Currentblue cross blue shield - tennesseePolicy N/A

β - Hemolytic Streptococcus Testing

Defines coverage and non-coverage criteria for laboratory testing to detect β-hemolytic streptococcal infections (throat, blood, skin/soft tissue, serology) including RADT, culture, NAATs, and specific serologic assays; applies per member benefits and notes Medicare/Medicaid specifications are elsewhere.

Policy Summary

Payerblue cross blue shield - tennessee

Policyβ - Hemolytic Streptococcus Testing

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument modified Centor criteria score and clinical features to support throat swab culture when score >=3 or when bacterial pharyngitis is suspected without viral features.

POLICY UPDATE CHANGES

No material clinical or coverage changes

1Key covered indication categories (throat culture, blood culture, skin/pus culture, serology for ARF/PSGN)

5Explicitly not covered test categories listed

1Threshold for Centor criteria

~20Cited guidelines/references

18CPT/HCPCS codes listed

3Major testing modalities discussed (antigen, NAAT, culture)

Coverage Summary

Scope: Defines coverage and non-coverage criteria for laboratory testing to detect β-hemolytic streptococcal infections (throat, blood, skin/soft tissue, and serology) including RADT, culture, NAATs, MALDI-TOF, and specific serologic assays; application depends on the individual's benefit coverage and applicable Medicare/Medicaid specifications.

Overview of coverage stance: Coverage is mixed — throat culture, blood culture, skin/pus culture, NAAT or RADT (with specified exceptions), and serologic testing for suspected post-infectious complications meet coverage when medical necessity criteria are met; multiple tests and modalities are explicitly not covered or considered investigational in other situations.

Thresholds summary: use the modified Centor criteria score >= 3 (or clinical suspicion of bacterial pharyngitis without viral features) to justify throat swab culture; routine testing generally not indicated in children < 3 years except in special circumstances. Benefit verification and Medicare/Medicaid specifications apply and must be checked before ordering.

Policy thresholds and quick facts

Modified Centor criteria threshold>= 3

Age consideration for routine testingChildren <3 years: testing generally not indicated (exceptions for outbreaks/high-risk contacts)

CPT/HCPCS codes listed (count)18 codes listed

Guideline/reference count (approx.)~20 guideline/references cited

Medical-Necessity Criteria

Covered when MEDICAL NECESSITY criteria are met

Bacterial culture, blood culture, skin/pus culture, NAAT or RADT (per exceptions), and serologic testing meet coverage when following conditions are met:

ANY of the following

When culture meets criteria
- Individual has a modified Centor criteria score of 3 or greater
- Individual is suspected of having bacterial pharyngitis in the absence of viral features (e.g., cough, oral ulcers, rhinorrhea)
- Following a negative rapid antigen diagnostic test (RADT) in a symptomatic child or adolescent
ALL of the following

Coding

Relevant CPT procedure codesCPT

86060	Antistreptolysin O; titer
86063	Antistreptolysin O; screen
86215	Deoxyribonuclease, antibody
86317	Immunoassay for infectious agent antibody, quantitative, not otherwise specified
86318	Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step-method (eg, reagent strip)
87040	Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates
87070	Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates
87071	Culture, bacterial; quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool
87077	Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate
87081	Culture, presumptive, pathogenic organisms, screening only

1–10 of 18

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Applicable CPT/HCPCS procedure codesmixed

86060	Antistreptolysin O; titer
86063	Antistreptolysin O; screen
86215	Deoxyribonuclease, antibody
86317	Immunoassay for infectious agent antibody, quantitative, not otherwise specified
86318	Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step-method (eg, reagent strip)
87040	Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates
87070	Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates
87071	Culture, bacterial; quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool
87077	Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate
87081	Culture, presumptive, pathogenic organisms, screening only

1–10 of 18

1/2

Provider Actions

Documentation Required

Apply Centor criteria to justify throat culture

Document modified Centor criteria score (tonsillar exudates, tender anterior cervical lymphadenopathy, fever, absence of cough) and clinical features to support throat swab culture when score >= 3 or when bacterial pharyngitis suspected without viral features. Note: document the modified Centor score used when ordering/testing.

Prior Authorization

Benefit verification required

Application of coverage criteria depends on the individual's benefit coverage at time of request; verify member benefits and applicable Medicare and Medicaid specifications per the policy's state and federal regulations section.

Background and Clinical Context

Clinical background: β-hemolytic streptococci include Group A (GAS, S. pyogenes), Group B (GBS, S. agalactiae), and Groups C/G (GCS/GGS, S. dysgalactiae subsp. equisimilis). These organisms cause pharyngitis, scarlet fever, acute rheumatic fever (ARF), post-streptococcal glomerulonephritis (PSGN), skin and soft tissue infections, invasive disease (bacteremia, sepsis, meningitis), and neonatal GBS disease.

Testing modalities: Bacterial culture (throat, blood, skin/pus) is considered the traditional gold standard for many specimen types; RADT (rapid antigen diagnostic tests) are point-of-care antigen assays; NAATs (direct/amplified nucleic acid amplification tests, including rapid molecular POC NAATs) detect streptococcal DNA/RNA; MALDI-TOF identifies organisms from pure cultures; and serology (ASO, anti-DNase B and other antistreptococcal antibodies) assesses prior/antecedent infection.

Performance characteristics and guidelines: Throat culture is the CDC gold standard; RADTs have high specificity but variable sensitivity (meta-analyses report summary sensitivities ~82-86%), so in children a negative RADT often requires backup culture or NAAT when RADT sensitivity <80%. NAATs and rapid nucleic acid tests are more sensitive (reported sensitivities up to ~97.5-98% and some NAATs approach culture performance) and negative NAATs generally do not require secondary arbitration. Multiple FDA-cleared NAATs (Lyra, Solana, GenePOC/Revogene, Accula) have high reported sensitivity and specificity; some HDA-based assays report sensitivity and specificity ~98% and rapid turnaround. MALDI-TOF is useful for rapid identification from isolates but may be inconclusive for less common organisms and is listed among tests not meeting coverage when used for streptococcus identification in certain contexts. Serologic titers (ASO, anti-DNase B) are useful to document antecedent GAS infection and are recommended for suspected ARF or PSGN, with rising titers (acute to convalescent) more informative than single measurements.

Evidence quick-reference

Definitions

Centor criteria: Four clinical items — tonsillar exudates, tender anterior cervical lymphadenopathy, fever, and absence of cough — each count one point; a modified Centor (McIsaac) score <3 makes GAS unlikely and testing is generally not required, while a score ≥3 supports testing for GAS pharyngitis.

LDT (Laboratory-Developed Test): A test developed and validated in-house; LDTs are regulated by CMS under CLIA as high-complexity tests, are not FDA-cleared, but may be used clinically following laboratory validation.

ASO / anti-DNase B: Serologic assays measuring antistreptococcal antibodies used as evidence of antecedent GAS infection; a rise in titer between acute and convalescent specimens is better evidence than a single titer; ASO typically peaks ~3–5 weeks after infection and anti-DNase B peaks later (6–8 weeks), and combined testing increases sensitivity/specificity for post-infectious complications.

Revision History

Policy Summary

Payerblue cross blue shield - tennessee

Policyβ - Hemolytic Streptococcus Testing

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument modified Centor criteria score and clinical features to support throat swab culture when score >=3 or when bacterial pharyngitis is suspected without viral features.

On This Page

Individuals who fail to demonstrate clinical improvement

Individuals who have progressive symptoms or clinical deterioration after the initiation of antibiotic therapy

Cases of suspected prosthetic joint infection

ALL of the following

Indication: cases of skin and/or soft tissue infections

ANY of the following

Serological titer testing for individuals with suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN)
Anti-streptolysin O (ASO) immunoassay
Hyaluronidase activity or anti-hyaluronidase immunoassay
Streptokinase activity or anti-streptokinase immunoassay

Not covered / Does not meet coverage criteria

Tests and situations specifically listed as not meeting coverage criteria

ANY of the following

Bacterial culture testing from a throat swab for suspected viral pharyngitis
If viral features (e.g., cough, rhinorrhea, hoarseness, oral ulcers, conjunctivitis) are present
ANY of the following
- As a follow-up test for individuals who have had either a bacterial culture test or a nucleic acid test for a streptococcal infection
- As a screening method in an asymptomatic patient
- For individuals with suspected viral pharyngitis
Serological titer testing for all situations not described as covered
Serological titers generally do not meet coverage except for suspected ARF or PSGN as specified
Simultaneous ordering of both direct probe and amplification probe for the same organism in a single encounter
ANY of the following
- Anti-streptolysin O immunoassay, hyaluronidase activity or anti-hyaluronidase immunoassay, streptokinase activity or anti-streptokinase immunoassay for all situations not described above
- Panel tests that screen and identify multiple streptococcal strains using immunoassay or nucleic acid-based assays (e.g., Solana Strep Complete Assay, Lyra Direct Strep Assay)
- MALDI-TOF identification of streptococcus
- Quantification of any strain of streptococcus using nucleic acid amplification, including PCR
- Nicotinamide-adenine dinucleotide activity or anti-nicotinamide-adenine immunoassay

Testing indications for Group A Streptococcus (GAS) pharyngitis

Testing recommended when clinical presentation suggests high pretest probability; not recommended with viral features or in children <3 years except special circumstances:

ALL of the following

DO NOT test when ANY of the following viral features present
- rhinorrhea
- cough
- hoarseness
- oral ulcers
- conjunctivitis
- anterior stomatitis
- discrete ulcerative oral lesions
- diarrhea
Children younger than 3 years: testing generally not indicated (except in outbreaks or high-risk contacts)
Test when ANY of the following increase likelihood
- acute onset sore throat with pharyngeal exudate
- pain on swallowing
- fever
- enlarged tender anterior cervical lymph nodes
- exposure to a person with GAS pharyngitis
Preferred testing approach
- Rapid antigen test performed; if positive, treat (no culture confirmation required due to high specificity)
- If rapid antigen negative in children AND rapid test sensitivity <80%: obtain throat culture or a more sensitive NAAT
- Direct or amplified NAATs are more sensitive; negative NAATs do not require secondary arbitration
Testing asymptomatic household contacts: not recommended except if contacts are at increased risk of sequelae (eg, ARF) or in multiple household members with infections

Laboratory confirmation for Acute Rheumatic Fever (ARF)

Laboratory evidence should be confirmed in suspected ARF cases:

ANY of the following

Increased or rising anti-streptolysin O (ASO) titer or anti-DNase B titer (rise better evidence than single titer)
Rise in titer is better evidence than single titer
Positive throat culture for Group A β-hemolytic streptococci
Positive rapid group A streptococcal carbohydrate antigen test in child with high pretest probability

Group B Streptococcus (GBS) testing in pregnancy and neonates

Screening and diagnosis recommendations for GBS:

ALL of the following

Antepartum screening timing: Antepartum screening for GBS at 36 0/7–37 6/7 weeks for all pregnant women unless intrapartum prophylaxis already indicated (ACOG)
Early-onset GBS infection diagnosed by blood or CSF culture; routine lab tests like CBC and CRP perform poorly in well-appearing infants
Late-onset GBS diagnosis based on isolation of GBS from blood, CSF, or other sterile sites; adequate intrapartum antibiotic prophylaxis does not protect against late-onset disease
Nucleic acid amplification-based identification from enrichment broth acceptable but not sufficient for all patients; perform antimicrobial susceptibility testing for GBS isolates from pregnant women with penicillin allergy
Nucleic acid amplification-based identification from enrichment broth acceptable but not sufficient for all patients; perform antimicrobial susceptibility testing for GBS isolates from pregnant women with penicillin allergy

Cultures and testing for skin/soft tissue and invasive infections

When to obtain cultures for non-pharyngeal infections:

ANY of the following

Gram stain and culture of pus/exudate recommended to identify S. aureus and/or β-hemolytic Streptococcus for impetigo/ecthyma, carbuncles, abscesses, pyomyositis (IDSA)
Cultures of blood and focal sites indicated in suspected invasive GAS infections
Blood cultures not routinely recommended in outpatient CAP; consider in hospitalized, moderate to severe, or deteriorating patients (ATS/IDSA/PIDS guidance)
Cultures of blood recommended in erysipelas/cellulitis for select high-risk patients (malignancy on chemo, neutropenia, severe immunodeficiency, immersion injuries, animal bites)

Use of rapid tests and NAATs

Test performance and operational recommendations:

ALL of the following

Rapid antigen tests: high specificity, variable sensitivity; positive result generally does not require culture confirmation
Direct NAATs and amplified NAATs are more sensitive than antigen tests; some rapid NAATs may be as sensitive as culture
Home use of FDA-cleared rapid tests discouraged due to false-positive colonization risk (AAP)
For Groups C and G: NAAT may be performed or throat culture with antigen testing on isolates; only large colony types identified
Laboratory-developed tests (LDTs) are regulated under CLIA as high-complexity tests and are not FDA-cleared but may be used clinically

Billing Rule

Do not order simultaneous direct probe and amplification probe

Simultaneous ordering of both direct probe and amplification probe for the same organism in a single encounter does not meet coverage and may be denied.

Denial Risk

RADT and serology use limitations

RADT ordered as a follow-up to culture/NAAT, for asymptomatic screening, or for suspected viral pharyngitis, and serological titers not indicated by ARF/PSGN criteria may be denied.

Documentation Required

Document clinical features when ordering GAS testing

Providers should document presence of clinical signs (e.g., fever, pharyngeal exudate, tender anterior cervical lymphadenopathy, absence of viral features such as cough or rhinorrhea) or exposure history to justify GAS testing and potential treatment.

Prior Authorization

None specified in this part

No explicit prior authorization requirements are listed in this portion of the policy.

Billing Rule

Use appropriate CPT codes for test performed

Report the specific CPT code corresponding to the test performed (e.g., antigen detection, NAAT, culture, ASO titers) using the policy's CPT code table: 87430, 87650, 87651, 87652, 87040, 87070, 86060, 86063.

87430
87650
87651
87652
87040
87070
86060
86063

Documentation Required

Confirmatory testing when indicated

If rapid antigen test sensitivity is <80% in pediatric patients and the rapid antigen is negative, perform secondary testing by throat culture or a more sensitive NAAT and document the rationale for confirmatory testing.

Denial Risk

Testing in low pretest probability or viral presentations may be denied

Testing patients with viral features or a modified Centor score <3 may be considered unnecessary and could be denied; avoid testing in these low pretest probability situations unless exceptions apply (e.g., outbreaks, high-risk contacts, or intention to treat).

Centor criteria recommendationDo not test when score <3; test or use RADT/culture when score >=3 or high suspicion without viral features

RADT vs NAAT performanceRADT sensitivity variable (~82-86%); RNAT/NAAT sensitivity higher (~97.5-98%); RADT specificity high

FDA-approved NAATs citedLyra (2014), Solana (2016), GenePOC Revogene (2019), Accula Strep A (2020)

Guideline consensusMultiple societies (CDC, AAP, ICSI, IDSA) advise against testing with viral features and support NAAT sensitivity over antigen tests