Identification of Microorganisms using Nucleic Acid Probes
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Defines coverage and reimbursement guidance for laboratory tests that identify microorganisms using nucleic acid probe, amplified probe, and quantification methods for Oscar Health members; applies to providers submitting claims for these tests.
No material clinical or coverage changes in this revision.
Coverage Criteria
Per-organism coverage criteria
Coverage status is determined per organism and per test type (Direct Probe, Amplified Probe, Quantification). Tests are designated as 'MCC' (meets criteria) or 'DNMCC' (does not meet criteria).
Do not order amplified probe and quantification for the same organism in a single encounter (simultaneous amplified probe + quantification = DNMCC).
Preferred molecular testing (Mycoplasma pneumoniae)
Covered when molecular testing is appropriate according to authoritative guidance
Source: CDC guidance
MRSA testing considerations
Covered as part of recommended testing strategies for MRSA
Source: CDC guidance
Public health–recommended molecular testing (enterovirus, RSV, mpox)
Covered when consistent with public health agency recommendations
Source: CDC
Source: CDC
Source: ECDC and UKHSA
HHV-6 quantitative testing criteria
Interpretation and quantification guidance (HHV-6)
Source: HHV-6 Foundation
Simultaneous ordering of an amplified probe test and a quantification test for the same organism within a single clinical encounter does not meet criteria. The policy’s per‑organism table distinguishes test types (Direct Probe, Amplified Probe, Quantification) and explicitly prohibits submitting both amplified probe and quantification for the same organism on the same encounter, which may lead to denial of coverage.
The policy notes that no guidance was found on Hepatitis G. It further states that the CDC does not recommend routine quantification by PCR for Bartonella, Legionella pneumophila, or Mycoplasma pneumoniae, although PCR testing can be performed for Bartonella and Legionella pneumophila when clinically appropriate.
The per‑organism table in the policy lists specific test‑type entries that are designated DNMCC (does not meet criteria). Examples include: Bartonella henselae quantification 87472 (DNMCC); Chlamydia pneumoniae direct probe 87485 (DNMCC) and quantification 87487 (DNMCC); Hepatitis G direct, amplified, and quantification 87525, 87526, 87527 (all DNMCC); HHV‑6 direct and amplified probes 87531, 87532 (DNMCC); Legionella pneumophila direct and quantification 87540, 87542 (DNMCC); Mycoplasma pneumoniae direct and quantification 87580, 87582 (DNMCC). These entries are not covered for the indicated CPT codes per the table.
The policy references the HHV‑6 Foundation guidance that qualitative PCR on whole blood is not useful to differentiate active from latent HHV‑6 infection. The document states that quantitative PCR on blood or tissues is preferred, and that viral load thresholds suggesting active infection include >200 copies per mL or >20 copies per µg DNA.
Covered Indications
Use of NAAT/PCR for organism-specific diagnosis where guideline-recommended (e.g., mpox, Chlamydia pneumoniae, C. difficile, CMV, MRSA, Mycoplasma pneumoniae).
Use NAAT/PCR when recommended by guideline or public health sources for organism-specific diagnosis.
References: WHO, CDC, IDSA/ASM guidance cited in policy
Diagnosis of suspected infection with specific organisms (e.g., Mycoplasma pneumoniae, non-polio enterovirus, RSV, orthopoxvirus/mpox) where molecular testing is recommended by public health guidance.
Diagnosis of suspected infection with specific organisms where molecular testing is recommended by public health guidance.
Source: CDC guidance
Source: CDC
Source: CDC
Sources: WHO, ECDC, UKHSA
Coding
| 87471 | Bartonella henselae amplified probe (MCC) |
| 87472 | Bartonella henselae quantification (DNMCC) |
| 87485 | Chlamydia pneumoniae direct probe (DNMCC) |
| 87486 | Chlamydia pneumoniae amplified probe (MCC) |
| 87487 | Chlamydia pneumoniae quantification (DNMCC) |
| 87493 | Clostridium difficile amplified probe (MCC) |
| 87495 | Cytomegalovirus direct probe (DNMCC) |
| 87496 | Cytomegalovirus amplified probe (MCC) |
| 87497 | Cytomegalovirus quantification (MCC) |
| 87498 | Enterovirus amplified probe (MCC) |
| 87471 | Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, amplified probe technique. |
| 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. |
| 87500 | Infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique. |
| 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. |
| 87531 | Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, direct probe technique. |
| unspecified | Infectious agent detection by nucleic acid (DNA or RNA); orthopoxvirus (eg, monkeypox virus), amplified probe technique; respiratory syncytial virus, amplified probe technique; Staphylococcus aureus, amplified probe technique; Staphylococcus aureus, methicillin-related amplified probe technique (as listed in Applicable CPT/HCPCS Procedure Codes section). |
Provider Actions & Billing
Authorization and medical necessity
Coverage is determined by applying this policy's criteria together with the member's benefit at the time of the request; services must meet authorization and medical necessity requirements to be eligible for reimbursement.
- See applicable CPT/HCPCS codes in the coding section when submitting authorization requests.
Use specified CPT/HCPCS codes
Bill using the specific CPT/HCPCS procedure codes listed in the policy's coding section for the organism and test type performed; refer to the enumerated codes for direct probe, amplified probe, and quantification tests when submitting claims.
- Codes listed in Section VIII of the policy correspond to the organism and test method (e.g., amplified probe, quantification).
Reserved
(Reserved)
Preferred molecular testing for select organisms
Use molecular testing (NAAT/PCR) as the preferred diagnostic method where indicated by authoritative guidance — for example, NAATs are the preferred method for Mycoplasma pneumoniae and molecular detection (PCR for mecA) is an available method for MRSA per CDC guidance.
- Order organism-specific NAAT/PCR when recommended by public health or specialty guidance to inform diagnosis and treatment decisions.
Documentation and coding
Providers are responsible for submission of accurate documentation of services performed and must code claims according to industry-standard coding guidelines when filing claims.
- Follow Uniform Billing, AMA CPT, HCPCS, ICD-10, CMS NCCI and other applicable coding resources referenced in the policy.
- Accurate documentation must accompany claims to support medical necessity.
Specimen documentation for mpox follow-up
When follow-up mpox testing is clinically required (for clinical deterioration or to inform discharge), include lesion swab(s) and a throat swab in viral transport medium; additional recommended specimens include blood in an EDTA tube and urine.
- Collect lesion swab(s) and throat swab per UKHSA guidance.
- Collect blood (EDTA) and urine when follow-up testing is indicated.
Coding and documentation compliance
Claims may be denied or recouped if appropriate coding/billing guidelines or current reimbursement policies are not followed; ensure coding and documentation comply with the industry and CMS guidance cited in the policy.
- Noncompliance with coding/billing guidelines or reimbursement policies can lead to denial or recoupment of payments.
Prohibited simultaneous testing
Do not order amplified probe testing and quantification for the same organism in a single encounter; simultaneous ordering of those two test types does not meet criteria and may result in denial.
- Simultaneous amplified probe and quantification for the same organism in one encounter is specifically listed as NOT MEETING CRITERIA.
LDT validation and regulation
If using laboratory-developed tests (LDTs), ensure they are validated and performed in accordance with CLIA '88 high-complexity requirements, since LDTs are regulated by CMS as high-complexity tests and lack FDA clearance; failure to validate per CLIA may result in noncompliance and potential denial.
- LDTs must be validated and are regulated by CMS as high-complexity tests under CLIA '88.
- FDA clearance is not required for clinical use, but CLIA validation is required to avoid CMS noncompliance.
Ordering Requirements
Who may order and how to order tests
Order tests according to clinical guidelines and specimen recommendations; clinicians, including licensed advanced practice providers, are considered appropriate orderers as described in referenced guidance.
Specimen collection per UKHSA for mpox
For mpox testing, collect lesion swab(s) in viral transport medium from vesicles/ulcers and obtain a throat swab for high‑risk contacts without skin lesions; follow UKHSA guidance for additional specimens when follow-up testing is required.
- Take a viral swab from a vesicle/ulcer and place in viral transport medium
- Obtain a throat swab for high‑risk contacts with systemic symptoms but no rash
- Collect lesion and throat swabs, blood in an EDTA tube, and urine when follow‑up testing is required
Frequency Limits
Not Covered / Does Not Meet Criteria
Tests explicitly designated DNMCC (does not meet criteria) in the per‑organism table are not covered for the CPT codes shown in that table. Providers should use the table to determine coverage status by organism and test type; entries marked DNMCC indicate the service is not covered for the listed procedure code.
The document contains no separate comprehensive cover/exclusion list beyond the per‑organism table. It specifically notes that no guidance was found on Hepatitis G and the policy does not explicitly endorse Hepatitis G testing; Hepatitis G entries in the table are designated DNMCC for direct probe, amplified probe, and quantification.
Background
Nucleic acid hybridization technologies such as PCR and related amplified probe methods detect pathogen DNA or RNA with high sensitivity and specificity and are widely used in clinical diagnostics. The policy highlights both advantages (faster turnaround, higher sensitivity) and limitations (contamination risk, variable validation and interpretation), and references the importance of quantitative methods—for example, to distinguish active versus latent HHV‑6 infection—when clinically indicated.
Definitions
Revision History
Policy governance approved the original documentation for 'Identification of Microorganisms using Nucleic Acid Probes'.
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