borrelia testing

Covered when ALL of the following are met:

Patient is symptomatic (one or more of: arthralgia, chills, headache, insect bite, myalgia, nausea, vomiting)

One of the following tests is ordered to detect Borrelia spp.: NAAT/PCR (CPT 87478), IFA IgG (CPT 86619), or immunoblot IgG/IgM (CPT 0043U/0044U)

Dengue testing

Not reimbursable under the following condition:

Hemagglutination inhibition test (CPT 86280) for individuals with a diagnosis of classical or hemorrhagic dengue fever is not reimbursable

Ehrlichiosis/Anaplasmosis testing

Covered when ALL of the following are met:

Patient is symptomatic (one or more of: fever; gastrointestinal symptoms including nausea, vomiting, diarrhea; headache; insect bite; malaise; myalgia; shaking chills)

One of the following tests is ordered to detect Anaplasma phagocytophilum or Ehrlichia chaffeensis: NAAT/PCR of whole blood (CPT 87468, CPT 87484) or IFA IgG (CPT 86666)

Rickettsiosis testing

Covered when ALL of the following are met:

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

IFA IgG for Rickettsia (CPT 86757) is ordered

Reimbursable up to twice when at least two weeks has passed between tests

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

West Nile testing

Covered when ALL of the following are met:

Patient is symptomatic (one or more of: abdominal pain, altered level of consciousness, arthralgia, fatigue, fever, headache, insect bite, maculopapular rash, myalgia, nausea, neck stiffness, vision loss, vomiting, weakness)

IFA IgM testing for West Nile virus (CPT 86788, CPT 86789) is ordered

IFA IgG for West Nile virus (CPT 86789) used for individuals with an established diagnosis is not reimbursable

Zika testing

Covered when ALL of the following are met:

Patient has one or more of the following clinical findings or exposures: 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

Test options

NAAT/PCR testing for Zika virus (CPT 87662)
IgM testing for Zika virus (CPT 86794)

References to Original Medicare LCD policies for Zika testing (A55326, A55327)

General exclusion for asymptomatic individuals

Not reimbursable when the following condition is met:

Any of the listed tests for Babesiosis, Borrelia, Dengue virus, Ehrlichiosis/Anaplasmosis, Plasmodium, Rickettsiosis, West Nile virus, or Zika virus are performed in asymptomatic individuals

References and scope note

Scope and references:

Scope: Policy applies to laboratory testing for vector-borne infections (Policy Number: LAB2023053) for Humana Medicare Advantage products

References: See cited CDC guidance, CDC Yellow Book, peer-reviewed literature, and clinical resources listed in the policy reference section

Applicable Procedure and Lab Codes

Applicable CPT/HCPCS/Lab codesmixed

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

1–10 of 17

1/2

example testmixed

LCMAL

Malaria, Molecular Detection, PCR (varies) - referenced test ID

Rickettsia IFA frequency

Policy frequency ruleIFA IgG to Rickettsia (CPT 86757) is reimbursable up to twice provided at least two weeks elapse between tests

Symptomatic requirementTesting is only reimbursable for individuals with listed symptoms (eg, fever, headache, rash, insect bite, myalgia, nausea, vomiting)

Non-reimbursable related testBlood culture (CPT 87040) is not reimbursable for individuals with a diagnosis of typhus fever or Rickettsiosis

Claims, Billing, and Provider Requirements

Note

Claims processing requirements

As a Medicare Advantage plan, claims payments are subject to plan requirements including medical necessity, reasonableness, and any applicable referral or authorization requirements.

Applies to Medicare Advantage unless superseded by Original Medicare LCDs

Denial Risk

Asymptomatic testing exclusion

For asymptomatic individuals, testing for Babesiosis, Borrelia, Dengue virus, Ehrlichiosis and Anaplasmosis, Plasmodium, Rickettsiosis, West Nile virus or Zika virus with the tests discussed in this policy is not reimbursable.

Note

Policy header

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

Scope, Definitions, and Applicability

Medicare Advantage scope

Applies toMedicare Advantage products (Humana) — policy guidance for claims payment

Policy identifierLAB2023053

Scope noteGuidance does not guarantee coverage or plan preauthorization; claims subject to state/federal law and provider contract terms

Applicable procedures / codes

Highlighted codeCPT 87469 — Infectious agent detection; Babesia microti

Selected antibody codesCPT 86757 — Antibody; Rickettsia; CPT 86788/86789 — West Nile virus antibodies

Molecular detection codesCPT 87468/87484 — Anaplasma/Ehrlichia; CPT 87662 — Zika NAAT

Other codesCPT 86280 — Hemagglutination inhibition test; CPT 87040 — Blood culture

Vector-borne infections (examples)

MalariaPlasmodium (malaria) — referenced in CDC Yellow Book and claims references

DengueDengue virus — testing guidance and references cited

West Nile virusWest Nile virus — included among referenced arboviral diseases

Rocky Mountain spotted fever (rickettsial diseases)Rickettsial diseases including Rocky Mountain spotted fever are cited in clinical references

BabesiosisBabesiosis — cited in clinical and diagnostic references (PCR detection studies)

Policy Summary

PayerHumana

PolicyLaboratory - Testing for Vector-Borne Infections

Policy CodePolicy LAB2023053

Change TypeNo material change

Effective Date07/2023

Next Review Date

SourceLink

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