The Tuberculin Skin Test (TST), often called the PPD test, determines if a person has been exposed to Mycobacterium tuberculosis, the bacterium that causes tuberculosis. The test involves injecting purified protein derivative (PPD) under the skin of the forearm, followed by a reading 48 to 72 hours later to check for a reaction. Since the TST is used for various reasons, from medical necessity to employment screening, insurance coverage is highly variable and depends on your specific health plan. Understanding how insurers categorize this screening is key to knowing your potential financial responsibility.
How Insurance Categorizes Tuberculosis Screening
Insurance plans generally categorize medical services as preventive or diagnostic, which determines cost. Preventive services screen for a condition before symptoms appear and are often covered at 100% with no cost-sharing under the Affordable Care Act (ACA) for non-grandfathered plans. The United States Preventive Services Task Force (USPSTF) recommends screening for latent tuberculosis infection (LTBI) in adult populations at increased risk, meaning this service is often covered without a copay or deductible.
If a healthcare provider orders the TST because you have symptoms of active tuberculosis, such as a persistent cough or unexplained weight loss, the test is considered diagnostic. Diagnostic testing is subject to your plan’s standard benefits, meaning you may incur a copayment, coinsurance, or a charge applied toward your annual deductible. The TST often falls into a gray area where classification depends on documented risk factors. For example, a TST ordered solely based on travel to a high-risk country may be coded as preventive screening, while a test ordered for a patient presenting with night sweats is diagnostic.
The type of insurance plan you have also influences coverage. For instance, a Health Maintenance Organization (HMO) may require you to use an in-network lab or clinic. Grandfathered health plans, which existed before the ACA, are not required to cover preventive services at no cost. Ultimately, coverage is determined by whether the insurer deems the TST “medically necessary” based on established clinical guidelines and your risk profile.
Coverage Based on Testing Purpose
The reason you need the TST is the most significant factor determining coverage. When a doctor recommends the TST based on a patient’s risk factors, such as close contact with an infected person or a weakened immune system, this is generally considered medically necessary routine screening. The test is often covered, sometimes at no cost if it meets the ACA’s preventive care criteria for high-risk groups. Coverage includes the injection administration and the required follow-up visit for reading the reaction size.
Testing mandated by a third party, such as an employer, school, or volunteer organization, is typically treated differently. Medical insurance covers healthcare needs, not administrative or occupational requirements. For instance, a TST required for a new healthcare worker or a university student is often not covered because it is a condition of employment or enrollment, not a medical concern. In these cases, the cost is usually the responsibility of the individual or the mandating organization.
Testing required for immigration or international travel also falls outside the scope of most standard health insurance policies. These requirements are considered non-medical administrative procedures. Individuals needing a TST for visa applications or immigration purposes should expect to pay for the test out-of-pocket, as these specific health checks are rarely covered by domestic health insurance. Many public health departments or community clinics offer these tests at a reduced fee.
Navigating Out-of-Pocket Costs and Alternative Testing
To confirm coverage, contact your insurance provider directly and ask about their specific policy for CPT code 86580, which is commonly used for the TST. You should also inquire about the potential fee for the required follow-up visit to have the injection site examined, as this second appointment may be billed separately. Without insurance coverage, a TST typically costs between $50 and $175, with the second visit sometimes incurring an additional charge.
If the TST is not covered, or if you have a high-deductible plan, you will be responsible for the full negotiated cost until your deductible is met. An alternative test is the Interferon-Gamma Release Assay (IGRA), a blood test marketed under names like QuantiFERON-TB Gold Plus. The IGRA is more expensive than the TST, typically ranging from $150 to $350 without insurance, but only requires one visit.
IGRA tests are often preferred by clinicians for individuals who have received the BCG vaccine, which can cause a false positive TST result, and for those who may not return for the TST reading. Some insurers may cover the IGRA more readily than the TST for high-risk individuals, viewing it as a more accurate diagnostic tool that potentially reduces the need for subsequent, more expensive follow-up testing. Checking your Evidence of Coverage document or calling your insurer will clarify which test, if any, is covered under your plan’s laboratory benefits.