Prior Authorization Required for Multiplex Panels

Prior authorization is required for syndromic/multiplex respiratory panels (6+ targets). Providers must obtain authorization when ordering these panels to ensure medical necessity and coverage.

• Affected codes: CPT 87632-87633, PLA codes 0202U/0223U/0225U/0240U/0241U/0528U

Group A Streptococcus Testing Step

For suspected Group A Streptococcus pharyngitis, perform rapid antigen detection testing per guideline-based workflow. If rapid antigen test is negative and clinical suspicion remains, perform a throat culture for Group A Streptococcus (CPT culture codes such as 87081/87880 may apply) — coverage expanded to patients through age 18.

• Step: 1) Rapid antigen test; 2) If negative and high clinical suspicion, obtain throat culture for confirmation.
• Coverage note: expanded age criteria up to 18 years.

Prior authorization not specified — meet medical necessity

No explicit prior authorization process is described in this policy; however, tests will only be covered when the applicable medical necessity criteria in the policy are met.

Check plan authorization for multiplex/PLA tests

The policy references multiple PLA and CPT codes for multiplex respiratory pathogen panels; confirm and follow any plan-specific authorization requirements when ordering tests represented by these PLA/CPT codes.

• Example PLA codes: 0202U, 0223U, 0225U, 0240U, 0241U, 0528U

Use in‑scope CPT/HCPCS codes per updated table

Use the CPT and HCPCS codes listed as in‑scope for this lab policy and bill per the updated CPT code table included in the policy when submitting claims.

• In‑scope examples include PLA codes (0202U, 0223U, 0528U) and CPT codes listed in the coding section.

Obtain negative RADT before GAS culture in ages 3–18

For children age 3–18 years, a negative rapid antigen detection test (RADT) is required before a Group A streptococcus throat culture is considered medically necessary.

Document clinical justification and qualifying details

Clinical documentation must show outpatient signs/symptoms of an acute respiratory infection and that test results will influence clinical management; where applicable, document specific qualifying criteria (e.g., immunocompromised status, severe pneumonia, airway disease exacerbation, or prior negative RADT for culture).

• Document signs/symptoms of acute respiratory infection.
• Document how test results will influence management.
• If applicable, document qualifying specifics (immunocompromised, severe pneumonia, prior RADT result, etc.).

Reference CPT descriptors and Appendix O for PLA coding

When reporting proprietary/PLA tests, reference current CPT code descriptors and Appendix O/AMA listings to determine appropriate PLA code assignment and ensure accurate coding.

• See Appendix O or the AMA CPT website to determine PLA code assignment (policy notes this guidance).

Use the updated CPT code table when billing

Policy revisions included an updated CPT code table; providers must use the updated CPT code table from the policy when submitting claims.

Denial risk: unsupported indications (multiplex or antibody tests)

Tests ordered for indications outside the policy's medical necessity criteria — for example, multiplex panels when criteria are not met or antibody tests for acute influenza or Group A strep — are not supported by current evidence and risk denial.

• Influenza A/B antibody tests and Group A streptococcus antibody tests are not supported for diagnosing acute infection.

Coding inclusion/exclusion does not guarantee coverage — verify guidance

Inclusion or exclusion of specific CPT/PLA codes in the policy does not guarantee coverage; providers should verify current coding guidance and plan coverage prior to claim submission.