CurrentBlue Cross Blue Shield - TennesseePolicy N/A

Diagnostic Testing of Influenza

Defines coverage and limitations for laboratory diagnostic testing of influenza (RIDTs, NAAT/RT-PCR, viral culture, serology) for BlueCross BlueShield of Tennessee members; applies coverage criteria to symptomatic and asymptomatic individuals and lists applicable CPT/HCPCS codes and guideline references. (Part 1 of 2 document.)

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

PolicyDiagnostic Testing of Influenza

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionDocument that the patient is symptomatic and that influenza activity is present in the community when submitting claims for a single rapid test or a traditional NAAT.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Allowed test per symptomatic encounter (one rapid test OR one traditional NAAT)

3Types of testing explicitly NOT covered (viral culture, serology, asymptomatic testing)

27Number of influenza tests listed under CPT 87804 on CMS CLIA-waived list (citation date)

~40Bibliographic references cited

Influenza Testing Coverage Criteria

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Coverage Criteria 6 Symptomatic individuals

When influenza activity has been documented in the community or geographic area, coverage is met when ONE (but not both) of the following is provided for a symptomatic individual:

ONE of

One single rapid flu test (either a point-of-care rapid nucleic acid amplification test [NAAT] or a rapid antigen test).
One single traditional NAAT.

Not Covered / Does Not Meet Coverage Criteria

The following testing DOES NOT meet coverage criteria:

ALL of the following

Viral culture testing for influenza.
Influenza testing for asymptomatic individuals (examples given: rapid antigen flu tests, rapid NAAT or RT-PCR tests, traditional RT-PCR tests, viral culture testing).
Serology testing for influenza.

Applicable CPT Codes and Coverage Status

Influenza serology / antibodyCPTNot Covered

86710

Antibody; influenza virus

Viral isolation / shell vialCPTNot Covered

87254

Virus isolation; centrifuge enhanced (shell vial) technique, includes identification with immunofluorescence stain, each virus

Immunofluorescent antigen detectionCPT

87275	Infectious agent antigen detection by immunofluorescent technique; influenza B virus
87276	Infectious agent antigen detection by immunofluorescent technique; influenza A virus

Immunoassay / rapid antigen testing (RIDT)CPTCovered

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
87804	Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Influenza

NAAT / RT-PCR and multiplex nucleic acid detectionCPTCovered

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

Documentation and Billing Guidance

Documentation Required

Symptomatic status and local influenza activity

Document that the patient meets symptomatic criteria (see Note 1: typical signs/symptoms) and that influenza activity has been documented in the community or geographic area when submitting claims for a single rapid test (point-of-care rapid NAAT or rapid antigen test) or for one traditional NAAT.

87400
87804
87501
87502
87503
87631

Denial Risk

Tests likely to be denied if used outside criteria

Viral culture (shell vial) testing, influenza serology, and influenza testing for asymptomatic individuals do not meet coverage criteria and are subject to denial if performed outside the stated coverage conditions.

86710
87254

Clinical and Testing Context

Rapid influenza diagnostic tests (RIDTs) are CLIA‑waived immunoassays designed for point‑of‑care use that detect influenza viral antigens and typically return results in about 15 minutes. Because RIDTs are antigen‑based, they offer rapid results useful for immediate clinical decisions but have substantially lower sensitivity than molecular methods and therefore generate more false negatives, particularly when prevalence is low or viral load is low early or late in illness (CDC; meta‑analysis pooled sensitivity ~62% versus high specificity) [[1],[8],[21 in source]].

Nucleic acid amplification tests (NAAT/RT‑PCR), including rapid point‑of‑care molecular NAATs, detect influenza RNA and are more sensitive and specific than RIDTs. RT‑PCR is considered the most sensitive and specific diagnostic modality and is preferred when accurate detection is needed for patient management, outbreak investigation, or for hospitalized or high‑risk patients; some rapid molecular POC platforms have performance comparable to laboratory PCR [[8],[14],[36]].

Viral culture (including conventional tissue culture and shell vial techniques) remains a laboratory standard for virus isolation and characterization but is time‑consuming (conventional culture averaging about 7 days; shell vial faster but still hours to days) and is not useful for initial clinical management when timely results are needed. Culture may be used for confirmatory testing or for isolate recovery during public health investigations or outbreak characterization [[10],[36]].

Serologic testing for influenza is not useful for outpatient diagnosis because interpretation requires paired acute and convalescent sera and is confounded by prior vaccination or past infection; single‑sample serology cannot reliably establish acute infection and therefore is not appropriate for initial diagnostic decision‑making in ambulatory settings [[1],[26],[27]].

Key Terms

Definitions

RIDTsRapid influenza diagnostic tests — CLIA‑waived immunoassays that detect influenza antigens and return results in approximately 15 minutes; have limited sensitivity compared with molecular methods.

NAATNucleic acid amplification test — molecular assays (including rapid point‑of‑care NAATs and RT‑PCR) used to detect influenza RNA with higher sensitivity and specificity than antigen tests.

Symptomatic (Note 1)Typical signs/symptoms include fever ≥100.4°F or feeling feverish/chills AND one or more of: cough, sore throat, headache/body aches, difficulty breathing/shortness of breath, fatigue, or runny/stuffy nose.