Confirm coverage before ordering

Confirm coverage with the payer before ordering tests listed as not meeting coverage criteria or when using multiplex/panel strategies or procedure codes that may require prior authorization. Benefit-specific rules (Medicare/Medicaid) and payer prior authorization requirements may apply.

• Confirm coverage for tests listed as NOT MEETING COVERAGE CRITERIA (e.g., panel tests, MALDI-TOF identification, quantitative NAAT) before ordering.
• Verify payer-specific prior authorization rules for CPT/HCPCS codes in the procedure code list (see Procedure codes requiring payer confirmation).

Testing reserved for high pretest probability

Reserve testing for patients with high pretest probability of GAS infection (for example, modified Centor/McIsaac score ≥3) or when absence of viral features is documented. Do not routinely test children <3 years or patients with clear viral features.

• Use modified Centor score (tonsillar exudates, tender anterior cervical lymphadenopathy, fever, absence of cough) and age to guide testing; score ≥3 supports testing.
• Avoid testing when viral symptoms (cough, rhinorrhea, hoarseness, oral ulcers, conjunctivitis) are present.
• Testing generally not indicated for children younger than 3 years (unless specific mitigating circumstances).

Procedure codes requiring payer confirmation

Some CPT/HCPCS procedure codes referenced in this policy may have payer-specific prior authorization or reimbursement rules. Confirm with the payer before ordering or billing.

• Relevant codes include, but may not be limited to: 86060, 86063, 86215, 86317, 86318, 87040, 87070, 87071, 87077, 87081, 87430, 87650, 87651, 87652, 87797, 87798, 87799, 87880.
• Procedure codes appearing in policy are for reference only and may not be all-inclusive; verify payer requirements for listed codes.

Tests likely to be denied

Ordering RADT or other tests in situations explicitly listed as not meeting coverage criteria (e.g., as screening in asymptomatic patients, follow-up to culture, for suspected viral pharyngitis, panel tests) may be denied.

• RADT DOES NOT MEET COVERAGE CRITERIA as a follow-up to culture, as screening in asymptomatic patients, or for individuals with suspected viral pharyngitis (except specific pediatric exceptions).
• Panel tests that identify multiple streptococcal strains, MALDI-TOF for streptococcus identification, and quantitative NAATs DO NOT MEET COVERAGE CRITERIA.

Indications-based testing

Indications-based testing: perform culture, RADT, NAAT, or serology only when coverage criteria and clinical indications are met (e.g., Centor ≥3, absence of viral features, suspected ARF requiring serology). Do not routinely test low-risk outpatients.

• Throat culture meets coverage when modified Centor ≥3, absence of viral features, or following a negative RADT in a symptomatic child/adolescent.
• Serological titers (ASO, anti-DNase B) meet coverage for suspected ARF or PSGN and require paired acute/convalescent titers to demonstrate rise.
• Do not routinely obtain sputum or blood cultures in outpatients with low suspicion for invasive GAS disease (see ATS/IDSA guidance).

Appropriate test utilization to avoid routine testing in low-risk outpatients

Avoid routine testing in low-risk outpatients; testing should generally be reserved for patients with high suspicion for GAS and when results will influence antibiotic treatment.

• Patients with Centor score <3 or with viral features generally do not require strep testing or antibiotics.
• Testing should be performed when there is intention to treat with antibiotics and a high pretest probability exists.

None specified: reimbursement and step-therapy

No additional payer-specific reimbursement restrictions or step-therapy requirements are specified in the provided excerpts beyond the coverage criteria and procedure-code verifications noted above.

• No step therapy requirements are described in these excerpts.
• Reimbursement is governed by the coverage criteria and payer-specific rules. Confirm with the payer as needed.

Documentation expectations

Document clinical findings and rationale when ordering tests: record modified Centor score (or its components), presence or absence of viral features, patient age, and intention to treat. For pediatric RADT reflex testing, document the negative antigen result and rationale for reflex culture/NAAT.

• For throat culture coverage, document modified Centor score ≥3 or absence of viral features.
• For pediatric RADT follow-up, document negative RADT result and clinical rationale for reflex culture or NAAT.
• When ordering rapid antigen or molecular tests, document signs/symptoms consistent with pharyngitis and test sensitivity considerations.

Laboratory evidence for ARF

Laboratory evidence for suspected acute rheumatic fever (ARF) must be confirmed by rising/paired ASO or anti-DNase B titers, or by a positive rapid antigen or throat culture when clinically appropriate. A single titer is less convincing than a documented rise between acute and convalescent samples.

• Obtain paired acute and convalescent ASO or anti-DNase B titers (≥2 weeks apart) to demonstrate rise.
• A positive throat culture or rapid antigen test can support antecedent GAS infection in appropriate clinical context.
• Recognize that titers peak weeks after infection; absence of rise may occur with delayed ARF presentations such as chorea.

Clinical indication and test sensitivity documentation

Document test sensitivity and clinical indication when ordering rapid antigen or molecular tests; in pediatric patients, use a two-step testing algorithm when using RADT (RADT with reflex to culture or sensitive NAAT if negative).

• Collect a dual swab in pediatric patients to enable reflex culture/NAAT if RADT is negative.
• If a RADT with sensitivity <80% is negative in a child, perform a second specimen tested by culture or a sensitive NAAT to arbitrate false negatives.
• Negative direct NAAT results typically do not require secondary arbitration.

No explicit documentation requirements listed

No explicit additional documentation requirements beyond those above are listed in the provided excerpts; however, retain clinical records that justify testing per coverage criteria and payer requests.

• Maintain documentation of signs/symptoms, modified Centor score, test results (including negative RADT when reflex testing performed), and rationale for testing.
• Device performance summaries and FDA clearances cited in the policy inform test selection but do not replace required clinical documentation.

Two-step testing algorithm (pediatrics)

Two-step testing algorithm in pediatrics: perform RADT at point-of-care with reflex to culture or sensitive NAAT if RADT is negative and clinical suspicion remains high. Collect dual swabs initially to enable reflex testing without recollection.

• Use RADT as initial test in children; if negative and RADT sensitivity <80%, reflex to culture or sensitive NAAT.
• Collect a dual swab at initial visit; discard second swab if RADT is positive to avoid repeat collection.

Reflex/back-up testing workflow

Reflex/back-up testing workflow: for children with negative RADT and persistent clinical suspicion, perform throat culture or a sensitive NAAT as a backup. For adults, secondary testing is not routinely required after negative RADT if clinical context allows.

• In pediatric patients, negative RADT should be followed by culture or sensitive NAAT when necessary to rule out false negatives.
• Direct and amplified NAATs are more sensitive and negative NAATs generally do not require arbitration by a secondary test.
• Document rationale for reflex testing in the medical record.

Arbitration testing in children after negative antigen

Arbitration testing in children after negative antigen: when a direct antigen test in pediatric patients is negative and the test sensitivity is <80%, perform a second specimen tested by culture or NAAT to arbitrate possible false negatives.

• If using a RADT known to have sensitivity <80% and result is negative in a symptomatic child, proceed to culture or sensitive NAAT on a second specimen.
• Collect and retain documentation of the negative antigen result and subsequent arbitration testing.

No step therapy requirements described

No step-therapy requirements are described in the provided excerpts; follow clinical guidelines (CDC, IDSA, AAP, ICSI) for diagnostic workflow and management decisions.

• No step therapy described in these excerpts.
• Follow cited clinical guidelines for testing algorithms and management.