Diagnostic Testing of Influenza — Coverage Criteria
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Covers outpatient diagnostic testing for influenza (RIDTs, NAAT/RT-PCR, viral culture, and serology) and defines which tests meet coverage criteria for Blue Cross Blue Shield - Tennessee members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Outpatient Influenza Testing
Initial outpatient diagnostic testing
Covered when ALL of the following are met
Typical signs include fever ≥100.4°F or feeling feverish/chills plus cough, sore throat, headache/body aches, difficulty breathing, fatigue, or runny/stuffy nose
Rapid NAATs with high sensitivity may be used alternatively to traditional NAAT; testing should be done when results will influence clinical management
Indications for influenza testing
Testing is recommended when results will influence clinical management or public health actions. Covered when ANY of the following are met:
Synthesis of CDC, IDSA, AAP, and other guideline recommendations in the policy
Test modality and confirmatory testing
Modality preference and confirmatory testing logic:
Recommendations reflect IDSA, AAEM, AAP, and CDC guidance and comparative performance data showing higher sensitivity of NAATs
Viral culture testing and serologic testing for influenza in the outpatient setting are excluded from coverage. The policy explicitly states that viral culture performed for outpatient diagnosis does not meet coverage criteria, and that serology testing for influenza does not meet coverage criteria under any circumstance.
Outpatient testing of asymptomatic individuals for influenza is excluded from coverage. The policy specifies that influenza testing in asymptomatic patients — including rapid antigen tests, rapid NAAT, traditional RT-PCR, and viral culture — does not meet coverage criteria. CDC guidance cited in the policy similarly states that if a patient is asymptomatic, testing is not recommended.
Do not test asymptomatic patients for influenza; additionally, do not perform testing when results will not change outpatient management once influenza is known to be circulating. The CDC algorithm summarized in the policy recommends testing symptomatic outpatients only when results will influence clinical management (for example, antiviral decisions or infection control), and otherwise advises empiric antiviral treatment without testing when testing will not alter management.
Testing when the patient is asymptomatic or when test results will not influence clinical management is considered not medically necessary. The policy designates screening of asymptomatic outpatients and testing that does not affect clinical decision-making as not meeting medical necessity criteria and therefore not covered.
Use of viral culture or serologic testing for routine initial diagnosis is not appropriate for outpatient care. The policy explains that viral culture is too slow to guide initial management in outpatients and that serologic testing is not useful for routine diagnosis because interpretation is confounded by vaccination and prior exposure; professional guidelines recommend molecular NAAT methods over culture or serology for initial diagnostic use.
CPT / CLIA-waived Test Coding
| 87804 | Influenza immunoassay with direct optical observation (CPT) — listed for many CLIA-waived influenza tests as of 7/24/2018 |
Provider Actions, Documentation & Billing Notes
Single-test coverage limitation
When influenza activity has been documented in the community for an outpatient symptomatic episode, perform only one diagnostic test per episode: either one point-of-care rapid NAAT or rapid antigen test OR one traditional NAAT — do not perform both for the same episode.
- Applies to outpatient symptomatic patients when community influenza activity is documented.
- Limit is one test per episode: either a single rapid flu test (POC rapid NAAT or rapid antigen) OR one traditional NAAT.
Government policy precedence and CLIA/FDA considerations
If a conflict exists between this policy and an applicable government (Medicare/Medicaid) policy, the government policy governs determinations; consult CMS/NCD/LCD guidance. A CLIA-waived test listing by CPT is maintained by CMS (e.g., many influenza tests mapped to CPT 87804) and FDA reclassification of antigen-based RIDTs imposes new controls and may affect availability and use.
- Government policies (NCDs/LCDs) supersede this policy when applicable.
- CMS maintains a CLIA‑waived test list by CPT code (87804) and FDA reclassification (effective 2/13/2017) changed requirements for many RIDTs.
Prior authorization
No prior authorization requirements are specified in the policy text provided.
- Providers do not need to obtain prior authorization per this document portion.
Consider empiric therapy when testing won’t change management
When influenza is circulating and testing will not change management, clinicians may consider empiric antiviral treatment without testing; test when results would influence clinical decisions such as admission, antiviral use, or infection control.
- Empiric antiviral therapy may be appropriate if test results will not alter treatment.
- Testing is recommended when results will influence clinical management (e.g., hospitalization decisions, antivirals, infection control).
Preferred testing sequence: NAAT over RIDT; confirm negatives when indicated
Prefer rapid molecular (NAAT) assays over rapid antigen (RIDT) tests in outpatients to improve detection; consider confirmatory RT‑PCR when a rapid antigen is negative but clinical suspicion is moderate-to-high or in outbreak investigations.
- Use rapid molecular/NAAT assays in outpatients to improve sensitivity versus RIDTs.
- If RAD/RIDT is negative but clinical suspicion remains high, obtain confirmatory RT‑PCR.
No step therapy rules required
No step therapy rules or sequencing requirements are described in the policy text.
- The policy does not impose step therapy or mandatory sequencing of tests prior to coverage.
Clinical documentation for outpatient testing
Document that the outpatient patient had signs and symptoms consistent with influenza (Note 1): fever ≥100.4°F or feeling feverish/chills plus one or more of cough, sore throat, headache/body aches, difficulty breathing/shortness of breath, fatigue, or runny/stuffy nose, and note evidence of influenza activity in the community when using testing to justify coverage.
- Record specific signs/symptoms (see Note 1) in the medical record.
- Document community/geographic evidence of influenza activity when relying on outpatient testing coverage.
Outbreak documentation and public health notification
For suspected institutional outbreaks, collect respiratory specimens from ill persons, notify public health authorities promptly, and send specimens to public health laboratories for molecular testing (RT‑PCR) when the cause is uncertain.
- Collect specimens from multiple ill persons to increase likelihood of detecting influenza.
- Notify public health authorities promptly and send specimens to public health labs for molecular confirmation.
Citations and guideline references
Policy includes peer‑reviewed citations and guideline references (CDC, IDSA, AAP, AAEM, and multiple studies) to support diagnostic test utilization and reimbursement; consult these references for clinical and laboratory guidance.
- References include CDC guidance and IDSA 2018 recommendations among other peer‑reviewed studies.
- These sources underpin modality preference, outbreak testing, and documentation recommendations.
Viral culture will be denied for outpatient testing
Ordering viral culture testing for influenza in the outpatient setting does not meet coverage criteria and will be denied.
- Viral culture is not covered for outpatient initial diagnosis.
Serology testing denied in all circumstances
Serologic testing for influenza does not meet coverage criteria under any circumstance and will be denied.
- Single‑specimen serology is unreliable; paired acute/convalescent sera are required for serologic diagnosis per guidelines.
Asymptomatic outpatient testing denied
Testing asymptomatic outpatients for influenza (any modality) does not meet coverage criteria and will be denied.
- Do not perform influenza testing for asymptomatic individuals in the outpatient setting.
Situations that affect authorization likelihood
Authorization likelihood is affected by clinical context: testing is recommended for symptomatic patients being admitted to hospital or when results will influence management or infection control; testing is not recommended for asymptomatic patients and may be unnecessary for some outpatients once influenza is documented to be circulating.
- Hospitalized symptomatic patients should be tested with molecular assays.
- Outpatient testing is appropriate when results will change treatment or control measures; otherwise consider empiric therapy.
No other explicit denial triggers specified
The policy text does not list any additional explicit denial triggers beyond the stated exclusions (viral culture, serology, asymptomatic testing).
- No other explicit denial triggers are specified in these document sections.
Background and Clinical Context
Influenza A and B cause seasonal respiratory illness with peak viral shedding occurring approximately 24–48 hours after symptom onset. Rapid antigen tests provide quick results but have lower sensitivity than molecular RT-PCR/NAAT methods; rapid molecular point-of-care NAATs approach laboratory RT-PCR performance and are preferred when testing will influence outpatient management.
Test Modality Definitions
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