Blue Cross Blue Shield - Tennessee Influenza Coverage

Coverage Criteria for Influenza Testing

Initial testing — symptomatic patients

Covered when ONE of the following is met for symptomatic individuals (and influenza activity documented in the community):

Acceptable tests for symptomatic patients: Either one single rapid flu test (point-of-care rapid NAAT or rapid antigen test) OR one single traditional NAAT meets coverage.

Rapid tests include point-of-contact NAAT or antigen. Traditional NAAT refers to lab-based NAAT/RT-PCR.

Not covered

Not covered tests/conditions: Viral culture testing for influenza; testing of asymptomatic individuals by any influenza test modality; serology testing for influenza.

These tests/conditions DO NOT MEET COVERAGE CRITERIA.

Clinical coverage criteria and test modality guidance

Covered testing preferences and indications as described by referenced guidelines:

Outpatient testing during influenza activity: Clinicians should test high-risk outpatients and those where results will influence management; rapid molecular assays are preferred over RIDTs.

Based on IDSA recommendations (Uyeki et al., 2018) and related guidance.

Hospitalized patients: Test for influenza on admission for all hospitalized patients with acute respiratory illness or worsening chronic cardiopulmonary disease, and for immunocompromised patients; use molecular assays (RT-PCR) rather than RIDT for hospitalized individuals.

IDSA and CDC recommendations favor molecular assays for hospitalized patients.

Institutional outbreak testing: Use RIDTs to identify possible outbreak cases in closed settings (e.g., nursing homes, hospitals) but recognize negative RIDT results do not exclude influenza; confirm negative or indeterminate results with molecular assays and send specimens to public health laboratory; notify public health authorities promptly.

CDC outbreak guidance recommends molecular confirmation and public health notification.

The policy specifies that for symptomatic individuals when influenza activity is documented in the community, coverage is limited to one of the following: either one single rapid flu test (which may be a point-of-care rapid NAAT or a rapid antigen test) OR one single traditional NAAT (e.g., laboratory-based RT-PCR). This reflects the coverage approach for initial diagnostic testing in outpatient settings where a single, timely test is sufficient to inform management.

Viral culture is not appropriate for initial or primary diagnosis because results are not available quickly enough to inform clinical management; it may, however, be used to confirm negative screening tests or to provide isolates for characterization in outbreak investigations. Serologic testing from a single specimen is likewise not recommended for routine diagnosis because a single serum specimen cannot be reliably interpreted; paired acute and convalescent sera collected 2–3 weeks apart are required for serologic diagnosis.

The provided reference excerpts do not list any explicit additional coverage exclusions beyond those stated elsewhere in this policy. Citations and guideline references are included for context and do not themselves introduce new exclusion statements.

Testing of asymptomatic individuals for influenza by any test modality (including rapid antigen tests, rapid NAAT or RT-PCR, traditional RT-PCR, or viral culture) does not meet coverage criteria under this policy and is therefore considered not medically necessary when requested for asymptomatic screening.

Serologic testing performed on a single serum specimen is not reliable for diagnosing acute influenza and is not appropriate for routine diagnostic use because interpretation requires paired acute and convalescent samples collected weeks apart.

Within these referenced excerpts there are no additional explicit statements categorizing other tests or circumstances as not medically necessary beyond those already noted for asymptomatic testing and single-sample serology.

Applicable Codes and Testing Thresholds

Applicable CPT codes for influenza diagnosticsCPT

87804	Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Influenza.
87400	Infectious agent antigen detection by immunoassay technique, (e.g., 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).
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.
87631	Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (e.g., 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.
87254	Virus isolation; centrifuge

Fever threshold — clinical symptom definition

Fever threshold>= 100.4 F (or subjective feeling feverish/chills plus one or more respiratory/systemic symptoms)

Associated required symptomsOne or more of: cough; sore throat; headaches/body aches; difficulty breathing/shortness of breath; fatigue; runny or stuffy nose

Use in documentationDocument fever >=100.4 F or feeling feverish/chills plus listed symptoms when applying symptomatic testing criteria

Provider Actions, Documentation & Billing Guidance

Documentation Required

Provider Actions: Testing Choice, Documentation & Coding Guidance

For symptomatic individuals (when community influenza activity is documented) one of the following meets coverage: a single rapid flu test (point-of-care rapid NAAT or rapid antigen) OR one single traditional NAAT. Rapid molecular assays (NAATs) are preferred over rapid antigen detection tests (RIDTs) in outpatients and for hospitalized patients because of higher sensitivity; consider molecular NAATs for improved detection before relying on antigen-based results. Negative RIDT results do not exclude influenza; reliance on a negative RIDT alone for hospitalized patients or outbreak investigations may miss cases — verify negative RIDT by molecular testing (RT‑PCR) when clinical suspicion remains or for outbreak confirmation. Viral culture and serology do not meet coverage for initial diagnosis and are not recommended routinely. Laboratory utilization guidance: follow IDSA/ASM recommendations to use molecular assays (RT‑PCR) for hospitalized patients and public health investigations; send specimens to public health or reference laboratories for molecular testing when RIDTs are negative but influenza is suspected, and for outbreak confirmation. Prior authorization: no prior authorization requirements are specified in the referenced guidance or regulatory sources for influenza testing; follow payer-specific billing rules if present.

Code verification (examples of relevant CPT codes to verify coverage with billing system): 87804 (Influenza immunoassay, direct optical observation); 87400 (Influenza A or B antigen detection, EIA/ELISA/FIA/IMCA); 87501-87503 (Influenza NAATs, single and multiplex); 87631 (Multiplex respiratory virus NAAT, 3-5 targets); 87275-87276 (Immunofluorescent antigen detection for influenza A/B); 86710 (Influenza antibody); 87254 (Virus isolation; centrifuge)
Preferred test modality: rapid molecular NAATs (point-of-care or lab-based RT‑PCR) over antigen-based RIDTs for greater sensitivity; use molecular assays for hospitalized patients and suspected outbreaks.

Background and Rationale

Influenza A and B are seasonal respiratory pathogens that commonly cause fever, malaise, and respiratory symptoms. Rapid influenza diagnostic tests (RIDTs) are CLIA-waived immunoassays that provide point-of-care results to inform treatment decisions quickly, while laboratory-based molecular assays (NAAT/RT-PCR) are more sensitive and specific but may have longer turnaround time. Viral culture is a reference method with slower turnaround and serology requires paired sera, so NAATs are generally preferred when diagnostic accuracy or confirmation is needed.

Definitions

RIDTs — Rapid influenza diagnostic tests

DefinitionRapid influenza diagnostic tests (RIDTs) are CLIA‑waived immunoassays that detect influenza viruses during the outpatient visit and provide rapid results to inform treatment decisions.

Typical settingPoint-of-care/outpatient visits to provide clinically relevant turnaround time for management

RoleUseful for rapid identification and initial outbreak detection but limited sensitivity compared with NAAT/RT‑PCR

NAAT — nucleic acid amplification test

DefinitionNAAT = nucleic acid amplification test; includes both rapid NAAT platforms and traditional laboratory NAATs (e.g., RT‑PCR).

Specimen/assay typesIncludes RT‑PCR single‑plex or multiplex real‑time RNA‑based assays and other molecular platforms referenced in guidance

OpenPayer

Diagnostic Testing of Influenza

Coverage Criteria for Influenza Testing

Applicable Codes and Testing Thresholds

Provider Actions, Documentation & Billing Guidance

Background and Rationale

Definitions