ModifiedPartners Health ManagementPolicy CG.CP.MP.03

Concert Infectious Disease: Dermatologic Testing

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Outpatient policy governing medical necessity criteria for laboratory testing to confirm suspected onychomycosis (microscopy/peroxidase, fungal culture, and NAAT/PCR), directed at providers ordering these tests for members/enrollees.

Policy Summary

PayerPartners Health Management

PolicyConcert Infectious Disease: Dermatologic Testing

Policy CodePolicy CG.CP.MP.03

Change TypeWording revised to clarify medical necessity for microscopy and culturecoding table added

Effective Date

Last ReviewNov 20, 2024

Next Review Date

Key ActionDocument signs/symptoms of onychomycosis and justify that test results will influence clinical management when ordering tests.

SourceLink

POLICY UPDATE CHANGES

For Fungal Culture for Onychomycosis and Microscopy/Peroxidase Tests for Onychomycosis, policy statements were reworded from 'may be considered medically necessary' to 'are considered medically necessary.'

Added CPT code table and moved the 'coding implications' section.

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ModifiedPartners Health ManagementPolicy CG.CP.MP.03

Concert Infectious Disease: Dermatologic Testing

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Policy Summary

PayerPartners Health Management

PolicyConcert Infectious Disease: Dermatologic Testing

Policy CodePolicy CG.CP.MP.03

Change TypeWording revised to clarify medical necessity for microscopy and culturecoding table added

Effective Date

Last ReviewNov 20, 2024

Next Review Date

Key ActionDocument signs/symptoms of onychomycosis and justify that test results will influence clinical management when ordering tests.

SourceLink

POLICY UPDATE CHANGES

Added CPT code table and moved the 'coding implications' section.

3test categories addressed

KOH preferredpreferred initial method

2 groupsCPT code groups shown

Outpatientintended setting

2024-11-20Last review date

2References listed

Coverage Criteria for Onychomycosis Testing

Microscopy/Peroxidase Tests

Microscopy/peroxidase tests for onychomycosis are considered medically necessary when ALL of the following are met:

Microscopy/Peroxidase medical necessity: A. The member/enrollee shows signs or symptoms of onychomycosis (e.g., nails that are discolored, deformed, brittle, and/or foul‑smelling; subungual debris; separation of the nail from the nail bed) AND B. Results of testing would influence the member/enrollee's clinical management.

If criteria not met, current evidence does not support use for other indications.

Fungal Culture for Onychomycosis

Fungal culture for onychomycosis (presumptive and/or definitive) are considered medically necessary when ALL of the following are met:

Fungal culture medical necessity: A. The member/enrollee shows signs or symptoms of onychomycosis (e.g., nails that are discolored, deformed, brittle, and/or foul‑smelling; subungual debris; separation of the nail from the nail bed) AND B. Results of testing would influence the member/enrollee's clinical management.

Current evidence does not support use for other indications.

Culture-Independent Molecular Tests (NAAT/PCR)

Culture-independent molecular tests (NAAT/PCR) for onychomycosis:

NAAT/PCR general stance: Current evidence does not support the use of culture-independent molecular tests (NAAT/PCR) for onychomycosis for all indications.

Molecular methods (eg, PCR) can increase detection of dermatophytes compared with culture but may detect nonpathogenic or dead organisms, which can limit clinical interpretation and identification of the true causative pathogen.

Laboratory testing to confirm suspected onychomycosis includes microscopy/peroxidase tests, fungal culture (presumptive and/or definitive), and culture‑independent molecular tests (NAAT/PCR). Microscopy/peroxidase tests and fungal culture are considered medically necessary when BOTH: (1) the member/enrollee shows signs or symptoms of onychomycosis (for example, nails that are discolored, deformed, brittle, and/or foul‑smelling; subungual debris; or separation of the nail from the nail bed) AND (2) test results would influence the member/enrollee’s clinical management. Current evidence does not support the use of these tests for other indications.

For culture‑independent molecular tests (NAAT/PCR), the policy states that current evidence does not support their use for onychomycosis for all indications; NAAT/PCR are not routine first‑line tests under this clinical policy and require plan‑level justification when considered.

When state Medicaid coverage provisions conflict with this clinical policy, the state Medicaid coverage provisions take precedence. Providers should consult the applicable state Medicaid manual and plan‑level administrative policies for any differing coverage rules or requirements.

The policy explicitly notes that NAAT/PCR testing for onychomycosis is not supported by current evidence for all indications and therefore is generally considered not medically necessary for routine use under this policy unless specific plan‑level justification is provided.

Coding and Billing Information

Fungal culture-related CPT codesCPT

87101	Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; skin, hair, or nail
87102	Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; other source (except blood)
87106	Culture, fungi, definitive identification, each organism; yeast
87107	Culture, fungi, definitive identification, each organism; mold

Microscopy and molecular/NAAT CPT codes (mixed organisms)CPT

87220	Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites (eg, scabies)
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
87500	Infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique
87640	Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, amplified probe technique
87641	Infectious agent detection by nucleic acid (DNA or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique
87650	Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, direct probe technique
87651	Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique
87652	Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, quantification

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Provider Actions, Documentation & Authorization

Billing Rule

Verify CPT coding before submission

CPT codes listed in this policy are provided for informational purposes only; providers must verify the most current and applicable CPT guidance prior to claims submission.

Codes shown (e.g., 87101, 87102, 87106, 87107, 87220, 87480–87482, 87500, 87640–87641, 87650–87653, 87798–87799, 87800–87801) are examples from the coding section and are not exhaustive.
Inclusion or exclusion of codes in this policy does not guarantee coverage.

Prior Authorization

Prior authorization determined by the Health Plan

This clinical policy provides medical necessity guidance to assist coverage decisions; whether prior authorization is required is determined by the adopting Health Plan and documented in plan-level administrative policies.

Background

Onychomycosis is a common fungal infection of the nails that more frequently affects toenails and typically presents with discoloration, splitting or deformation, increased brittleness, subungual debris, and possible separation of the nail from the nail bed. Because non‑fungal and non‑infectious nail disorders can mimic onychomycosis, laboratory confirmation (for example, microscopy or culture) is recommended before initiating systemic antifungal therapy to ensure appropriate management.

Definitions and Test Descriptions

KOH preparation (potassium hydroxide)

DefinitionKOH (potassium hydroxide) preparation: a microscopy technique that rapidly detects fungal elements from nail, skin, or hair samples.

Preferred diagnostic methodPreferred initial diagnostic method for onychomycosis per AAFP because it is highly specific, provides rapid results, and is cost‑effective.

Clinical useDiagnosis by KOH preparation alone is sufficient to initiate treatment; if KOH is negative but clinical suspicion remains high, additional testing may be performed.

SettingIntended for outpatient use to confirm fungal infection before initiating antifungal therapy.

NAAT/PCR (culture-independent molecular tests)

DefinitionNAAT/PCR (culture‑independent molecular tests): molecular methods that can increase detection of dermatophytes compared with culture.

Revision History

2025-02administrativeLatest

Approval recorded following annual review that reworded policy statements for Fungal Culture and Microscopy/Peroxidase Tests from 'may be considered medically necessary' to 'are considered medically necessary', and added policy number to header.

2024-11revision

Annual review updated policy wording for Fungal Culture and Microscopy/Peroxidase Tests from 'may be considered medically necessary' to 'are considered medically necessary' and added policy number to header.

2024-02

Policy Summary

PayerPartners Health Management

PolicyConcert Infectious Disease: Dermatologic Testing

Policy CodePolicy CG.CP.MP.03

Change TypeWording revised to clarify medical necessity for microscopy and culturecoding table added

Effective Date

Last ReviewNov 20, 2024

Next Review Date

Key ActionDocument signs/symptoms of onychomycosis and justify that test results will influence clinical management when ordering tests.

SourceLink

On This Page

Prior authorization requirements, if any, are set by the Health Plan and may differ from the policy's medical necessity statements.

Step Therapy

No step therapy required

No step therapy requirements are specified in this portion of the policy.

Documentation Required

Include required clinical documentation with test requests

Document clinical signs or symptoms of onychomycosis and the clinical rationale that test results will influence management when ordering diagnostic testing.

Examples of signs/symptoms to document: discolored, deformed, brittle, and/or foul-smelling nails; subungual debris; separation of the nail from the nail bed.
Document how test results will affect treatment decisions (e.g., need to confirm fungal etiology prior to systemic antifungal therapy).

Documentation Required

Adhere to coverage documents and legal requirements

Follow applicable coverage documents, contracts, and state/federal requirements when requesting coverage for dermatologic infectious disease testing; the policy is a guide but does not replace plan-level or legal requirements.

Coverage decisions are subject to the terms, conditions, exclusions and limitations of the member's coverage documents and to state and federal law.

Denial Risk

Testing may be denied for lack of clinical indication

Tests may be considered not supported or denied when clinical indications do not meet the policy's medical necessity criteria.

Examples include absence of signs/symptoms of onychomycosis or when test results would not influence clinical management.

Denial Risk

Denial risk due to coverage document limits

Coverage and administration of benefits are governed by the member's coverage documents and applicable state/federal requirements; services inconsistent with those documents may be denied.

The policy does not guarantee payment; Health Plan-level administrative policies and legal requirements control final coverage decisions.

Limitation — detection of nonviable organismsMay detect nonpathogenic or dead fungus, which can limit ability to identify the true causative pathogen.

Clinical implicationCurrent evidence does not support use of NAAT/PCR for all indications for onychomycosis; interpretation may be limited when detected organisms are not viable.

Role in practiceCan increase detection rates compared with culture but may require additional methods (eg, RFLP) for strain identification in treatment failures; not routinely implemented in practice per guidelines.

Health Plan — definition

Definition'Health Plan' means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan's affiliates, as applicable.

Role of policyThe clinical policy provides guidance on medical necessity to assist in coverage decisions and benefit administration; it is not a payment guarantee or contract.

ApplicabilityCoverage decisions remain subject to the terms, conditions, exclusions, and limitations of the Health Plan's coverage documents and applicable state and federal requirements.

Added 'Lab' to the policy title, removed CPT and ICD-10 codes from the policy reference table, added a CPT code table, and moved the 'coding implications' section.

2024-03correction

Corrected CPT code descriptions in the CPT code table.

2023-11development

Policy developed and reviewed by an external specialist.