ModifiedArizona Complete HealthPolicy N/A

Respiratory Testing (Lab) — Outpatient diagnostic testing for respiratory pathogens

Defines medical necessity criteria for outpatient respiratory pathogen testing (syndromic multiplex panels, targeted viral panels, bacterial panels, Group A strep testing, and related antibody/culture tests) for members of health plans affiliated with Centene Corporation (Arizona Complete Health).

Policy Summary

PayerArizona Complete Health

PolicyOutpatient respiratory pathogen testing — coverage with clinical criteria

Policy CodePolicy N/A

Change TypeCoding table updatescriteria expansion for GAS culture

Effective DateN/A

Next Review DateN/A

Key ActionEnsure clinical documentation shows outpatient signs/symptoms of acute respiratory infection and that test results will influence management before ordering/testing.

SourceLink

POLICY UPDATE CHANGES

Added 'Lab' to policy title.

Removed CPT and ICD-10 codes from policy reference table; added CPT code table and moved the 'coding implications' section.

Updated CPT code table — corrected code descriptions and removed code 0373U.

Expanded coverage criteria for Group A Streptococcus pharyngitis cultures to include patients up to 18 years old (was previously up to 14 years).

Added CPT code 0528U as an in-scope CPT code; removed deleted codes U0003, U0004, and U0005.

Reordered codes in CPT code table numerically.

6+syndromic panel threshold

5 or fewertargeted panel threshold

Ages 3-18

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GAS culture age range

48-72hoptimal treatment window

U0001,87632-87637…example CPT/HCPCS list

Coverage Criteria — Respiratory Pathogen Testing

Syndromic/Multiplex Respiratory Panels with 6 or More Targets — Covered when ALL of the following are met

ALL of the following

The member/enrollee presents in the outpatient setting with signs or symptoms of an acute respiratory infection.
AND
- The member/enrollee is immunocompromised.
- The member/enrollee has severe pneumonia.
- The member/enrollee has exacerbations of airway disease.
Results of the testing will influence the member's/enrollee's clinical management.

SARS-CoV-2, RSV, or Influenza A/B, OR Multiplex Respiratory Viral Panels with 5 or Fewer Targets — Covered when ALL of the following are met

ALL of the following

The member/enrollee presents in the outpatient setting with signs or symptoms of an acute respiratory infection.
Results of the testing will influence the member's/enrollee's clinical management.

Bacterial Respiratory Infection/Pneumonia Panels — Covered when ALL of the following are met

ALL of the following

The member/enrollee presents in the outpatient setting with signs or symptoms of an acute respiratory infection.
AND
- New or worsening lung infiltrates.
- Moderate to severe upper respiratory illness.
- Has received empiric antibiotics before obtaining cultures.
- Has possible multidrug-resistant bacteria or polymicrobial infection.

Group A Streptococcus Pharyngitis Tests — Covered when ALL of the following are met

ALL of the following

ANY of the following
- The member/enrollee has acute pharyngitis.
- Fever.
- Tonsillopharyngeal inflammation.
- Patchy tonsillopharyngeal exudates.
- Palatal petechiae.

Group A Streptococcus Pharyngitis Culture — Covered when ALL of the following are met

ALL of the following

The member/enrollee is between the ages of 3 years and 18 years.
The member/enrollee had a negative group A streptococcus rapid antigen detection test (RADT).
ANY of the following
- The member/enrollee has acute pharyngitis.
- Fever.
- Tonsillopharyngeal inflammation.

Guideline-based indications and notes — Background-based indications referenced from guideline excerpts

ALL of the following

For syndromic/multiplex respiratory panels with ≥6 targets: IDSA supports use in immunocompromised and critically ill patients with pneumonia and for those with exacerbations of airway disease.
For SARS-CoV-2, RSV, influenza A/B, or multiplex viral panels with ≤5 targets: IDSA notes multiplex molecular testing may be cost-effective and CDC recommends testing symptomatic patients and consideration of RSV during season.
For bacterial respiratory/pneumonia panels: IDSA indicates bacterial NAAT may be useful for new or worsening lung infiltrates, moderate to severe illness, prior empiric antibiotics, or concern for multidrug-resistant or polymicrobial infection.
Influenza A/B antibody tests and group A streptococcus antibody tests (single-sample serology) are not recommended for routine diagnosis of acute infection and are not clinically useful for acute diagnosis.

Coding and Test Codes

Prior Authorization

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

Billing Rule

Use In-Scope and Updated Codes

Order only in-scope CPT/HCPCS/PLA codes listed in the CPT code table. Use the most current CPT descriptors and PLA assignments (Appendix O / AMA CPT website) when submitting claims. Removed/deleted codes (e.g., U0003, U0004, U0005, 0373U) must not be used.

Use updated CPT code table numeric ordering; include PLA codes where applicable (0202U, 0223U, 0225U, 0240U, 0241U, 0528U).

Provider Actions, Authorization & Documentation

Prior Authorization

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.

Prior Authorization

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

Billing Rule

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.

Background and Rationale

Respiratory illnesses such as influenza, RSV, and SARS-CoV-2 cause substantial morbidity and mortality and often present with overlapping clinical signs, which can make pathogen identification by clinical exam alone unreliable. Rapid and accurate outpatient testing can guide targeted treatment and public health actions; when antiviral therapy is considered, treatment is most effective if started within 48–72 hours of symptom onset. This policy applies to outpatient testing and prioritizes targeted or multiplex testing when results will influence clinical management and when specific clinical criteria are met (for example: immunocompromised status, severe pneumonia, exacerbation of airway disease, or features indicating bacterial infection).

Definitions and Clinical Thresholds

inv-37: Severe pneumonia — IDSA/ATS criteria

Severe pneumonia definitionPer IDSA/ATS: presence of one major criterion or at least three minor criteria

Major criteria examplesSeptic shock requiring vasopressors; respiratory failure requiring mechanical ventilation

Minor criteria examplesRR>30; PaO2/FiO2<250; multilobar infiltrates; confusion/disorientation; BUN>20 mg/dL; WBC<4,000/µL; platelets<100,000/µL; core temperature<36°C; hypotension requiring aggressive fluids

inv-38: Airway disease definition

Included conditionsAirway disease is a nonspecific term that includes COPD, emphysema, cystic fibrosis, asthma, and bronchiectasis

Clinical relevance

Policy Revision History

2023-11policy_developed

Policy developed and reviewed by external specialist (Revision Date 11/23).

2024-02coding_changes

Added 'Lab' to policy title; removed CPT and ICD-10 codes from the policy reference table; added a CPT code table and moved the 'coding implications' section (Revision Date 02/24).

2024-03cpt_table_update

Updated CPT code table with corrected code descriptions and removed code 0373U (Revision Date 03/24).

Policy Summary

PayerArizona Complete Health

PolicyOutpatient respiratory pathogen testing — coverage with clinical criteria

Policy CodePolicy N/A

Change TypeCoding table updatescriteria expansion for GAS culture

Effective DateN/A

Next Review DateN/A

Key ActionEnsure clinical documentation shows outpatient signs/symptoms of acute respiratory infection and that test results will influence management before ordering/testing.

SourceLink

On This Page

Results of the testing will influence the member's/enrollee's clinical management.

Anterior cervical lymphadenitis.

Scarlatiniform rash.

The member/enrollee does NOT have clinical and epidemiological features that strongly suggest a viral etiology (e.g., cough, rhinorrhea, hoarseness, and oral ulcers).

Results of the testing will influence the member's/enrollee's clinical management.

Patchy tonsillopharyngeal exudates.

Anterior cervical lymphadenitis.

Scarlatiniform rash.

The member/enrollee does NOT have clinical and epidemiological features that strongly suggest a viral etiology (e.g., cough, rhinorrhea, hoarseness, and oral ulcers).

Results of the testing will influence the member's/enrollee's clinical management.

IDSA and AAFP guidance support throat swab testing (RADT and/or culture) for GAS pharyngitis because clinical features alone do not reliably discriminate GAS from viral pharyngitis except when overt viral features are present; in children/adolescents a negative RADT should be backed up by culture.

Denial Risk

Denial Triggers for Unsupported Indications

Requests for multiplex testing will be denied when submitted for unsupported indications (e.g., routine screening, asymptomatic individuals, or indications not listed as medically necessary in this policy).

Denial triggers: asymptomatic screening; routine pre-procedure testing without clinical signs/symptoms; indications outside policy-defined scenarios.

Documentation Required

Required Clinical Justification

Clinical justification must be documented in the medical record and submitted with authorization or upon request. Documentation should include signs/symptoms of acute respiratory infection, the clinical setting (outpatient), and how results will influence management. For severe pneumonia, document IDSA/ATS major or ≥3 minor criteria as applicable.

Required: symptom onset, exam findings (eg, cough, dyspnea, fever), risk factors (immunocompromised status, airway disease), and anticipated change in treatment or disposition.
If claiming severe pneumonia, list major/minor criteria (eg, RR>30; PaO2/FiO2<250; BUN>20 mg/dL; WBC<4,000/µL; platelets<100,000/µL; temp<36°C).

Step Therapy

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.

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

Step Therapy

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.

Note

No action specified

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Note

No action specified

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Documentation Required

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.).

Documentation Required

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).

Billing Rule

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

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.

Denial Risk

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.

Listed airway diseases are considered high-risk indications for multiplex panel coverage when exacerbated

Policy usageExacerbation of airway disease qualifies as one high-risk criterion for syndromic panels (6+ targets)

inv-39: Signs and symptoms of acute respiratory infection

Common symptomsUpper or lower respiratory tract symptoms such as cough, runny nose, sore throat, bronchitis, pneumonia, bronchiolitis

Influenza-like illness (ILI)Defined as fever plus cough or sore throat

Severe signsRespiratory distress (difficulty breathing, increased respiratory rate, use of accessory muscles) — relevant to medical necessity for testing

inv-40: Moderate to severe upper respiratory illness

DefinitionModerate to severe upper respiratory illness includes one or more clinical findings of lower respiratory illness (eg, pneumonia, severe cough/bronchitis, shortness of breath, difficulty breathing)

Implication for coveragePresence of these findings supports medical necessity for bacterial or multiplex testing when results affect management

Example presentationsWorsening cough with dyspnea, new infiltrate on chest imaging, or severe bronchitis symptoms

inv-41: Severe pneumonia (duplicate definition entry)

Severe pneumonia (IDSA/ATS)Presence of one major criterion (septic shock needing vasopressors or respiratory failure requiring mechanical ventilation) or at least three minor criteria (eg, RR>30; PaO2/FiO2<250; multilobar infiltrates; confusion; BUN>20 mg/dL; WBC<4,000/µL; platelets<100,000/µL; temp<36°C; hypotension needing aggressive fluids)

Policy roleIdentification of severe pneumonia supports use of syndromic (6+ target) multiplex testing under medical necessity criteria

inv-42: Airway disease (duplicate definition entry)

Term scopeAirway disease includes COPD, emphysema, cystic fibrosis, asthma, and bronchiectasis

Clinical contextExacerbations of these conditions are included as high-risk indications for syndromic multiplex testing

inv-43: Signs and symptoms of acute respiratory infection (duplicate entry)

Signs/symptoms listCough, runny nose, sore throat, bronchitis, pneumonia, bronchiolitis, with or without fever; ILI defined as fever plus cough or sore throat

Respiratory distressDifficulty breathing often with increased respiratory rate and use of accessory muscles — flags more severe illness

RelevanceThese signs/symptoms are required for medical necessity of outpatient respiratory testing per policy

inv-44: Multiplex nucleic acid detection for respiratory viruses with differing numbers of targets (3-5; 6-11; 12-25)

3-5 target panelsCPT descriptors include panels for multiple respiratory virus targets in the 3-5 range (eg CPT 87631/87632 descriptions)

6-11 target panelsCPT descriptor for multiplex respiratory virus tests includes 6-11 targets (CPT 87632)

12-25 target panelsCPT descriptor for multiplex respiratory virus tests includes 12-25 targets (CPT 87633)

inv-45: Infectious agent antigen detection by immunoassay (Influenza, RSV, SARS-CoV-2)

Influenza antigen test codeCPT 87804: Infectious agent antigen detection by immunoassay; Influenza

RSV antigen test codeCPT 87807: Infectious agent antigen detection by immunoassay; respiratory syncytial virus

SARS-CoV-2 antigen test codeCPT 87811: Infectious agent antigen detection by immunoassay; SARS-CoV-2

2024-11annual_review_material_change

Annual review: expanded Group A Streptococcus pharyngitis culture coverage to include patients up to 18 years old and incorporated AAFP 2024 evidence review language; added CPT code 0528U; removed deleted codes U0003, U0004, and U0005; reordered CPT code table numerically (Revision Date 11/24).

2025-02-25approvalLatest

Document approval recorded (Approval Date 02/25).