CurrentBlue Cross Blue Shield - TennesseePolicy N/A

β-Hemolytic Streptococcus Testing Coverage Criteria

Defines coverage criteria for laboratory testing to detect β-hemolytic streptococcal infections (e.g., Group A, B, C, G) including culture, RADT, nucleic acid tests, and serologies for BlueCross BlueShield of Tennessee members.

Policy Summary

PayerBlue Cross Blue Shield - Tennessee

Policyβ-Hemolytic Streptococcus Testing Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSupport orders with clinical documentation such as a modified Centor score ≥3, absence of viral features, or a documented negative RADT when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

13procedure codes included

10coverage statements

multipleguideline references

A/B/C/Gstreptococcal groups

Coverage criteria for β-hemolytic streptococcal testing

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Coverage decisions distinguish single-target testing and culture-based approaches from broader multiplex panels and routine repeat/ screening uses. For example, bacterial throat culture is supported when clinical criteria are met (see Modified Centor score guidance) or when a symptomatic child/adolescent has a negative RADT and further confirmation is needed; by contrast, RADT used as a follow-up after culture or nucleic acid testing, or as asymptomatic screening, does not meet coverage criteria except in the limited exception for certain asymptomatic children under age three with mitigating circumstances. Similarly, blood cultures are covered when there is clinical deterioration, lack of improvement, or suspected prosthetic joint infection, and skin/pus cultures are covered when a streptococcal skin/soft tissue infection is suspected. These examples illustrate when individual tests or cultures are appropriate versus when multiplex or routine repeat testing is not covered.

Clinical indications considered medically necessary

inv-28: Detection of streptococcal infection causing respiratory illness (throat culture) when modified Centor >=3, suspected bacterial pharyngitis without viral features, or after negative RADT in symptomatic child/adolescent.

Detection of group A streptococcal infection causing respiratory illness by throat culture is covered when ANY of the following are present:

Detection of streptococcal infection (throat): Modified Centor score >=3>= 3

Modified Centor components as defined in policy Note 1

Detection of streptococcal infection (throat): Suspected bacterial pharyngitis without viral features

Viral features include cough, oral ulcers, rhinorrhea

Detection of streptococcal infection (throat): Following a negative RADT in a symptomatic child or adolescent

inv-29: Blood cultures when lack of clinical improvement, progressive symptoms after antibiotics, or suspected prosthetic joint infection.

Blood cultures to evaluate streptococcal infection are covered when ANY of the following clinical scenarios apply:

Blood culture coverage: Lack of clinical improvement

Clinical documentation should support indication

Blood culture coverage: Progressive symptoms or clinical deterioration after initiation of antibiotic therapy

Blood culture coverage: Suspected prosthetic joint infection

Refer to IDSA guidance as needed

inv-30: Skin/pus cultures for suspected streptococcal skin and soft tissue infections.

Bacterial culture from skin swab or pus is covered when used to evaluate suspected streptococcal skin and soft tissue infection.

Skin/pus culture coverage: Skin or wound swab or pus culture for suspected streptococcal skin/soft tissue infection

Order supported by clinical findings per laboratory guidance

inv-31: Serologic assays for suspected acute rheumatic fever or post-streptococcal glomerulonephritis.

Serologic assays are covered when used to evaluate suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN).

Serologic assays coverage: Use of serological titer testing and streptococcal-specific immunoassays to support diagnosis of ARF or PSGN

Serology outside these contexts does not meet coverage criteria

inv-32: Diagnostic scope — group A streptococcal pharyngitis; GBS screening in pregnancy/peripartum; detection of groups C and G when clinically indicated.

Diagnostic testing scope includes group A streptococcal pharyngitis diagnosis, GBS screening in pregnancy/peripartum contexts, and detection of groups C and G when clinically indicated.

Diagnostic scope: Diagnosis of group A streptococcal pharyngitis

Supported by comparative studies of rapid antigen and molecular assays

Diagnostic scope: Screening for group B Streptococcus in pregnancy/peripartum context

Follow pregnancy/GBS guidance

Diagnostic scope: Detection of groups C and G when clinically indicated

Refer to clinical guidance on non-group A streptococcal infections

Tests and uses considered not covered or generally denied

Tests commonly denied under the policy include RADT when used as a follow-up after culture or nucleic acid testing, for asymptomatic screening, or for suspected viral pharyngitis (except limited exceptions), and RADT in most asymptomatic or follow-up settings is specifically listed as not meeting coverage criteria. Also listed as not covered are panel assays that detect multiple streptococcal strains (for example, Solana Strep Complete and Lyra Direct Strep) and MALDI-TOF identification of streptococcus. The policy additionally excludes nucleic acid quantification of streptococcal strains and certain enzymatic or serologic assays when used outside the specified ARF/PSGN contexts.

Some excerpts state that no specific exclusions or not‑medically‑necessary statements are present in those sections. Where the excerpts are silent, the full policy and cited guideline literature should be consulted to confirm whether other exclusions apply.

Billing and procedure codes

Serology / Immunoassay CPT codesCPT

86060	Antistreptolysin O; titer
86063	Antistreptolysin O; screen
86215	Deoxyribonuclease, antibody
86317	Immunoassay for infectious agent antibody, quantitative, NOS
86318	Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step-method

Culture, antigen, and nucleic acid CPT codesCPT

87040	Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates
87070	Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates
87071	Culture, bacterial; quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool
87077	Culture, aerobic isolate, additional methods required for definitive identification, each isolate
87081	Culture, presumptive, pathogenic organisms, screening only
87430	Infectious agent antigen detection by immunoassay; Streptococcus, group A
87650	Infectious agent detection by nucleic acid; Streptococcus, group A, direct probe
87651	Infectious agent detection by nucleic acid; Streptococcus, group A, amplified probe
87652	Infectious agent detection by nucleic acid; Streptococcus, group A, quantification
87797	Infectious agent detection by nucleic acid, NOS; direct probe technique, each organism

1–10 of 13

1/2

Referenced test types (no explicit billing codes listed in these chunks)mixed

No codes listed

Modified Centor score threshold used in policy summaries

Modified Centor score threshold>= 3

Purpose of thresholdUsed to determine coverage for bacterial throat culture

Centor components referenceTonsillar exudates, tender anterior cervical lymphadenopathy, fever, and absence of cough (1 point each)

Coding guidanceProcedure codes listed in the policy are the codes affected by the coverage determinations and should be used for claims and any required pre-authorization processes

Serology CPT examples86060, 86063, 86215, 86317, 86318

Culture and molecular CPT examples87040, 87070, 87071, 87077, 87081, 87430, 87650-87652, 87797-87799, 87880

Provider actions, documentation, and billing cautions

Denial Risk

Denials, documentation, and clinical guidance

Denied: Ordering bacterial throat culture for suspected viral pharyngitis will be denied and DOES NOT MEET COVERAGE CRITERIA. Document clinical findings that support a modified Centor score ≥3 or absence of viral features (eg, cough, rhinorrhea, oral ulcers) when ordering streptococcal testing.

Denied for viral pharyngitis: Bacterial throat culture in cases of suspected viral pharyngitis is not covered.
Documentation requirement: Clinical documentation should support modified Centor score or explicit absence of viral features, and include RADT results and clinical findings where applicable.
Policy references: This policy cites multiple clinical practice guidelines and literature (IDSA, NICE, AAP, CDC, ASM, UpToDate) to inform appropriate ordering and laboratory utilization.
No additional provider actions explicitly stated in these chunks.

Note

Prior authorization

No prior authorization requirements are specified in the provided excerpts.

Billing Rule

Procedure codes and billing cautions

Watch billing/coding: procedure codes listed in the policy must be billed consistent with coverage criteria; tests explicitly listed as not meeting coverage criteria (eg, multiplex streptococcal panels, MALDI-TOF identification, nucleic acid quantification, certain serologies, RADT in specified scenarios) should not be billed as covered.

Codes affecting coverage decisions are enumerated in the CPT/HCPCS list in the policy.
Do not bill for panel tests that screen multiple streptococcal strains (eg, Solana Strep Complete Assay) as covered.
RADT is not covered for asymptomatic screening, follow-up testing, or suspected viral pharyngitis except specific exceptions noted (eg, certain asymptomatic children <3 with mitigating circumstances).

Ordering and laboratory utilization requirements

Documentation Required

Support laboratory orders with documented clinical findings

Orders must be supported by clinical findings: document the modified Centor score (>=3) or absence of viral features, and document a negative RADT when culture is being performed following RADT.

Modified Centor score >=3 supports throat culture coverage.
Absence of viral features (e.g., cough, oral ulcers, rhinorrhea) supports suspected bacterial pharyngitis.
Document negative RADT when culture follows a negative RADT in a symptomatic child/adolescent.

Step Therapy

Follow cited clinical and microbiology laboratory utilization guidance when ordering

Follow the clinical practice guidelines and microbiology laboratory utilization guidance cited in the policy when ordering tests and determining who may order and how samples are handled.

Refer to the IDSA/ASM Guide to Utilization of the Microbiology Laboratory and society-specific guidelines cited in the policy for ordering and laboratory handling guidance.

Key definitions and diagnostic terms

Modified Centor criteria — elements and scoring summary

Modified Centor criteria elements1 point each: tonsillar exudates; tender anterior cervical lymphadenopathy; fever; absence of cough

InterpretationScore of 3 or greater supports testing (see policy threshold >= 3)

Use in documentationClinical documentation should support Centor score when ordering throat cultures

Rapid tests — rapid molecular and antigen assays

Rapid molecular assays referencedAlere i Strep A Rapid Molecular Assay; Solana Group A Streptococcus Assay; GenePOC Revogene (examples cited)

Rapid antigen assaysPoint‑of‑care rapid antigen tests (RADT) for Group A Streptococcus

Policy limits on RADTRADT does not meet coverage criteria as follow-up after culture or nucleic acid test, as screening in asymptomatic patients, or for suspected viral pharyngitis (except specified asymptomatic children <3 with mitigating circumstance)

GBS screening — Group B streptococcal screening in pregnancy and neonatal risk management

GBS screening contextScreening for Group B Streptococcus in pregnancy and peripartum context; neonatal risk management guidance cited

ReferencesUpToDate guidance and Pediatrics/Red Book citations included in policy references

Intrapartum rapid screeningStudies of rapid intrapartum vaginal screening for GBS are cited (utility for identifying infants at risk discussed)

Frequency limits and reuse considerations

Frequency limits key value

Frequency limits — generalNo explicit frequency limits specified in the policy excerpts

Action when orderingOrdering should be clinically justified per indications; frequency subject to clinical documentation

Where to find limitsIf present, frequency rules would appear in the laboratory frequency limits section of full policy

Frequency limits key value

Frequency rules absentNo frequency limits or numeric repetition restrictions are provided in the cited reference excerpts

Related guidanceClinical guideline references (IDSA, NICE, AAP) cited elsewhere may inform appropriate testing intervals

Local benefit determinationApplication of any frequency limits may depend on individual member benefits at time of request

Background on β-hemolytic streptococci and test types

β‑hemolytic streptococci addressed by this policy include Group A (Streptococcus pyogenes), Group B (Streptococcus agalactiae), and Groups C and G (Streptococcus dysgalactiae). Clinical presentations covered range from pharyngitis (group A) to skin and soft tissue infections, and invasive disease scenarios where blood cultures are appropriate. Serologic testing (for example, antistreptolysin O titers and related assays) is included when evaluating suspected post‑infectious conditions such as acute rheumatic fever (ARF) or post‑streptococcal glomerulonephritis (PSGN). The policy aligns these diagnostic approaches with the clinical scenarios that warrant culture, rapid molecular or antigen testing, and serology as described.

Policy revision history and references

created/updated

Policy content and coverage criteria defining indications and exclusions for β-hemolytic streptococcus testing (throat culture, blood culture, skin/pus cultures, serologies) were documented in the policy text.

2014-04-16FDA clearance referenced

FDA approval of the Lyra Direct Strep Assay (k133833) cited in policy as an FDA-cleared nucleic acid test for Group A and Groups C/G detection.

2016-10-25FDA clearance referenced

FDA approval of the Solana Strep Complete Assay (K162274) cited in policy as an in vitro diagnostic for detection of Groups A, C and G.

2019-03-06FDA clearance referenced

FDA approval of GenePOC's Strep A assay for use with the Revogene instrument cited in policy.

2020-11-09FDA clearance referencedLatest

FDA approval of Mesa Biotech's Accula Strep A Test (semi-automated PCR) cited in policy.