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B-Hemolytic Streptococcus Testing
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Defines coverage criteria, indications, and limitations for laboratory testing to detect beta-hemolytic streptococcal infections (including Groups A, B, C, G) for Oscar Health members and guidance for providers on claims and documentation.
No material clinical or coverage changes in this revision.
Coverage Criteria for B-hemolytic Streptococcus Testing
Detection of streptococcal infection causing respiratory illness (throat culture)
Covered when ANY of the following are met:
Centor criteria components and RADT reflex guidance referenced in Notes and Scientific Background
Skin and soft tissue infections
Covered when ALL of the following are met:
Culture description and rationale (CDC gold standard) provided in Scientific Background
Suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN)
Covered when ANY of the following serologic tests are ordered for suspected ARF or PSGN:
Rising ASO/anti-DNase B between acute and convalescent samples is best evidence of antecedent infection; ASO peaks ~3–5 weeks, ADB ~6–8 weeks
Not covered / Does not meet criteria
Tests or situations explicitly listed as not meeting criteria:
Guideline-driven testing criteria
Guideline-recommended testing and documentation behaviors (CDC, AAP, AHA) summarized as rule-sets
Sources: CDC, AAP
Source: AAP
Sources: CDC, IDSA, assay performance summaries
Source: AAP, AHA
Sources: ACOG, ASM
Guideline-based testing criteria
Relevant clinical testing recommendations from cited guidelines (not an exhaustive policy decision set in this part):
ACOG Committee Opinion #797
ICSI consensus
IDSA guidance
AAP
Panel or multiplex assays that screen for multiple streptococcal strains, assays that report quantitative results of streptococcal organisms by nucleic acid amplification (including PCR), and certain enzymatic/antibody-based assays are explicitly listed as not meeting criteria. Examples called out in the policy include multi-organism panels such as the Solana Strep Complete Assay and Lyra Direct Strep Assay, quantification of streptococcal strains by NAAT/PCR, and nicotinamide-adenine dinucleotide activity assays or corresponding immunoassays. Claims for these tests may be subject to noncoverage because the evidence does not establish that they are required or beneficial for diagnosis or treatment.
The AAP guidance cited in the policy indicates that testing children younger than 3 years generally is not indicated for GAS pharyngitis in industrialized countries due to the very low risk of rheumatic fever. The AAP also advises that home use of FDA-cleared rapid tests is discouraged because of the risk of false-positive results representing colonization rather than true infection.
Guideline sources referenced by the policy recommend against routine microbiologic testing in certain outpatient pneumonia settings: the ATS/IDSA guideline advises not to obtain sputum Gram stain and culture routinely and not to obtain blood cultures routinely for adults with outpatient community-acquired pneumonia. The pediatric PIDS-IDSA guidance similarly advises against routine blood cultures in nontoxic, fully immunized children with outpatient CAP and limits sputum culture/Gram stain to hospitalized children who can produce sputum or children who fail to improve.
No additional explicit exclusions are stated in the provided publication-history or governance chunks beyond those enumerated elsewhere in the policy document.
For indications and situations not described as meeting criteria, the policy states that serologic and enzymatic assays such as the antistreptolysin O (ASO) immunoassay, hyaluronidase activity or anti-hyaluronidase immunoassay, and streptokinase activity or anti-streptokinase immunoassays do not meet criteria and therefore are not covered for routine diagnostic use.
The policy follows guideline recommendations that testing asymptomatic individuals and children with clear viral features (for example, rhinorrhea, cough, hoarseness, oral ulcers, conjunctivitis) is not recommended and is therefore generally considered not medically necessary for diagnosis of GAS pharyngitis.
The NICE assessment cited in the policy concludes that rapid tests for group A streptococcal infection are not recommended for routine adoption for people with sore throat because they offer limited additional benefit over clinical scoring alone in terms of improving prescribing, stewardship, or patient outcomes.
Within the portions of the document provided for review there are no additional explicit statements labeled as 'not medically necessary' beyond the items already referenced in the policy excerpts.
Coding and Procedure Codes
| No codes listed |
| 86060 | Antistreptolysin O; titer. |
| 86063 | Antistreptolysin O; screen. |
| 86215 | Deoxyribonuclease, antibody. |
| 86581 | Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation. |
| 87070 | 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. |
| 87081 | Culture, presumptive, pathogenic organisms, screening only. |
| 87651 | Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, direct probe technique. |
| 87652 | Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique / quantification (as listed). |
| 87797 | Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism. |
| 87798 | Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism. |
| 87799 | Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; quantification, each organism. |
| 87880 | Infectious agent antigen detection by immunoassay with direct optical (i.e., visual) observation; Streptococcus, group A. |
| K162274 | 510(k) premarket notification of intent to market Solana Strep Complete Assay (FDA) (2016). |
| K183366 | 510(k) Substantial Equivalence Determination Desion Summary (FDA). |
| K201269 | Groups A, C And G Beta-Hemolytic Streptococcus Nucleic Acid Amplification System (FDA). |
Provider Actions, Authorization, and Documentation
Authorization tied to member benefits
Coverage and reimbursement for streptococcal testing are subject to the member’s benefit coverage and applicable regulations at the time of service; services must meet authorization and medical necessity guidelines for the procedure, diagnosis, and member’s state of residence.
- Verify member benefits and any authorization requirements prior to ordering testing.
- Ensure testing and coding align with the member’s state residency and applicable regulations.
No explicit prior authorization specified in policy excerpts
The policy text and supporting clinical evidence discuss assay performance and workflows but do not state any specific prior authorization requirements for streptococcal assays in the provided excerpts.
- Documented clinical utility and comparative performance of NAAT/HDA assays are presented, but no Oscar-specific PA rules are listed in these chunks.
Referenced procedure codes may be subject to payer rules
Procedure codes listed in Section VIII are referenced by the policy and may be subject to payer-specific prior authorization or billing rules; verify Oscar Health requirements before submitting claims.
No general prior authorization requirement stated
The provided policy excerpts do not impose a general prior authorization requirement for streptococcal testing.
- If payer-specific PA applies, it will be detailed outside the excerpted policy sections—check member documents and Oscar Health portals.
Two-step testing workflow for pediatric pharyngitis (collect dual swab)
For pediatric patients, if a less-sensitive RADT is negative, follow-up testing with a more sensitive NAAT or throat culture is recommended; collecting a dual swab at the initial visit is a suggested workflow to enable reflex testing.
- Collect dual swab specimens initially so the second swab can be used for NAAT or culture if RADT is negative.
- Have a mechanism to notify the family and initiate antibiotics if the backup culture/NAAT returns positive.
Two-step testing in pediatrics per CDC/guidelines
CDC and guideline-based guidance endorse a two-step pediatric pathway: in children older than 3 years, a negative RADT should be followed by throat culture (or NAAT); ensure backup testing is available and families can be contacted with positive results.
- Follow CDC guidance to obtain throat culture when RADT is negative in children >3 years.
- Ensure processes are in place to contact families and start antibiotics if backup testing is positive.
No additional denial triggers listed in excerpts
No explicit denial triggers beyond those related to noncoverage of tests listed as 'DO NOT MEET CRITERIA' and failure to follow government policy are detailed in the excerpts.
- Primary denial risks derive from ordering noncovered assays or failing to comply with payer/government coverage rules.
No insurer step therapy requirements specified
No step therapy requirements are specified in the policy excerpts; the document instead describes recommended testing algorithms (eg, RADT → culture/NAAT in children) rather than insurance-imposed step therapy.
- Follow guideline-recommended diagnostic algorithms, but do not assume formal payer step therapy mandates are present unless specified in member benefits.
Documentation and medical necessity required on claims
Providers are responsible for submitting accurate documentation supporting medical necessity; services must meet authorization and medical necessity guidelines and be coded per industry-standard coding guidance.
- Include clinical indication (eg, modified Centor score, presence/absence of viral features) and relevant signs/symptoms in the medical record when ordering testing.
- Code claims in accordance with CPT/HCPCS and payer instructions to avoid denials or recoupment.
Document laboratory evidence of antecedent GAS infection for sequelae
When diagnosing suspected post-streptococcal sequelae (eg, PSGN or acute rheumatic fever), document laboratory evidence of preceding GAS infection such as isolation of GAS from throat or skin or elevated streptococcal antibody titers (ASO/anti-DNase B).
- Include acute and convalescent antibody titers when relevant; note ASO peaks ~3–5 weeks and ADB peaks ~6–8 weeks after infection.
- Retain laboratory reports showing positive throat culture, RADT, or NAAT as evidence of antecedent infection.
Susceptibility testing for penicillin-allergic pregnant patients
Perform antimicrobial susceptibility testing on GBS isolates from pregnant women with penicillin allergy and include reporting options for vancomycin when appropriate, per ASM guidance.
- Order susceptibility testing for GBS isolates when the pregnant patient has documented penicillin allergy.
- Ensure laboratory reports specify susceptibility and alternative agent recommendations (eg, vancomycin options).
Evidence and guideline references provided for clinical decisions
The policy’s evidence references and guideline citations are provided to support clinical and laboratory testing decisions; use the listed references (Section IX) and cited guidelines (CDC, AAP, AHA, IDSA, ASM) when determining appropriate testing workflows.
- Refer to Section IX evidence-based references and cited guideline excerpts for clinical justification when ordering or documenting tests.
- Use CDC/AAP guidance for pediatric RADT/backup culture workflows and ASM/ACOG guidance for GBS in pregnancy.
Denial risk for noncovered tests or improper coding
Claims may be denied or recouped if coding/billing guidelines or reimbursement policies are not followed; tests listed as 'DO NOT MEET CRITERIA' (for example, panel assays that screen multiple streptococcal strains, quantitative NAATs, and certain enzymatic/serologic assays) are subject to noncoverage.
- Avoid ordering panel NAATs or quantitative nucleic acid amplification for streptococcal testing when policy states they DO NOT MEET CRITERIA (eg, Solana Strep Complete, Lyra Direct Strep Assay used as panel screening).
- Review Section III exclusions before submitting claims to prevent denials or recoupments.
Risk of missed diagnosis if pediatric RADT negative not followed by backup testing
Failure to obtain or to follow-up a throat culture (or NAAT) after a negative RADT in children older than 3 years, when indicated, risks missed GAS diagnosis; ensure backup testing and a process to contact families for positive results.
- Collect backup specimen or have reflex testing available when using RADT in children >3 years.
- Document the mechanism to notify family and initiate antibiotics if backup testing is positive.
Government policy supersedes policy where conflicts exist
If there is a conflict between this Policy and applicable government policies (LCDs/NCDs/state Medicaid), the government policy will govern determinations; failure to follow applicable government policy may result in denial.
- Check for relevant LCDs/NCDs or state Medicaid rules that may supersede this policy prior to ordering or billing.
- Follow government coverage determinations where applicable.
Background and Rationale
Group A Streptococcus (GAS) is identified in the policy as the most common bacterial cause of acute pharyngitis; Groups C and G streptococci can produce clinically similar pharyngitis. The policy references culture, RADT, NAAT, serology, and MALDI-TOF as laboratory methods used for identification, and notes that the Centor clinical criteria help determine testing need (a Centor score of ≥3 is the typical threshold prompting testing).
Definitions and Key Terms
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