Coverage criteria for laboratory testing to detect β-hemolytic Streptococcus (including Group A, B, C, G) across respiratory and skin/soft tissue infections and for serologic testing related to post-streptococcal complications; applies to Capital Bluecross members per their benefit coverage determinations.
Key ActionReserve testing for patients with high clinical suspicion (e.g., modified Centor ≥3) and document Centor elements when ordering throat culture or RADT; perform backup culture in children >3 with negative RADT.
No material clinical or coverage changes in this revision.
Centor ≥3Throat culture threshold
Children/adolescentsRADT negative → culture
5-15%GAS in adult pharyngitis
≈97.5%RNAT sensitivity
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.
~20
Procedure codes listed
Coverage Criteria for β-Hemolytic Streptococcus Testing
Throat/Respiratory Testing (Culture)
Bacterial throat culture MEETS COVERAGE CRITERIA when ANY of the following are met:
Throat culture coverage: Modified Centor criteria score of 3 or greater.Centor >=3
Per policy: indication (III.1.a).
Throat culture coverage: Suspected bacterial pharyngitis in the absence of viral features (e.g., cough, oral ulcers, rhinorrhea).
Per policy: indication (III.1.b).
Throat culture coverage: Following a negative rapid antigen diagnostic test (RADT) in a symptomatic child or adolescent.age: child/adolescent
Per policy: indication (III.1.c).
Skin/Soft Tissue Infections
Bacterial culture testing from skin swab or pus MEETS COVERAGE CRITERIA when ordered for suspected streptococcal skin/soft tissue infection.
Skin/soft tissue culture: Culture testing for streptococcal infection from a skin swab or from pus ordered for suspected streptococcal skin or soft tissue infection.
Per policy: indication (III.2).
Serologic Testing for ARF/PSGN
Testing MEETS COVERAGE CRITERIA when ordered for suspected acute rheumatic fever or post-streptococcal glomerulonephritis:
Serologic tests for ARF/PSGN: Serological titer testing (e.g., rising ASO or anti‑DNase B), anti‑streptolysin O immunoassay, hyaluronidase activity or anti‑hyaluronidase immunoassay, and streptokinase activity or anti‑streptokinase immunoassay to document preceding Group A Streptococcus infection.
Used to demonstrate prior GAS infection in suspected ARF/PSGN (AHA, CDC; policy III.3).
Not Covered / Does Not Meet Coverage Criteria
The following DO NOT MEET COVERAGE CRITERIA unless otherwise specified:
Not covered tests: RADT used as a follow-up to a prior bacterial culture or nucleic acid test.
Policy exclusion (III.4.a).
Not covered tests: RADT as a screening method in an asymptomatic patient (except asymptomatic children <3 years with a mitigating circumstance).age <3 exception
Policy exclusion (III.4.b).
Not covered tests: Serological titer testing and specified antistreptococcal immunoassays in situations not explicitly listed as covered.
Policy exclusion (III.5; III.7).
Not covered tests:
Indications for diagnostic testing and follow-up
Covered testing when clinical and age criteria met:
High clinical suspicion for GAS pharyngitis: Testing (RADT, NAAT, or throat culture) is appropriate when there is high clinical suspicion for group A streptococcal pharyngitis and when antibiotic therapy would be considered; use clinical decision rules such as modified Centor (McIsaac) or FeverPAIN to stratify likelihood.Centor/McIsaac >=3 or FeverPAIN >=4
ICSI consensus: do not test when modified Centor <3 or viral features present (ICSI 2017).
Children older than 3 with negative RADT: In children older than 3 years, a negative RADT should be followed by a backup throat culture, and there should be a mechanism to contact the family and initiate antibiotics if the culture is positive.age >3
CDC and AAP recommend follow‑up culture for children >3 (CDC guidance; AAP Red Book).
Adults and other ages:
Test selection and performance
Choice of diagnostic modality based on performance and setting:
RADT (rapid antigen) use: RADTs have high specificity but variable sensitivity (summary sensitivities reported in meta-analyses and studies in the 82–86% range to ~96% for some assays); when sensitivity is limited, negative results in children may require backup testing.sensitivity ~82-86% (summary) or assay‑specific higher values
Performance varies by assay and population; see Cohen meta-analysis and individual RIDT studies.
NAAT / Rapid nucleic acid tests: NAATs and RNATs (including POC NAAT) demonstrate higher sensitivity and specificity (meta-analysis RNAT sensitivity ~97.5%, specificity ~95.1%) and in some settings can be used as standalone diagnostic tests; some FDA‑cleared NAATs (Lyra, Solana, Simplexa) show high performance and faster turnaround.RNAT sensitivity ~97.5%
Multiple studies and FDA‑cleared assays support high diagnostic accuracy and potential cost-effectiveness of POC NAATs.
Special populations and sequelae
Special-case diagnostic recommendations:
Intrapartum GBS testing: PCR‑based intrapartum GBS testing has high sensitivity and specificity and low invalid rates and may be used to direct intrapartum antibiotic prophylaxis; antepartum culture screening is recommended at 36 0/7–37 6/7 weeks unless intrapartum prophylaxis indications exist.GA 36 0/7–37 6/7 weeks for antepartum screening
Studies suggest intrapartum PCR can better predict early‑onset sepsis; ACOG/ASM recommendations support screening interval and acceptable methods.
Evaluation for ARF: Obtain laboratory evidence of antecedent GAS infection (rising ASO/anti‑DNase B titers, positive throat culture, or positive rapid test in high pretest probability) when evaluating for acute rheumatic fever per AHA/Jones criteria.
A rise in titer is better evidence than a single titer (AHA).
PSGN consideration: Documenting preceding GAS infection by isolation from throat or skin or by elevated streptococcal antibodies aids diagnosis of post‑streptococcal glomerulonephritis.
Covered when guideline-based criteria met
Guideline-based testing indications and recommendations
Evidence for prior GAS infection: Laboratory evidence of prior GAS infection can include increased or rising ASO or anti‑DNase B titers, a positive throat culture for group A β‑hemolytic streptococci, or a positive rapid group A streptococcal antigen test in a child with high pretest probability.
AHA/Jones criteria and CDC guidance support these laboratory markers (AHA; CDC).
When to test for GAS pharyngitis (ICSI): Do not test patients with modified Centor scores <3 or when viral features (rhinorrhea, cough, oral ulcers, hoarseness) are present; reserve testing for patients with high suspicion and where antibiotics would be given.Centor >=3 preferred
ICSI 2017 consensus recommendation.
Use of rapid antigen and NAAT (IDSA/ASM): Direct and amplified NAATs are more sensitive than direct antigen tests; in children, a negative antigen test from an assay with sensitivity <80% should be followed by NAAT or culture; negative direct NAAT results generally need not be arbitrated.
Panel tests that screen for multiple streptococcal strains or perform multiplex identification using immunoassay or nucleic acid–based methods (for example, assays that simultaneously report group A, B, C/G, and alpha‑hemolytic streptococci) DO NOT MEET COVERAGE CRITERIA. The policy also excludes molecular quantification of streptococcal strains (e.g., nucleic acid amplification–based quantification) and specified enzymatic immunoassays such as nicotinamide‑adenine dinucleotide activity or anti‑NAD immunoassays.
Routine testing for group A streptococcal (GAS) pharyngitis is not recommended for children younger than 3 years and should generally be avoided in patients with clear viral features (rhinorrhea, cough, hoarseness, oral ulcers) or a modified Centor score 3. Testing should be reserved for patients with higher pretest probability where antibiotic treatment would be considered; exceptions for asymptomatic children 3 years are limited to specific mitigating circumstances (for example, a symptomatic household member).
For community‑acquired pneumonia (CAP), routine sputum Gram stain and culture and routine blood cultures are NOT recommended for adults treated in the outpatient setting. Similarly, blood cultures are not routinely indicated for nontoxic, fully immunized children with outpatient CAP; blood cultures are recommended for hospitalized or clinically deteriorating patients per guideline guidance.
The references section lists evidence sources and guideline citations but does not itself state additional explicit coverage exclusions beyond those enumerated in the policy. Consult the policy exclusion lists for the specific tests and situations that do not meet coverage criteria.
Serological titer testing (including antistreptolysin O and related immunoassays), and certain antistreptococcal immunoassays do MEET COVERAGE CRITERIA when ordered for evaluation of suspected acute rheumatic fever or post‑streptococcal glomerulonephritis. However, these serologic tests DO NOT MEET COVERAGE CRITERIA when requested in situations not explicitly described as covered by the policy.
Testing of asymptomatic household contacts is generally not recommended and does not meet coverage criteria, except in narrowly defined circumstances when contacts are at increased risk of sequelae or when a specific mitigating circumstance for an asymptomatic child under 3 years exists. Routine screening of asymptomatic contacts is discouraged.
The routine, universal adoption of rapid tests for all individuals with sore throat is not recommended by some guideline bodies (for example, NICE) because rapid tests have limited impact on prescribing and patient outcomes compared with clinical scoring alone. Diagnostic stewardship—reserving testing for patients with sufficient clinical pretest probability (for example, modified Centor ≥ 3)—is advised.
This references section contains only evidence citations and guideline sources to support the clinical recommendations and does not itself define new coverage decisions or additional policy requirements.
Procedure and Billing Codes
Serology CPT CodesCPTCovered
86060
Antistreptolysin O; titer
Mixed serology, culture, and NAAT CPT CodesCPTCovered
86063
Antistreptolysin O; screen
86215
Deoxyribonuclease, antibody
86317
Immunoassay for infectious agent antibody, quantitative, not otherwise specified
86318
Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step-method
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, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate
87430
Infectious agent antigen detection by immunoassay technique, qualitative or semiquantitative; Streptococcus, group A
87650
Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, direct probe technique
1–10 of 15
1/2
Antigen detection CPT CodesCPTCovered
87880
Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group A
Centor criteria threshold — key measure used in coding/coverage decisions
Centor threshold>= 3 (modified Centor score) — threshold at which bacterial throat culture meets coverage criteria
Use caseApplies to detection of streptococcal respiratory infection from throat swab when modified Centor ≥3
Documentation neededClinical documentation should support Centor elements (tonsillar exudates, tender anterior cervical lymphadenopathy, fever, absence of cough)
Provider Actions, Documentation, and Denial Risk
Documentation Required
Provider Actions, Documentation, and Denial Risk
Actionable provider guidance, documentation requirements, and denial triggers for β-hemolytic Streptococcus testing.
Testing indication and follow-up: Use RADT, NAAT (direct or amplified), or throat culture guided by clinical assessment (e.g., modified Centor/McIsaac or FeverPAIN) and intended management. Test only when there is clinical suspicion of GAS and intention to treat with antibiotics. Do not test patients with modified Centor score <3 or with viral features (cough, rhinorrhea, hoarseness, oral ulcers). For children older than 3 years, follow a negative RADT with a throat culture or a more sensitive NAAT when the RADT sensitivity is known to be <80%; have a mechanism to contact families and initiate antibiotics if the backup culture is positive.
Two-step RADT → NAAT/culture in pediatrics: In pediatric patients, if RADT is negative and the RADT sensitivity is <80%, obtain a second throat swab for NAAT or culture. A convenient workflow is to collect a dual swab at the initial encounter to permit reflex testing without re-swabbing.
Testing stewardship / step approach: Reserve testing for patients with higher pretest probability (e.g., modified Centor ≥3) and when positive results would change management. Avoid routine rapid testing in patients with clear viral features or low pretest probability.
Listed procedure codes — check prior auth: Applicable CPT/HCPCS codes include serology (e.g., 86060, 86063), DNase/antibody assays (86215), immunoassays (86317, 86318), streptococcal antigen immunoassays (87430, 87880), culture codes (87070, 87071, 87077), and nucleic acid detection codes (87650, 87651, 87652, 87797-87799). Providers should verify member-specific benefit coverage and prior authorization requirements before ordering (see policy header and payer-specific tools).
Background and Evidence Summary
Group A Streptococcus (GAS) is responsible for a minority of acute pharyngitis cases in adults—approximately 5–15%—while groups C and G account for about 5–10%. Clinical scoring systems such as the Centor (modified/McIsaac) criteria are used to estimate pretest probability and guide testing decisions; a modified Centor score of ≥3 is a common threshold to consider diagnostic testing for GAS.
Definitions and Diagnostic Terms
Centor criteria — Clinical scoring system
ComponentsTonsillar exudates; tender anterior cervical lymphadenopathy; fever; absence of cough — each criterion = 1 point
Scoring implicationModified Centor score ≥3 indicates testing (culture) per policy
Clinical documentationPolicy specifies documentation should support the Centor elements when claiming indication for throat culture
RADT — Rapid antigen diagnostic testing
DefinitionRapid antigen diagnostic testing (RADT) performed on a throat swab at point-of-care or transported to a lab
Performance noteRADTs vary considerably in sensitivity and specificity; many have high specificity but variable sensitivity
Policy Revision History
2026-03-01policy reviewLatest
Policy last reviewed; clinical content assessed and retained without material changes to coverage criteria.
2018-09-25effective date
Policy became effective providing coverage criteria for β-hemolytic Streptococcus testing, including throat culture, RADT/NAAT guidance, and serologic testing for sequelae.
2019-02-26evidence update
Inclusion of BMC Infectious Diseases 2019 systematic data on diagnosis and management of group A streptococcal pharyngitis to support testing pathways.
Key ActionReserve testing for patients with high clinical suspicion (e.g., modified Centor ≥3) and document Centor elements when ordering throat culture or RADT; perform backup culture in children >3 with negative RADT.
Simultaneous ordering of both direct probe and amplification probe for the same organism in a single encounter.
Policy exclusion (III.6).
Not covered tests: Panel tests that screen multiple streptococcal strains (e.g., Solana Strep Complete, Lyra Direct Strep Assay) or immunoassay/NAAT panels that identify multiple streptococcal species.
Policy exclusion (III.5.a; III.8.a).
Not covered tests: Quantification of any streptococcal strain using nucleic acid amplification methods (including PCR).
Policy exclusion (III.5.b; III.8.b).
Not covered tests: Nicotinamide‑adenine dinucleotidase (NAD) activity testing or anti‑NAD immunoassay.
Policy exclusion (III.5.c; III.8.c).
In adults and age groups other than pediatric where ARF risk is low, throat culture after a negative RADT is not routinely indicated unless special risk factors exist; positive RADT or culture confirms GAS pharyngitis.
CDC: backup culture not routinely indicated for adults (CDC guidance).
Culture:
Throat culture remains the gold standard reference method and is used for backup in pediatric scenarios and for confirmation when required for public health or evaluation of sequelae, despite longer turnaround time.
Culture is the reference standard in many studies and policy statements.
MALDI‑TOF and molecular panels: MALDI‑TOF provides rapid organism identification from pure culture; molecular blood‑culture identification panels can shorten time to organism identification and antibiotic optimization but may not replace culture for certain determinations.
MALDI‑TOF and BCID panels improve turnaround and agreement metrics in studies.
PSGN is primarily due to GAS; rare GCS cases reported (CDC).
assay‑dependent sensitivity threshold ~80%
IDSA guidance on testing algorithms and arbitration.
GBS screening in pregnancy (ACOG): All pregnant women should undergo antepartum GBS screening at 36 0/7–37 6/7 weeks unless intrapartum prophylaxis is already indicated.GA 36 0/7–37 6/7 weeks
ACOG Committee Opinion #797; endorsed by ASM.
NICE stance on rapid tests: NICE does not recommend routine adoption of rapid strep A tests for people with sore throat because their impact on prescribing and outcomes is limited compared with clinical scoring alone.
NICE guidance discourages routine use of rapid tests.
Prior authorization: No specific prior authorization requirements are stated in the referenced guidance; however, coverage is subject to the member's benefit plan and any applicable payer prior authorization program. Always check eligibility and prior authorization status with the payer before performing non-emergent testing.
Triggers for denial / non-coverage: RADT performed as a follow-up to an existing bacterial culture or nucleic acid test, RADT used for asymptomatic screening (except the narrow exception for asymptomatic children under age 3 with mitigating circumstance), simultaneous ordering of direct probe and amplification probe for the same organism in a single encounter, serological titer testing or certain streptococcal immunoassays in situations not specified as meeting coverage criteria, panel tests that identify multiple streptococcal strains, and nucleic acid quantification of streptococcal strains DO NOT MEET COVERAGE CRITERIA.
Potential denial risk from lack of culture follow-up in children: For children >3 years with a negative RADT, failure to perform or arrange backup throat culture or sensitive NAAT per guidance may place the claim at risk for denial when the policy requires confirmatory testing after negative RADT in this age group.
Required clinical documentation: Document elements supporting the clinical decision to test, including Centor/McIsaac score components (tonsillar exudates, tender anterior cervical lymphadenopathy, fever history, absence of cough) and presence/absence of viral features, age, signs/symptoms prompting testing, and treatment intent. For pediatric negative RADT with reflex culture/NAAT, document the plan for backup testing and mechanism to notify family if culture returns positive.
Recommended diagnostic documentation: When serology is used to demonstrate antecedent GAS infection (e.g., for suspected acute rheumatic fever or PSGN), document paired acute and convalescent titers (timing at least two weeks apart) or rising ASO/anti-DNase B titers when applicable. For microbiologic confirmation, document positive throat culture, positive RADT/NAAT, or other laboratory evidence per guideline recommendations.
This section provides evidence-based references: CDC, IDSA, AAP, AHA, ICSI, and other peer-reviewed guidance cited in the policy underpin recommended testing pathways, two-step pediatric algorithms, and the limitations/unsupported uses of various assays. Providers should follow these evidence-based recommendations and the policy's covered indications when ordering tests.
No step therapy requirements included: There are no step-therapy or quantity limit programs described in the cited references for streptococcal testing in this policy.
Pediatric follow-upIn pediatric patients, a negative RADT with known sensitivity <80% should be followed by NAAT or culture (two-step algorithm)
NAAT — Nucleic Acid Amplification Test
DefinitionNAAT = Nucleic Acid Amplification Test; amplifies DNA/RNA to detect microorganisms (includes PCR and HDA methods)
PerformanceNAATs are generally more sensitive than antigen tests; negative direct NAATs do not require arbitration by secondary test
FormatsAvailable as point-of-care rapid NAATs and laboratory-based assays (e.g., Lyra PCR, Solana HDA)
MALDI-TOF — mass spectrometry identification from culture
DefinitionMALDI-TOF = matrix-assisted laser desorption/ionization–time of flight mass spectrometry for rapid identification from pure culture
LimitationsMay be inconclusive for less common organisms and may require additional bench or molecular tests
Clinical utilityCompared favorably with molecular BCID panels for speed; used after culture to ID isolates by spectral database matching
Laboratory evidence of preceding Group A Streptococcus infection
Acceptable serologic evidenceRising or elevated anti-streptolysin O (ASO) or anti-DNase B titers indicate preceding GAS infection
Culture/antigen evidenceA positive throat culture for group A β-hemolytic streptococci or a positive rapid group A antigen test in high pretest probability supports prior infection
Timing noteASO peaks ~3–5 weeks post-infection; anti-DNase B peaks ~6–8 weeks; rising titer (acute to convalescent) is best evidence
Acceptable GBS identification methods
Phenotypic/proteomic methodsAcceptable methods include CAMP test, latex agglutination, and mass spectrometry for GBS identification
NAAT from enrichment brothNAAT-based identification from enrichment broth is acceptable but may not be sufficient alone for all patients
Unacceptable direct methodsLatex agglutination directly from enrichment broth and direct-from-specimen immunoassays are unacceptable for GBS detection per ASM
Group A streptococcal pharyngitis — clinical guidance and testing recommendations
Clinical focusGroup A streptococcal pharyngitis guidance covers diagnosis (RADT, NAAT, culture) and management per multiple guideline sources
Testing stewardshipUse clinical scores (Centor/McIsaac/FeverPAIN) to reserve testing for patients with higher pretest probability
Special testing notesChildren with negative RADT may require backup culture; serology used to document prior infection for ARF/PSGN evaluation
2021-07-23evidence reference added
ASM guideline for detection and identification of Group B Streptococcus (updated July 23, 2021) added to references supporting GBS-related recommendations.
2021-05-01economic evidence added
US cost-effectiveness and budget impact analysis of point-of-care NAAT for Streptococcus (May 1, 2021) incorporated to inform test selection and performance considerations.
2024-05-15evidence update
UpToDate review on acute rheumatic fever (updated May 15, 2024) cited to support serologic testing guidance for ARF evaluation.
2024-04-09evidence update
UpToDate coverage of Group A Streptococcus virulence and diagnostics (updated April 9, 2024) added to reference list for clinical context and laboratory methods.
2025-08-06evidence update
CDC clinical guidance on diagnosing acute rheumatic fever (updated August 6, 2025) included in evidence list for recommendations on laboratory confirmation of prior GAS infection.
2025-08-05evidence update
CDC clinical guidance for Group A Streptococcal pharyngitis (updated August 5, 2025) referenced to support testing indications and follow-up recommendations.