Highmark Commercial Medical Policy - Pennsylvania

Medical Policy: L-140-008
Topic: Genitourinary Conditions Molecular Testing
Section: Laboratory
Effective Date: July 1, 2018
Issue Date: July 2, 2018
Last Reviewed: March 2018

Molecular testing for genitourinary conditions may include nucleic acid testing, flow cytometry, immunohistochemistry, or other specialized molecular studies.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

Chlamydia Trachomatis 

Testing may be considered medically necessary in asymptomatic individuals when the following criteria are met:

Indications for testing in symptomatic individuals:

Testing Policy:

Quantitative testing for chlamydia trachomatis (87492) is considered experimental/investigational and, therefore, non-covered due to lack of scientific evidence demonstrating medical necessity.

Procedure Codes
87490, 87491, 87492



Neisseria Gonorrhoeae (N. Gonorrhoeae)

Testing may be considered medically necessary for individuals when the following criteria are met:

Testing policy:

Quantitative testing for N. gonorrhoeae (87592) is considered experimental/investigational and, therefore, non-covered due to lack of scientific evidence demonstrating medical necessity.

Procedure Codes
87590, 87591, 87592



Trichomonas Vaginalis

Testing may be considered medically necessary for individuals when the following criteria are met:

Testing Policy:

Repeat testing more frequently than every three months is considered not medically necessary.

Procedure Codes
87660, 87661



Candida Species

Testing may be considered medically necessary for individuals when the following criteria are met:

Testing Policy:

Quantitative testing for Candida albicans (87482) is considered experimental/investigational and, therefore, non-covered due to lack of scientific evidence demonstrating medical necessity.

Procedure Codes
87480, 87481, 87482



Gardnerella Vaginalis

Gardnerella Vaginalis may be considered medically necessary when the following criteria are met:

Indications for asymptomatic individuals

Indications for symptomatic individuals

Testing Policy:

Testing in males is considered not medically necessary.

Quantitative testing for Gardnerella vaginalis (87512) is considered experimental/investigational and, therefore, non-covered due to lack of scientific evidence demonstrating medical necessity.

Procedure Codes
87510, 87511, 87512



Herpes simplex virus (HSV)

Testing may be considered medically necessary for individuals when the following criteria are met:

Testing Policy:

Procedure Codes
87528, 87529, 87530



Human Papillomavirus (HPV)

Testing may be considered medically necessary for individuals when the following criteria are met:

Testing for low-risk (non-oncogenic) types of HPV (87623) is considered experimental/investigational and, therefore, non-covered due to lack of scientific evidence demonstrating medical necessity.

Testing policy:

HPV testing before age 21 for any indication (asymptomatic or symptomatic) is non-covered.

Low-risk (nononcogenic) HPV testing is considered not medically necessary.

Flow cytometry (e.g., HPV OncoTect) (88184, 88185, and/or 88187) methods for HPV detection is considered experimental/investigational and, therefore, non-covered due to lack of scientific evidence demonstrating medical necessity.

Procedure Codes
87623, 87624, 87625 , 88184, 88185, 88187, 88365, G0476



Infectious Agent, Not Otherwise Specified

Testing may be considered medically necessary for individuals when the following criteria are met:

Testing policy:

NAAT for infectious agents not otherwise specified (87797, 87798, 87799) has not been demonstrated for the detection and management of sexually transmitted infections and is considered experimental/investigational and, therefore, non-covered.

Procedure Codes
87797, 87798, 87799



Refer to the diagnosis code attachment for additional information:

  • Testing is presumed to be done for sexually transmitted infections when billed with an ICD code included in the attachment. 
  • ICD10 codes in the attachment may be used to support medical necessity as described in the above policies.
    • Tables of ICD codes related to specific policies are referenced throughout this document. ICD10 codes are provided in separate sections. The correct section should be referenced based on the ICD code set in effect at that time.

Refer to the table attachment for additional information:

  • Codes addressed in this policy will be evaluated for medical necessity based upon the medically necessary criteria.


Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Testing for genitourinary conditions, is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.


The policy position applies to all commercial lines of business


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

A network provider can bill the member for the non-covered service.

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Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer: If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.