CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Diagnostic Testing of Influenza — Coverage Criteria

Defines coverage and limitations for influenza diagnostic tests (rapid antigen/NAAT, traditional NAAT, culture, serology) for BlueCross BlueShield Tennessee members; applies when selecting tests for symptomatic and asymptomatic individuals.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyDiagnostic Testing of Influenza — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionOrder only one rapid flu test (point-of-care rapid NAAT or rapid antigen) OR one traditional NAAT for symptomatic patients when community influenza activity is documented; avoid culture, serology, and testing asymptomatic individuals.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1single rapid flu test allowed per symptomatic individual

1single traditional NAAT allowed per symptomatic individual

0viral culture tests covered

0testing for asymptomatic individuals covered

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for Influenza Diagnostic Testing

Initial diagnostic testing (symptomatic)

Covered when ONE of the following conditions is met for symptomatic individuals while influenza activity is documented in the community:

Allowed diagnostic tests for symptomatic individuals: One single rapid flu test (either a point-of-care rapid NAAT or a rapid antigen test).one test

Only one rapid flu test is covered per symptomatic individual when community influenza activity is documented.

Allowed diagnostic tests for symptomatic individuals: One single traditional NAAT.one test

Only one traditional NAAT is covered per symptomatic individual when community influenza activity is documented.

ALL of the following

Excluded tests (do not meet coverage): Viral culture testing for influenza.
Excluded tests (do not meet coverage): Influenza testing for asymptomatic individuals (including rapid antigen, rapid NAAT/RT-PCR, traditional RT-PCR, viral culture).
Excluded tests (do not meet coverage): Serology testing for influenza.

Viral culture testing for influenza and routine testing of asymptomatic individuals are specifically addressed in the policy as not meeting coverage criteria. The policy text states that viral culture testing for influenza DOES NOT MEET COVERAGE CRITERIA, and that testing asymptomatic persons with rapid antigen tests, rapid NAAT/RT‑PCR, traditional RT‑PCR, or viral culture DOES NOT MEET COVERAGE CRITERIA.

The referenced citations summarized in the policy do not enumerate additional explicit exclusions beyond those listed in the coverage criteria. The policy notes that the cited literature includes diagnostic comparison and decision‑analysis studies but does not specify further tests or scenarios to exclude from coverage.

Under this policy, influenza testing in asymptomatic individuals and serologic testing for influenza are considered not medically necessary. The policy language explicitly states that testing asymptomatic individuals (including rapid antigen, rapid NAAT/RT‑PCR, traditional RT‑PCR, and culture) DOES NOT MEET COVERAGE CRITERIA, and that serology testing for influenza DOES NOT MEET COVERAGE CRITERIA.

The cited references focus on comparative performance of diagnostic modalities and clinical guidance for use of testing but do not themselves designate specific tests or clinical scenarios as not medically necessary. The policy therefore relies on its coverage statements rather than the individual referenced studies to define noncoverage.

Applicable Coding and Technical Definitions

Applicable CPT/HCPCS codesCPT

86710	Antibody; influenza virus.
87254	Virus isolation; centrifuge enhanced (shell vial) technique, includes identification with immunofluorescence stain, each virus.
87275	Infectious agent antigen detection by immunofluorescent technique; influenza B virus.
87276	Infectious agent antigen detection by immunofluorescent technique; influenza A virus.
87400	Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Influenza, A or B, each.
87501	Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, includes reverse transcription, when performed, and amplified probe technique, each type or subtype.
87502	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, first 2 types or sub-types.
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 (List separately in addition to code for primary procedure).
87631	Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets.
87804	Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Influenza.

Fever definition

Fever threshold>= 100.4 °F or feeling feverish/chills

Associated symptoms (one or more required)Cough; sore throat; headaches and/or body aches; difficulty breathing/shortness of breath; fatigue; runny or stuffy nose

Use in documentationDocument presence of fever (>=100.4 °F or feeling feverish/chills) plus at least one other listed symptom when ordering influenza testing

Provider Actions, Documentation & Denial Triggers

Documentation Required

Coverage requirement for influenza testing

Coverage for influenza testing is limited to symptomatic individuals meeting the clinical criteria below; when community influenza activity is documented, one of the following meets coverage criteria for symptomatic individuals: (a) one single rapid flu test (either a point-of-care rapid NAAT or a rapid antigen test) or (b) one single traditional NAAT. Viral culture and serology do not meet coverage criteria. Influenza testing of asymptomatic individuals (including rapid antigen, rapid NAAT/RT‑PCR, traditional RT‑PCR, and viral culture) does not meet coverage criteria.

Symptomatic criteria example: fever ≥100.4°F or feeling feverish/chills AND one or more of cough, sore throat, headache/body aches, dyspnea, fatigue, runny/stuffy nose.
Allowed test types for symptomatic members: one rapid POC NAAT OR rapid antigen OR one traditional NAAT.
Not covered: viral culture, serology, and testing of asymptomatic individuals.

Prior Authorization

Prior authorization not addressed in this section

Background

Background: Influenza A and B cause acute respiratory illness with systemic symptoms and can result in increased morbidity among high‑risk groups. Point‑of‑care rapid influenza diagnostic tests (RIDTs) and rapid molecular NAATs provide timely results to inform outpatient treatment, while traditional NAAT/RT‑PCR and viral culture are alternative laboratory methods. The policy permits a single rapid flu test (either a point‑of‑care rapid NAAT or a rapid antigen test) or one single traditional NAAT for symptomatic individuals when local influenza activity is documented, and states that culture, serology, and testing of asymptomatic persons do not meet coverage criteria.

Definitions and Test Types

RIDTs

DefinitionCLIA-waived immunoassays that detect influenza during the outpatient visit and provide rapid results to inform treatment decisions

Regulatory noteMany RIDTs were affected by FDA reclassification of antigen-based rapid influenza tests (effective Feb 13, 2017) which instituted new minimum standards and reactivity testing

CodingAs of Aug 14, 2023, 27 different influenza tests are listed with CPT code 87804 for influenza immunoassay with direct optical observation

LDTs (Laboratory-developed tests)

DefinitionLaboratory-developed tests (LDTs) are in-house assays validated by the performing laboratory and regulated by CMS as high-complexity CLIA tests; they are not FDA-approved/cleared

Regulatory statusLDTs remain permitted for clinical use but are subject to CLIA '88 high-complexity laboratory regulation rather than FDA clearance