555 Form

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Medical Policy Identification of Microorganisms Using Nucleic Acid Probes Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History
Policy Number: 555 BCBSA Reference Number: 2.04.10 (For Plan internal use only) NCD/LCD: N/A
Related Policies
• Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease #171 • Multitarget Polymerase Chain Reaction Testing for Diagnosis of Bacterial Vaginosis #711 • Pathogen Panel Testing #045 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

The use of nucleic acid testing using a direct or amplified probe technique (without quantification of viral load) may be considered MEDICALLY NECESSARY for the following microorganisms:

• Bartonella henselae or quintana • Bordetella pertussis • Candida species
• Chlamydia pneumoniae • Chlamydiatrachomatis • Clostridium difficile • Enterococcus, vancomycin-resistant (eg, enterococcus vanA, vanB) • Enterovirus • Herpes simplex virus • Human papillomavirus
• Influenza virus • Legionella pneumophila • Mumps • Mycobacterium species • Mycobacterium tuberculosis • Mycobacterium avium intracellulare • Mycoplasma genitalium (MG)

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• Mycoplasma pneumoniae • Neisseria gonorrhoeae • Rubeola (measles) • Staphylococcus aureus • Staphylococcus aureus, methicillin resistant • Streptococcus, group A • Streptococcus, group B • Trichomonas vaginalis • Zika virus.

The use of molecular diagnostics for the diagnosis and management of Borrelia burgdorferi infection (Lyme disease) is addressed in policy #171.

The use of multitarget polymerase chain reaction testing for the diagnosis of Bacterial vaginosis is addressed in policy #711.

For Candida species, culture for yeast remains the criterion standard for identifying and differentiating these organisms. Although sensitivity and specificity are higher for nucleic acid amplification tests (NAATs) than for standard testing methods, the CDC and other association guidelines do not recommend NAATs as first-line testing for Candida species. The CDC Centers for Disease Control and Prevention (2015) classifies uncomplicated vulvovaginal candidiasis as being sporadic or infrequent; or mild to moderate; or, in non-immunocompromised women, as likely to be caused by C. albicans. A presumptive diagnosis can be made in the clinical care setting. However, for complicated infections, the CDC states that NAATs may be necessary to test for multiple Candida subspecies. Complicated vulvovaginal candidiasis is classified as being recurrent or severe; or, in women with uncontrolled diabetes, debilitation, or immunosuppression, as less likely to be caused by a C. albicans species.

Antibiotic sensitivity of streptococcus A cultures is generally not performed for throat cultures. However, if an antibiotic sensitivity is considered, then the most efficient method of diagnosis would be a combined culture and antibiotic sensitivity.

In the evaluation of group B streptococcus, the primary advantage of a DNA probe technique compared with traditional culture techniques is the rapidity of results. This advantage suggests that the most appropriate use of the DNA probe technique is in the setting of impending labor, for which prompt results could permit the initiation of intrapartum antibiotic therapy.

It should be noted that the technique for quantification includes both amplification and direct probes; therefore, simultaneous coding for both quantification with either amplification or direct probes is not warranted.

Many probes have been combined into panels of tests. For the purposes of this policy, other than the gastrointestinal pathogen panel and central nervous system panel, only individual probes are reviewed.

The use of nucleic acid testing using a direct or amplified probe technique (with or without quantification of viral load) may be considered MEDICALLY NECESSARY for the following microorganisms: • Cytomegalovirus • Hepatitis B virus • Hepatitis C virus • HIV-1 • HIV-2 • Human herpesvirus 6.

The use of nucleic acid testing with quantification of viral load is considered INVESTIGATIONAL for microorganisms that are not included in the list of microorganisms for which probes with or without quantification are considered MEDICALLY NECESSARY.

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The use of nucleic acid testing using a direct or amplified probe technique of viral load is considered INVESTIGATIONAL for the following microorganisms: • Gardernella vaginalis • Hepatitis G.

CPT codes 87797, 87798, and 87799 describe the use of direct probe, amplified probe, and quantification, respectively, for infectious agents not otherwise specified. A discussion of every infectious agent that might be detected with a probe technique is beyond the scope of this policy.

The use of the following nucleic acid testing panels (with or without quantification of viral load for viral panel elements) including but not limited to, is considered INVESTIGATIONAL: • Central nervous system pathogen panel • Gastrointestinal pathogen panel • Urinary pathogen panels (including but not limited to Uroswab).

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required. Medicare HMO BlueSM Prior authorization is not required. Medicare PPO BlueSM Prior authorization is not required. CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue:

CPT Codes CPT
codes:

Code Description 87471 Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, amplified probe technique 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

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87485 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, direct probe technique 87486 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, amplified probe technique 87487 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia pneumoniae, quantification 87490 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, direct probe technique 87491 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique 87493 Infectious agent detection by nucleic acid (DNA or RNA); Clostridium difficile, toxin gene(s), amplified probe technique 87494 Chlamydia trachomatis and Neisseria gonorrhoeae, multiplex 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 87498 Infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique, includes reverse transcription when performed 87500 Infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique 87501 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, includes reverse transcription, when performed, and amplified probe technique, each type or subtype 87502 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, first 2 types or sub-types 87503 Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, each additional influenza virus type or sub-type beyond 2 (List separately in addition to code for primary procedure) 87516 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis B virus, amplified probe technique 87517 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis B virus, quantification 87520 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, direct probe technique 87521 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, amplified probe technique, includes reverse transcription when performed 87522 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performed 87523 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis D (delta), quantification, including reverse transcription, when performed 87528 Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, direct probe technique 87529 Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, amplified probe technique 87531 Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, direct probe technique 87532 Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, amplified probe technique 87534 Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, direct probe technique

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87535 Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, amplified probe technique, includes reverse transcription when performed 87536 Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, quantification, includes reverse transcription when performed 87537 Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, direct probe technique 87538 Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, amplified probe technique, includes reverse transcription when performed 87539 Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, quantification, includes reverse transcription when performed 87540 Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, direct probe technique 87541 Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, amplified probe technique 87550 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria species, direct probe technique 87551 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria species, amplified probe technique 87555 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, direct probe technique 87556 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, amplified probe technique 87560 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium- intracellulare, direct probe technique 87561 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium- intracellulare, amplified probe technique 87563 Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma genitalium, amplified probe technique 87564 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacterium tuberculosis, rifampin resistance, amplified probe technique 87580 Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, direct probe technique 87581 Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, amplified probe technique 87590 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, direct probe technique 87591 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique 87623 Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44) 87624 Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (eg, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68), pooled result 87625 Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), types 16 and 18 only, includes type 45, if performed 87626 Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), separately reported high-risk types (eg, 16, 18, 31, 45, 51, 52) and high-risk pooled result(s) 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

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87653 Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group B, amplified probe technique 87660 Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, direct probe technique 87661 Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, amplified probe technique 87662 Infectious agent detection by nucleic acid (DNA or RNA); Zika virus, amplified probe technique

The following CPT codes are considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue:

CPT Codes CPT
codes:

Code Description 87472 Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, quantification 87475 Infectious agent detection by nucleic acid (DNA or RNA); Borrelia burgdorferi, direct probe technique 87482 Infectious agent detection by nucleic acid (DNA or RNA); Candida species, quantification 87483 Infectious agent detection by nucleic acid (DNA or RNA); central nervous system pathogen (eg, Neisseria meningitidis, Streptococcus pneumoniae, Listeria, Haemophilus influenzae, E. coli, Streptococcus agalactiae, enterovirus, human parechovirus, herpes simplex virus type 1 and 2, human herpesvirus 6, cytomegalovirus, varicella zoster virus, Cryptococcus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets 87492 Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, quantification 87510 Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, direct probe technique 87511 Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, amplified probe technique 87512 Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, quantification 87513 Infectious agent detection by nucleic acid (DNA or RNA); Helicobacter pylori (H. pylori), clarithromycin resistance, 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 87527 Infectious agent detection by nucleic acid (DNA or RNA); hepatitis G, quantification 87530 Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, quantification 87533 Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, quantification 87542 Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, quantification 87552 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria species, quantification 87557 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, quantification 87562 Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium- intracellulare, quantification 87582 Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, quantification

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87592 Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, quantification 87594 Infectious agent detection by nucleic acid (DNA or RNA); Pneumocystis jirovecii, amplified probe technique 87627 Infectious agent detection by nucleic acid (DNA or RNA); joint space pathogens and drug resistance genes, multiplex amplified probe technique, 26 or more targets 87652 Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, quantification 0321U Infectious agent detection by nucleic acid (DNA or RNA), genitourinary pathogens, identification of 20 bacterial and fungal organisms and identification of 16 associated antibiotic-resistance genes, multiplex amplified probe technique 0323U Infectious agent detection by nucleic acid (DNA and RNA), central nervous system pathogen, metagenomic next-generation sequencing, cerebrospinal fluid (CSF), identification of pathogenic bacteria, viruses, parasites, or fungi 0402U Infectious agent (sexually transmitted infection), Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Mycoplasma genitalium, multiplex amplified probe technique, vaginal, endocervical, or male urine, each pathogen reported as detected or not detected

The following CPT codes are considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity:

CPT Codes CPT
codes:

Code Description 87505 Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets 87506 Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets 87507 Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets

Description Nucleic Acid Probes A nucleic acid probe is used to detect and identify species or subspecies of organisms by identifying nucleic acid sequences in a sample. Nucleic acid probes detect genetic materials, such as RNA or DNA, unlike other tests, which use antigens or antibodies to diagnose organisms.

The availability of nucleic acid probes has permitted the rapid direct identification of microorganism DNA or RNA. Amplification techniques result in exponential increases in copy numbers of a targeted strand of microorganism-specific DNA. The most used amplification technique is polymerase chain reaction (PCR) or reverse transcriptase PCR. In addition to PCR, other nucleic acid amplification techniques have been developed, such as transcription-mediated amplification, loop-mediated isothermal DNA amplification, strand displacement amplification, nucleic acid sequence-based amplification, and branched-chain DNA signal amplification. After amplification, target DNA can be readily detected using a variety of techniques. The amplified product can also be quantified to assess how many microorganisms are present. Quantification of the number of nucleic acids permits serial assessments of response to treatment; the

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most common clinical application of quantification is the serial measurement of HIV RNA (called viral load).

The direct probe technique, amplified probe technique, and probe with quantification methods vary based on the degree to which the nucleic acid is amplified and the method for measurement of the signal. The direct probe technique refers to detection methods in which nucleic acids are detected without an initial amplification step. The amplified probe technique refers to detection methods in which either target, probe, or signal amplification is used to improve the sensitivity of the assay over direct probe techniques, without quantification of nucleic acid amounts. • Target amplification methods include PCR (including PCR using specific probes, nested or multiplex PCR), nucleic acid-based sequence amplification, transcription-mediated amplification, and strand displacement amplification. Nucleic acid-based sequence amplification and transcription-mediated amplification involve amplification of an RNA (rather than a DNA) target. • Probe amplification methods include ligase chain reaction. • Signal amplification methods include branched DNA (bDNA) probes and hybrid capture methods using an anti-DNA/RNA hybrid antibody.

The probe with quantification techniques refers to quantitative PCR or real-time PCR methods that use a reporter at each stage of the PCR to generate absolute or relative amounts of a known nucleic acid sequence in the original sample. These methods may use DNA-specific dyes (ethidium bromide or SYBR green), hybridization probes (cleavage-based [TaqMan] or displaceable), or primer incorporated probes.

Direct assays will generally have lower sensitivity than amplified probes. In practice, most commercially available probes are amplified, with a few exceptions. For this evidence review, indications for direct and/or amplified probes without quantification are considered together, while indications for a probe with quantification are considered separately.

Classically, identification of microorganisms relies either on the culture of body fluids or tissues or identification of antigens, using a variety of techniques including direct fluorescent antibody technique and qualitative or quantitative immunoassays. These techniques are problematic when the microorganism exists in very small numbers or is technically difficult to culture. Indirect identification of microorganisms by immunoassays for specific antibodies reactive with the microorganism is limited by difficulties in distinguishing between past exposure and current infection.

Potential reasons for a nucleic acid probe to be associated with improved clinical outcomes compared with standard detection techniques include the following (note: in all cases, for there to be clinical utility, making a diagnosis should be associated with changes in clinical management, which could include initiation of effective treatment, discontinuation of other therapies, or avoidance of invasive testing): • Significantly improved speed and/or efficiency in making a diagnosis. • Improved likelihood of obtaining any diagnosis in cases where standard culture is difficult. Potential reasons for difficulty in obtaining standard culture include low numbers of the organisms (e.g., HIV), fastidious or lengthy culture requirements (e.g., Mycobacteria, Chlamydia, Neisseria species), or difficulty in collecting an appropriate sample (e.g., herpes simplex encephalitis). • There is no way to definitively make a diagnosis without nucleic acid testing. • The use of nucleic acid probe testing provides qualitatively different information than that available from standard cultures, such as information regarding disease prognosis or response to treatment. These include cases where quantification of viral load provides prognostic information or is used to measure response to therapy.

The risks of nucleic acid testing include false-positive and false-negative results, inaccurate identification of pathogens by the device, inaccurate interpretation of test results, or incorrect operation of the instrument. • False-positive results can lead to unnecessary treatment, with its associated toxicities and side effects, including allergic reaction. In addition, true diagnosis and treatment could be delayed or missed altogether.

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• False-negative results could delay diagnosis and initiation of proper treatment. • It is possible that these risks can be mitigated by the use of a panel of selected pathogens indicated by the clinical differential diagnosis while definitive culture results are pending.

Summary Description Nucleic acid probes are available for the identification of a wide variety of microorganisms. Nucleic acid probes can also be used to quantitate the number of microorganisms present. This technology offers advantages over standard techniques when rapid identification is clinically important, microbial identification using standard culture is difficult or impossible, and/or treatment decisions are based on quantitative results.

Summary of Evidence For individuals who have signs and/or symptoms of meningitis and/or encephalitis who receive a nucleic acid-based central nervous system (CNS) pathogen panel, the evidence includes a systematic review and a pivotal prospective study. Relevant outcomes include test accuracy and validity, other test performance measures, medication use, symptoms, and change in disease status. Access to a rapid method that can simultaneously test for multiple pathogens may lead to the faster initiation of more effective treatment and conservation of cerebrospinal fluid (CSF). The available CNS panel is highly specific for the included organisms, but the sensitivity for each pathogen is not well-characterized. More than 15% of positives in the largest clinical validity study were false-positives. A negative panel result does not exclude infection due to pathogens not included in the panel. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have signs and/or symptoms of gastroenteritis who receive a nucleic acid-based gastrointestinal (GI) pathogen panel, the evidence includes prospective and retrospective evaluations of the tests’ sensitivity and specificity and prospective studies on utility. Relevant outcomes include test accuracy and validity, other test performance measures, medication use, symptoms, and change in disease status. The evidence suggests that pathogen panels are likely to identify both bacterial and viral pathogens with high sensitivity, compared with standard methods. Access to a rapid method for etiologic diagnosis of infections may lead to more effective early treatment and infection control measures. However, in most instances, when a specific pathogen is suspected, individual tests could be ordered. There may be a subset of patients with an unusual presentation who would warrant testing for a panel of pathogens at once, but that subset has not been well defined. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have signs and/or symptoms of respiratory infection who receive a nucleic acid-based respiratory pathogen panel, the evidence includes systematic reviews, 3 randomized controlled trials (RCTs), and quasi-RCT. Relevant outcomes include test accuracy and validity, other test performance measures, medication use, symptoms, and change in disease status. One systematic review reported that all 3 reviewed multiplex polymerase chain reaction systems were highly accurate. Three RCTs and 1 quasi- RCT evaluated utility of a respiratory panel and found benefits in time-to-treat, targeted antibiotic prescriptions, and length of hospital stay. In addition, 1 subanalysis found fewer antibiotics being prescribed for patients diagnosed with the panel. The panel did not significantly affect duration of antibiotic use, readmission, or mortality rates. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome.

Policy History Date Action 1/2026 Clarified coding information. 11/2025 Clarifications made to investigational statements. 11/2025.
8/2025 Annual policy review. Policy updated with literature review through April 4, 2025; references added. Policy statements unchanged. 7/2025 Clarified coding information. 1/2025 Clarified coding information.

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11/2024 Annual policy review. Policy updated with literature review through May 2, 2024; references added. Mycoplasma genitalium added to list of medically necessary nucleic acid testing. Clarified coding information. Effective 11/1/2024. 5/2024 Clarified coding information. 1/2024 Clarified coding information. 12/2023 Policy clarified. Transferred respiratory virus panel testing to MP 045 Pathogen Panel Testing. 8/2023 Annual policy review. References added. Policy statements unchanged. 4/2023 Clarified coding information. 1/2023 Clarified coding information. 9/2022 Policy clarified.
• Ongoing investigational urinary tract infection panel transferred to new MP 045 Pathogen Panel.
• Ongoing medically necessary nucleic acid testing for the following microorganisms transferred to new MP 0045 Pathogen Panel: ▪ Babesiosis
▪ Ehrlichiosis, unspecified
▪ Tick-borne rickettsiosis, unspecified. 8/2022 Clarified coding information. Annual policy review. Description, summary, and references updated. Policy statements unchanged. 7/2022 Clarified coding information. 1/2022 Clarified coding information. 11/2021 Policy clarified to include that urinary tract infection panel is considered investigational. 4/2021 Clarified coding information. 5/2020 Clarified coding information. 3/2020 New medically necessary and investigational indications described. Policy statements changed accordingly and edited for clarity. Clarified coding information. Effective 3/11/2020.

Nucleic acid testing is medically necessary for: ▪ Chlamydia pneumoniae ▪ Bordetella Pertussis ▪ Mumps ▪ Rubeola (measles) ▪ Influenza virus ▪ Zika virus.

Nucleic acid testing respiratory virus panel (without quantification of viral load) is considered medically necessary.

Nucleic acid testing is investigational for: ▪ Central nervous system pathogen panel ▪ Gastrointestinal pathogen panel

Nucleic acid testing using direct or amplified probe technique is investigational for Gardernella vaginalis. 1/2020 Clarified coding information. 2/2019 Annual policy review. Description, summary and references updated. Policy statements unchanged. 5/2018 Annual policy review. Investigational statement added for central nervous system pathogen panel. Prior Authorization Information reformatted. Clarified coding information. Effective 5/1/2018. 1/2018 Clarified coding information. 8/2016 Clarified coding information.

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7/2016 Annual policy review. C. difficile added to list of medically necessary probes.
Effective 7/1/2016.
5/2016 Annual policy review. Direct and amplified assays (without quantification) grouped for medically necessary statements. Medically necessary statement added for non- quantified nucleic acid-based testing for enterovirus, Legionella pneumophila, Mycoplasma pneumoniae, and Bartonella spp, and for quantified testing for human herpesvirus 6. Borrelia testing removed from policy. Effective 5/1/2016. 3/2016 Annual policy review. CPT code 87481 is only medically necessary for severe, treatment resistant Candida infection. Effective 3/1/2016. 7/2015 Local Coverage Determination (LCD): Infectious Disease Molecular Diagnostic Testing (L31747) added. 2/2015 Annual policy review. New investigational indications described. Effective 2/1/2015. 1/2015 Clarified coding information. 3/2014 New medical policy describing ongoing investigational and medically necessary indications. Effective 3/1/2014.
Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

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