Modifiedmedical mutual - ohioPolicy AHS - G2119

Diagnostic Testing of Influenza

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Defines coverage criteria for laboratory testing to detect influenza (RIDTs, NAAT/RT‑PCR, culture, serology) in outpatient and asymptomatic settings for Medical Mutual - Ohio members.

Policy Summary

Payermedical mutual - ohio

PolicyDiagnostic Testing of Influenza

Policy CodePolicy AHS - G2119

Change TypeCoverage criteria revisedbilling note and code removals added

Effective DateFeb 1, 2026

Last ReviewSep 4, 2025

Next Review DateSep 4, 2025

Key ActionDocument one influenza test per symptomatic encounter; bill up to two units if a single test detects both influenza A and B.

SourceLink

POLICY UPDATE CHANGES

Updated background, guidelines, and evidence-based scientific references; literature review necessitated changes in coverage criteria.

Note: One influenza test may detect influenza A and/or influenza B. When both influenza A and influenza B are detected by a test represented by CPT codes 87400, 87501, or 87804, up to two units may be billed at a single visit.

CPT code 87631 (respiratory infection panels that include flu testing) was removed from this policy and is instead addressed in AHS-G2149 Pathogen Panel testing.

Updated signs and symptoms of the flu to align with the CDC.

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Modifiedmedical mutual - ohioPolicy AHS - G2119

Diagnostic Testing of Influenza

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Sign up for medical mutual - ohio Policy AHS - G2119 alerts

Get alerted when Policy AHS - G2119 changes without checking for updates manually.

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Defines coverage criteria for laboratory testing to detect influenza (RIDTs, NAAT/RT‑PCR, culture, serology) in outpatient and asymptomatic settings for Medical Mutual - Ohio members.

Policy Summary

Payermedical mutual - ohio

PolicyDiagnostic Testing of Influenza

Policy CodePolicy AHS - G2119

Change TypeCoverage criteria revisedbilling note and code removals added

Effective DateFeb 1, 2026

Last ReviewSep 4, 2025

Next Review DateSep 4, 2025

Key ActionDocument one influenza test per symptomatic encounter; bill up to two units if a single test detects both influenza A and B.

SourceLink

POLICY UPDATE CHANGES

Updated background, guidelines, and evidence-based scientific references; literature review necessitated changes in coverage criteria.

CPT code 87631 (respiratory infection panels that include flu testing) was removed from this policy and is instead addressed in AHS-G2149 Pathogen Panel testing.

Updated signs and symptoms of the flu to align with the CDC.

1single rapid flu test allowed for symptomatic individuals

1single traditional NAAT allowed for symptomatic individuals

0viral culture coverage (does not meet criteria)

0serology coverage (does not meet criteria)

0testing for asymptomatic individuals (not covered)

27influenza tests listed with CPT 87804 as of Aug 14, 2023

Coverage Criteria for Influenza Testing

inv-01: Covered testing for symptomatic individuals

Covered when ALL of the following are met for symptomatic individuals:

Symptomatic testing coverage: Patient is symptomatic with typical influenza signs/symptoms (see Note 1).

Typical signs include fever, cough, sore throat, headache, myalgia, fatigue, runny/stuffy nose, vomiting/diarrhea (children).

Permitted tests (choose one): Either one single rapid flu test (point-of-care rapid NAAT or rapid antigen test) OR one single traditional NAAT.1 test per symptomatic episode

If a single test detects both influenza A and B (CPT 87400, 87501, or 87804), up to two units may be billed at a single visit.

inv-02: Not covered — asymptomatic testing

Not covered: asymptomatic individuals: Influenza testing (e.g., rapid antigen, rapid NAAT/RT‑PCR, traditional RT‑PCR, viral culture) for asymptomatic individuals does not meet coverage criteria.

inv-03: Not covered — viral culture

Not covered: viral culture: Viral culture testing for influenza does not meet coverage criteria.

inv-04: Not covered — serology

Not covered: serology: Serology (antibody) testing for influenza does not meet coverage criteria.

inv-05: Medical necessity criteria

Covered when testing meets clinical indications described by CDC, IDSA, AAP, and other specialty guidance:

Outpatient symptomatic testing when results influence management: Test symptomatic outpatients if results will influence clinical management (e.g., antiviral decisions, reduce unnecessary antibiotics, or inform infection control). Consider testing high-risk or immunocompromised outpatients during influenza activity.

Based on CDC, IDSA, AAP guidance.

Hospitalized patients: Test all patients requiring hospitalization with acute respiratory illness (with or without fever), patients with acute worsening of chronic cardiopulmonary disease, and immunocompromised or high-risk patients; use molecular assays (RT‑PCR) rather than RIDTs for hospitalized patients.

IDSA/AAP recommendations.

Institutional outbreak testing: In a closed setting, do not test a single symptomatic individual; when multiple persons are symptomatic, perform RT‑PCR testing if results would change control strategies or if high-risk persons are present; use RIDTs for rapid screening but confirm negatives with molecular assays when outbreak cause is uncertain.

CDC outbreak algorithm.

Viral culture testing, serologic testing, and testing of asymptomatic individuals are excluded from coverage. The policy explicitly states that viral culture testing for influenza does not meet coverage criteria, serology testing for influenza does not meet coverage criteria, and that influenza testing for asymptomatic individuals does not meet coverage criteria.

Serologic testing is not recommended for routine diagnosis because results from a single serum specimen cannot be reliably interpreted and paired acute/convalescent sera (2–3 weeks apart) are required. Viral culture is not recommended for initial or primary diagnosis because results are not available in a timely manner to inform clinical management; culture may be considered for confirmation or isolate characterization in outbreak or specialized settings.

Respiratory infection panels that include influenza testing (CPT 87631) are not addressed in this policy and have been removed; claims for CPT 87631 are managed under the separate policy AHS‑G2149 Pathogen Panel testing.

Influenza testing for asymptomatic individuals and serology testing are explicitly stated as not meeting coverage criteria and therefore do not meet the policy’s coverage requirements.

Testing asymptomatic patients is not recommended. The CDC guidance referenced in the policy advises against testing asymptomatic individuals and reserves testing for symptomatic patients when results will influence clinical management or for specific outbreak situations.

When Testing Is Covered

inv-35: Symptomatic individuals with typical influenza signs and symptoms — One test per symptomatic individual: either one rapid flu test (POC rapid NAAT or rapid antigen) OR one traditional NAAT. If a single tes...

One test per symptomatic individual: One test per symptomatic encounter: either one rapid flu test (point‑of‑care rapid NAAT or rapid antigen) OR one traditional NAAT.1 test per encounter

See Note 2: when a single test detects both influenza A and B (CPT 87400, 87501, or 87804), up to two units may be billed.

inv-36: Symptomatic patients when test results will influence clinical management; hospitalized patients with acute respiratory illness; outbreak investigations in closed settings when multiple cases or high-risk persons are present.

When testing influences management: Test symptomatic patients when results will influence clinical management (e.g., antiviral decisions) and consider testing high‑risk or immunocompromised outpatients during influenza activity.

CDC and IDSA guidance.

Services Not Covered

Viral culture, serology testing, and testing of asymptomatic individuals are not covered under this policy. Ordering any of these for members is likely to be outside the coverage criteria described.

Serologic testing for routine diagnosis and viral culture for initial diagnosis are not recommended. Serology requires paired sera and is unreliable from a single specimen; viral culture results are not timely for guiding initial clinical management.

Respiratory infection panel testing represented by CPT 87631 has been removed from this policy and is addressed in the separate policy AHS‑G2149; such panel claims should be submitted under that policy rather than this one.

Procedure Codes and Billing Notes

Billing units when both A and B detectedCPT

87400	Influenza A detection; antigen, multiple types if applicable (listed in policy as example)
87501	Influenza B detection; antigen, multiple types if applicable (listed in policy as example)
87804	Influenza antigen detection (example code listed in policy)

Billing unitization notemixed

Note	When both influenza A and influenza B are detected by a test represented by CPT codes 87400, 87501, or 87804, up to two units may be billed at a single visit.

Applicable CPT/HCPCS Procedure CodesCPT

86710	Antibody; influenza virus.
87254	Virus isolation; centrifuge enhanced (shell vial) technique, includes identification with immunofluorescence stain, each virus.
87275	Infectious agent antigen detection by immunofluorescent technique; influenza B virus.
87804	Infectious agent antigen detection by immunoassay with direct optical (i.e., visual) observation; Influenza.
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, each additional influenza virus type or sub-type beyond 2 (List separately in addition to code for primary procedure).

Covered CPT Codes with billing noteCPTCovered

87400	Influenza A/B antigen; immunoassay with multiple step technique (document text references for billing when both A and B detected)
87501	Influenza A and B, antigen detection by immunoassay; multiple step technique (document text references for billing when both A and B detected)
87804	Influenza virus antigen detection by immunoassay (document text references for billing when both A and B detected)

Billing notemixed

Note	When both influenza A and influenza B are detected by a single test represented by CPT codes 87400, 87501, or 87804, up to two units may be billed at a single visit.

Moved/Removed CPT CodesCPTNot Covered

87631

Infectious agent detection by nucleic acid (e.g., respiratory infection panels that include influenza) - removed from this policy

inv-15: Billing unitization when both A and B detected — Up to 2 units may be billed at a single visit

Billing unitization ruleWhen a single influenza test (represented by CPT codes 87400, 87501, or 87804) detects both influenza A and influenza B, up to 2 units may be billed for that single visit.

Applicable CPT codes (examples)87400, 87501, 87804 (codes cited in the billing unit note).

Documentation expectationDocument that a single test detected both A and B when billing multiple units for one visit.

Policy change historyNew billing note added in 09/04/2025 revision clarifying unitization when both A and B are detected.

Provider Actions and Documentation

Prior Authorization

Prior authorization — none stated

No prior authorization requirements are specified in this policy document.

Note

Procedure code references — verify coding/prior auth

Procedure codes are provided for reference; providers should verify coding and any applicable prior authorization requirements since listed codes may not be all-inclusive.

Codes listed include 86710, 87254, 87275, 87804, 87502, 87503 (see policy for full descriptions).

Prior Authorization

Prior authorization note — unitization clarified; no PA stated

The policy clarifies billing unitization when a single test detects both influenza A and B (CPT 87400, 87501, 87804); no explicit prior authorization requirements are stated in this section.

Ordering and Specimen Requirements

Note

Ordering requirements — follow CDC guidance for clinical utility

Order testing in alignment with CDC and professional society guidance: test symptomatic outpatients when results will influence management and use molecular assays for hospitalized patients.

CDC algorithm: test symptomatic hospitalized patients; test symptomatic outpatients only if results influence clinical management.

Documentation Required

Ordering requirements — send outbreak specimens to public health labs

For suspected institutional outbreaks, collect specimens from ill persons and send them to public health laboratories for molecular testing (RT‑PCR); use RIDTs only for rapid screening and confirm negatives with molecular assays when outbreak cause is uncertain.

Public health labs provide more accurate influenza testing by molecular assays and viral culture; notify public health authorities promptly.

Frequency Limits

inv-38: rapid NAAT/rapid antigen OR traditional NAAT — One influenza test per symptomatic encounter (either one rapid test or one traditional NAAT)

Per-encounter limitOne influenza test per symptomatic encounter: either one point-of-care rapid NAAT or rapid antigen test OR one traditional NAAT.

Applies toSymptomatic individuals (see Note 1 for typical signs and symptoms).

Billing implicationIf a single test detects both A and B, see billing unitization guidance for possible billing of up to 2 units.

inv-39: No explicit frequency limits provided in this section.

Frequency limits statedNo explicit frequency limits are provided elsewhere in this section beyond the one-test-per-symptomatic-encounter guidance.

Implication

Definitions and Test Types

inv-29: RIDTs — Rapid influenza diagnostic tests (RIDTs)

DefinitionRapid influenza diagnostic tests (RIDTs) — CLIA‑waived immunoassays that can detect influenza viruses during the outpatient visit and provide rapid results to inform treatment decisions.

Performance noteRIDTs have lower sensitivity compared with RT‑PCR and may yield false negatives, especially during outbreaks.

Typical useUseful for rapid outpatient decision-making and outbreak screening, but negative RIDT results may require confirmation with molecular assays.

inv-30: NAAT — Nucleic acid amplification test

DefinitionNAAT — Nucleic acid amplification test; molecular assays (e.g., RT‑PCR) used to detect influenza viral RNA.

Preferred settingRecommended for hospitalized patients and for confirming outbreaks due to higher sensitivity and specificity than RIDTs.

Background

Influenza A and B cause seasonal respiratory illness characterized by abrupt onset of fever, myalgia, headache and respiratory symptoms. Rapid influenza diagnostic tests (RIDTs) provide quick, point-of-care results useful for outpatient decision-making but have limited sensitivity compared with molecular NAAT/RT‑PCR; molecular assays are preferred for hospitalized patients and for outbreak confirmation. Antiviral therapy is most effective when started early, and testing recommendations prioritize symptomatic patients when results will affect clinical management.

Policy Summary

Payermedical mutual - ohio

PolicyDiagnostic Testing of Influenza

Policy CodePolicy AHS - G2119

Change TypeCoverage criteria revisedbilling note and code removals added

Effective DateFeb 1, 2026

Last ReviewSep 4, 2025

Next Review DateSep 4, 2025

Key ActionDocument one influenza test per symptomatic encounter; bill up to two units if a single test detects both influenza A and B.

SourceLink

On This Page

Use of RIDTs: RIDTs may be used for rapid screening (especially point‑of‑care) but have limited sensitivity and possible false positives during low activity; negative RIDT results do not exclude influenza and should be confirmed by molecular methods when clinically important.

CDC and IDSA guidance.

Hospitalized/acutely ill patients: Hospitalized patients with acute respiratory illness, patients with acute worsening of chronic cardiopulmonary disease, and immunocompromised/high‑risk patients should be tested; molecular assays are preferred.

IDSA/AAP recommendations.

Outbreak investigations: For outbreak investigations in closed settings, perform RT‑PCR testing when multiple cases or high‑risk persons are present; do not test a single symptomatic person for outbreak confirmation.

CDC outbreak algorithm.

inv-37: Testing for suspected influenza infection in symptomatic patients and in outbreak/institutional settings per CDC and IDSA guidance.

Guideline references for testing indications: Testing for suspected influenza infection in symptomatic patients and in outbreak/institutional settings should follow CDC and IDSA guidance; professional society guidance (e.g., AAP) informs specific populations such as children.

See CDC guide for community testing and CDC outbreak guidance; see IDSA clinical practice guidelines and AAP Red Book recommendations.

Note: When both influenza A and B are detected by a test represented by CPT codes 87400, 87501, or 87804, up to two units may be billed at a single visit.

Step Therapy

Testing vs empiric treatment — test when results change management

When influenza is circulating, clinicians should test symptomatic outpatients when results will influence clinical management and should test hospitalized patients; empirical antiviral treatment may be used if testing will not change management.

CDC: test symptomatic patients if results will influence management; do not test asymptomatic patients.
IDSA: test high-risk outpatients and hospitalized patients when results influence management; consider empiric treatment if testing will not change management.

Documentation Required

Required documentation — document symptoms and one test per encounter

For symptomatic individuals, document typical influenza signs and symptoms and limit billing to one influenza test per symptomatic encounter (either a single rapid test OR one traditional NAAT).

Typical signs/symptoms include: fever or chills, cough, sore throat, headache, myalgia, fatigue, runny/stuffy nose; vomiting/diarrhea more common in children.
Perform and bill only one influenza test per symptomatic episode (rapid NAAT/rapid antigen OR traditional NAAT).

Documentation Required

Outbreak reporting and reference testing — notify public health and send specimens

Notify public health authorities promptly of any suspected institutional outbreak and send respiratory specimens from ill persons to public health laboratories for molecular testing (RT‑PCR) for confirmation.

Collect specimens from multiple symptomatic persons during suspected outbreaks and send to public health labs for more accurate molecular testing.
Follow applicable government (LCD/NCD) policies where conflicts exist.

Billing Rule

Billing unit documentation — up to two units when A and B both detected

When a single test detects both influenza A and B (CPT 87400, 87501, or 87804), billing may include up to two units for that single visit; document the test result accordingly.

This unitization applies when both A and B are detected by the same test represented by the listed CPT codes.

Denial Risk

Denial triggers — asymptomatic testing, culture, serology

Ordering viral culture, serology, or influenza testing for asymptomatic individuals does not meet coverage criteria and will trigger coverage denial.

Policy explicitly states viral culture and serology testing do not meet coverage criteria.
Influenza testing for asymptomatic individuals (including rapid antigen, rapid NAAT/RT‑PCR, traditional RT‑PCR, viral culture) does not meet coverage criteria.

Denial Risk

Testing indications and denials — do not test asymptomatic patients

Testing asymptomatic patients is not recommended; performing testing when not clinically indicated (e.g., asymptomatic without outbreak context) risks coverage denial.

CDC: do not recommend testing asymptomatic individuals.
Policy: influenza testing for asymptomatic individuals does not meet coverage criteria.

Denial Risk

Panel testing code removed — redirect CPT 87631 to AHS‑G2149

CPT code 87631 (respiratory infection panels that include influenza) has been removed from this policy and is addressed under AHS‑G2149; claims submitted under this policy for 87631 may be denied or redirected.

Revision history: Removed CPT 87631 and redirected to AHS‑G2149 Pathogen Panel testing.

Note

Ordering requirements — no explicit provider restrictions in this policy

This document does not impose specific ordering-provider restrictions; follow CDC, IDSA, and other professional guidance for appropriate testing contexts.

Policy references CDC and professional society guidance which address testing contexts and indications.

Policy does not specify additional time-based retest intervals or repeat testing rules in this section.

Reference noteOrdering should follow clinical utility per CDC/IDSA guidance when frequency is clinically indicated.

inv-40:

Placeholder entryNo additional frequency limit content provided in the referenced module of the brief.

Revision noteRevision history includes policy updates; no new frequency constraints were added in the cited revision.

Related policyMulti-pathogen panel code (87631) removed and addressed under AHS-G2149; frequency for panel testing is covered there.

Regulatory noteMany molecular assays are laboratory‑developed tests (LDTs) regulated under CLIA as high‑complexity tests.

inv-31: Rapid influenza diagnostic test (RIDT) — antigen detection tests that provide rapid results but have limited sensitivity and variable ability to detect viral antigens compared with RT-PCR.

DescriptionRIDT — Antigen detection tests that provide rapid results but have limited sensitivity and variable ability to detect viral antigens compared with RT‑PCR.

LimitationsHigh false negative rates and variable antigen detection performance; negative results do not reliably exclude influenza.

Use guidanceCan be used for rapid screening, particularly in point‑of‑care settings; confirm negatives with molecular tests when clinically important.

inv-32: Nucleic acid amplification test (NAAT)/RT-PCR — molecular assays recommended for hospitalized patients and outbreak confirmation due to higher sensitivity and specificity.

DescriptionNAAT/RT‑PCR — Molecular assays recommended for hospitalized patients and outbreak confirmation due to higher sensitivity and specificity compared with RIDTs.

Clinical recommendationUse molecular assays rather than RIDTs for hospitalized patients; molecular testing is preferred for outbreak investigations when results will guide control strategies.

Confirmation roleMolecular assays are recommended to confirm negative RIDT results when clinically necessary.

inv-33: Molecular point-of-care diagnostics

DefinitionMolecular point‑of‑care diagnostics — Rapid molecular NAAT platforms cleared or used at point‑of‑care to provide faster molecular results than traditional lab PCR.

UtilityOffer higher sensitivity than antigen RIDTs while providing more rapid turnaround time suitable for outpatient decision‑making.

Regulatory contextSome molecular point‑of‑care assays may be CLIA‑waived or regulated as high‑complexity LDTs; verify test status and requirements.

inv-34: AAP Red Book — Authoritative pediatric guidance on influenza prevention and control

ResourceAAP Red Book — Authoritative pediatric guidance on influenza prevention and control (Red Book® 2024–2027, Committee on Infectious Diseases).

RelevanceCited as a specialty reference supporting testing and management recommendations for pediatric patients.

Use in policyReferenced among evidence-based sources (CDC, IDSA, ACOG, NIH) informing coverage and clinical guidance in this policy.