Diagnostic Testing of Influenza
Customize your policy alerts
Sign up for blue cross blue shield - louisiana Policy AHS - G2119 alerts
Get alerted when Policy AHS - G2119 changes without checking for updates manually.
Monitor payer policy activity
Coverage rules for laboratory testing to diagnose influenza (RIDTs, NAAT/RT-PCR, culture, serology) for Blue Cross Blue Shield of Louisiana members; applies to outpatient and related settings as described in the policy.
CC1 edited for clarity and a reference to new Note 2 was added.
Added Note 2 specifying that when a single influenza test detects both A and B (CPT 87400, 87501, or 87804), up to two units may be billed at a single visit.
Removed CPT code 87631 (respiratory infection panels that include flu testing are addressed in AHS-G2149 Pathogen Panel testing).
Coverage Criteria for Influenza Testing
inv-01: Symptomatic testing — covered criteria
Covered when ALL of the following are met:
See Note 1 for symptom list (fever/chills, cough, sore throat, headache, myalgia, fatigue, nasal symptoms, vomiting/diarrhea in children).
When both influenza A and B are detected by CPT codes 87400, 87501, or 87804, up to two units may be billed at a single visit (see Note 2).
inv-02: Not covered — asymptomatic testing and other modalities
Viral culture not covered for initial/primary diagnosis because results are not timely to inform clinical management; may be used for confirmation in outbreak investigation per guidance but does not meet coverage criteria here.
Serology is not useful for routine diagnosis because single serum specimens are not reliably interpretable and paired sera are required.
inv-03: Medically necessary testing criteria
Covered when guidance from clinical societies or CDC supports testing — generally when results will influence management or for hospitalized/high-risk patients or outbreak investigation.
CDC and specialty society guidance recommend molecular testing for hospitalized patients.
IDSA and AAP recommend targeted outpatient testing when results affect management.
CDC recommends molecular confirmation during outbreaks and cautions about RIDT sensitivity; test multiple persons to increase detection likelihood.
Recommendations reflect IDSA/CDC/AAP guidance on preferred modalities and limitations of RIDTs.
Viral culture and serologic testing for influenza are explicitly excluded from meeting coverage criteria. The policy states that viral culture testing for influenza DOES NOT MEET COVERAGE CRITERIA and that serology testing for influenza DOES NOT MEET COVERAGE CRITERIA, reflecting that these modalities are not accepted methods for routine diagnostic coverage under this policy.
Do not perform influenza testing in asymptomatic individuals — the CDC guidance cited in the policy specifically recommends against testing asymptomatic patients. For symptomatic outpatients, testing should be limited to situations where results will influence clinical management (for example, antiviral decisions, infection control, or further diagnostic workup); the policy instructs that if test results will not influence management, testing should be avoided.
CPT code 87631 (respiratory infection panels that include influenza testing) has been removed from this policy. Claims for testing that would be reported using CPT 87631 should be addressed under the separate policy AHS‑G2149 Pathogen Panel testing rather than under this influenza testing policy.
Influenza testing for asymptomatic individuals is considered not medically necessary and does not meet coverage criteria. The policy explicitly lists influenza testing for asymptomatic persons (including rapid antigen, rapid NAAT/RT‑PCR, traditional RT‑PCR, and viral culture) as not meeting coverage criteria.
Viral culture should not be used for initial or primary diagnosis because results are not available in a timely manner to inform clinical management; serologic testing is not appropriate for acute diagnosis because interpretation requires paired acute and convalescent sera collected weeks apart. Consequently, these methods are not appropriate for routine, point‑of‑care diagnostic use.
Procedure Codes and Billing Guidance
| 86710 | Antibody; influenza virus. |
| 87275 | Infectious agent antigen detection by immunofluorescent technique; influenza B virus. |
| 87276 | Infectious agent antigen detection by immunofluorescent technique; influenza A virus. |
| 87503 | Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, each additional influenza virus type or sub-type beyond 2. |
| 87804 | Infectious agent antigen detection by immunoassay with direct optical (i.e., visual) observation; Influenza (CPT listing associated with waived status tests). |
| 87400 | Influenza A/B antigen detection; single or dual-detection (as represented in Note 2) |
| 87501 | Influenza virus, amplified probe technique; detection of influenza A and/or B (as represented in Note 2) |
| 87804 | Infectious agent antigen detection by immunoassay technique, influenza (as represented in Note 2) |
| 87631 | Respiratory infection panel (removed from this policy and addressed in AHS-G2149) |
Provider Actions, Documentation, and Billing Notes
Limit testing to one covered influenza test per symptomatic visit
For symptomatic individuals, one influenza test per visit meets coverage: either one single rapid flu test (a point-of-care rapid NAAT or a rapid antigen test) OR one single traditional NAAT. This policy allows only one covered influenza test per symptomatic visit (see Note 2 for billing when a single test detects both A and B).
- Allowed: one rapid NAAT or rapid antigen test OR one traditional NAAT per symptomatic visit.
Include procedure codes and clinical rationale with coverage requests
Procedure codes in the policy are provided for reference; include appropriate CPT/HCPCS codes when requesting coverage and ensure documentation supports medical necessity. Examples of antigen/rapid-test codes referenced include CPT 87400, 87501, and 87804.
Prior authorization not required here; follow billing unit guidance for dual-detection tests
This section contains no prior authorization requirement. Billing guidance: when a single influenza test detects both influenza A and B (tests represented by CPT 87400, 87501, or 87804), up to two units may be billed at a single visit.
No additional provider action specified
Not specified in this section.
No step therapy required for influenza testing
No step therapy requirements apply to influenza diagnostic testing in this section; step therapy is not specified.
- Policy lists step therapy as not applicable—no sequencing or prior therapeutic trials required for influenza testing.
Document typical influenza signs and symptoms to support testing
Document signs and symptoms consistent with influenza (Note 1) to support symptomatic testing, including fever/feeling feverish or chills, cough, sore throat, headache, muscle/body aches, fatigue, runny or stuffy nose, and vomiting and/or diarrhea in children.
- Include symptom documentation from Note 1 when requesting coverage (fever/chills, cough, sore throat, headache, myalgia, fatigue, nasal symptoms, vomiting/diarrhea in children).
Document dual-detection results when billing two units
If billing up to two units at a single visit, explicitly document that both influenza A and B were detected by the test(s) represented by CPT codes 87400, 87501, or 87804; document the specific test used and the results supporting two-unit billing.
Document intended clinical impact of testing
Document that testing is anticipated to influence clinical management (for example, to inform antiviral treatment decisions, infection control measures, or further diagnostic workup) especially for outpatient and pediatric patients.
- State how results will affect treatment, infection control, or further testing to support medical necessity for outpatient testing.
Billing: up to two units allowed for single dual-detection tests
When a single influenza test detects both influenza A and B (represented by CPT codes 87400, 87501, or 87804), up to two units may be billed at a single visit; providers should document the test(s) used and results supporting billing of two units.
Denial risk: asymptomatic testing, viral culture, and serology are not covered
Testing for influenza in asymptomatic individuals, viral culture testing, and serology testing do not meet coverage criteria and may be denied if submitted for coverage under this policy.
- Do not submit claims for influenza testing in asymptomatic patients under this policy.
- Viral culture and serology are explicitly excluded from coverage criteria and are potential denial triggers.
Avoid testing asymptomatic patients or testing unlikely to change management
Do not perform testing in asymptomatic patients and avoid testing when results will not influence clinical management; such testing is discouraged and may be a basis for denial if performed without documented clinical impact.
- If results will not change management (e.g., antiviral decisions, infection control), testing is not recommended.
- For asymptomatic individuals, the CDC and this policy do not recommend testing.
Do not bill CPT 87631 under this policy — redirect panel claims to AHS-G2149
Claims for respiratory infection panels that include influenza testing using CPT 87631 are removed from this policy and should be submitted under AHS-G2149 Pathogen Panel testing; billing influenza under this policy with CPT 87631 may be denied.
Background and Scope
Influenza A and B cause seasonal respiratory illness characterized by sudden onset of systemic and respiratory symptoms. The policy notes that typical symptoms (see Note 1) guide testing decisions and that viral titers in respiratory secretions are highest early in illness, which supports selecting timely molecular or point‑of‑care tests for symptomatic patients. Rapid antigen tests offer quick results but have lower sensitivity than molecular RT‑PCR/NAAT methods, which are preferred for hospitalized or high‑risk patients.
Definitions and Notes
Policy Revision History
Reviewed and updated background, guidelines, and evidence-based references; CC1 edited for clarity, Note 1 updated to align signs/symptoms with CDC, added Note 2 clarifying billing up to two units when a single test detects both influenza A and B, and CPT 87631 removed from this policy.
Reviewed and updated background, guidelines, and evidence-based scientific references; literature review did not necessitate modifications to coverage criteria.
Reviewed and updated background, guidelines, and evidence-based scientific references; no modifications to coverage criteria required and all coverage criteria edited for clarity and consistency.
Updated background, guidelines, and evidence-based scientific references; literature review did not necessitate modifications to coverage criteria; CC1 and CC3 edited for clarity and consistency.
Initial policy implementation for diagnostic testing of influenza.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.