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 (see Policy Guidelines):
Bartonella henselae or quintana
Bordetella pertussis
Candida species
Chlamydia pneumoniae
Chlamydia trachomatis
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 pneumoniae
Neisseria gonorrhoeae
Rubeola (measles)
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
Staphylococcus aureus
Staphylococcus aureus, methicillin-resistant
Streptococcus, group A
Streptococcus, group B
Trichomonas vaginalis
Zika virus.
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.
The use of nucleic acid testing using a direct or amplified probe technique is considered investigational for the following microorganisms:
Gardnerella vaginalis
Hepatitis G.
The use of the following nucleic acid testing panel (without quantification of viral load) may be considered medically necessary:
Respiratory virus panel.
The use of the following nucleic acid testing panels (with or without quantification of viral load for viral panel elements) is considered investigational:
Central nervous system pathogen panel
Gastrointestinal pathogen panel.
