CurrentPremera BluecrossPolicy 15.01.018

Diagnostic Testing of Influenza

Defines Premera Bluecross reimbursement policy for influenza diagnostic testing — which tests are reimbursable or not, clinical indications (symptomatic vs asymptomatic), and lists relevant CPT codes and clinical guidance references. This is part 1 of 2; contains policy description, indications, coding list, scientific background, guidance citations, and definitions/terminology.

Policy Summary

PayerPremera Bluecross

Policy15.01.018 Diagnostic Testing of Influenza

Policy CodePolicy 15.01.018

Change TypeNew routine test management policy

Effective DateFeb 6, 2026

Next Review Date

Key ActionProviders must document that the patient is symptomatic and that influenza activity is documented in the community to qualify for reimbursable testing.

SourceLink

POLICY UPDATE CHANGES

New policy approved October 14, 2025 and effective for dates of service on or after February 6, 2026 following 90-day provider notification.

For symptomatic individuals during documented influenza activity, one rapid flu test (rapid NAAT or rapid antigen) or one traditional nucleic acid amplification test is reimbursable.

Viral culture, serology, and influenza testing for asymptomatic individuals are not reimbursable.

1Allowed test per symptomatic episode

3Not reimbursable test types

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Coverage Summary & Indications

This policy (Premera Routine Test Management Policy 15.01.018) defines reimbursable versus non‑reimbursable influenza diagnostic testing. Effective date: February 6, 2026; policy approved/last revised October 14, 2025. For symptomatic individuals during documented community influenza activity, one reimbursable test is allowed: either one rapid flu test (a point‑of‑care rapid NAAT or a rapid antigen test) OR one traditional nucleic acid amplification test (NAAT/RT‑PCR). Viral culture, serology, and testing of asymptomatic individuals are not reimbursable. This document is part 1 of 2.

Coverage Indications

Covered/reimbursable testing when ALL of the following apply:

ALL of the following

Individual is symptomatic (see Note 1 Typical Influenza Signs and Symptoms).
Influenza activity has been documented in the community or geographic area.
ONE of the following (only one reimbursable):
- One single rapid flu test (either a point-of-care rapid nucleic acid amplification test (NAAT) or a rapid antigen test).
- One single traditional NAAT.

Reimbursable testing for symptomatic individuals during documented influenza activity

Covered when ALL of the following are met:

ALL of the following

Individual is symptomatic
See Note 1 for Typical Influenza Signs and Symptoms.
There is documented influenza activity in the community or geographic area
ONE of
- One rapid flu test (rapid NAAT or rapid antigen)
- One traditional nucleic acid amplification test

Glossary — Rapid influenza diagnostic tests (RIDTs): CLIA‑waived immunoassays that detect influenza viruses during the outpatient visit. NAAT: nucleic acid amplification test. RT‑PCR: reverse‑transcriptase polymerase chain reaction.

Not Reimbursable / Exclusions

Tests that are not reimbursable under this policy:

ANY of the following

Viral culture testing for influenza is not reimbursable.
For asymptomatic individuals, influenza testing (e.g., rapid antigen flu tests, rapid NAAT or RT-PCR tests, traditional RT-PCR tests, viral culture testing) is not reimbursable.
Serology testing for influenza is not reimbursable.

Not reimbursable

The following are NOT reimbursable under this routine test management policy:

ANY of the following

CPT and Related Codes

Listed CPT codes (influenza testing and related)CPT

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.
87276	Infectious agent antigen detection by immunofluorescent technique; influenza A virus.
87400	Infectious agent antigen detection by immunoassay technique, (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Influenza, A or B, each.
87501	Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, includes reverse transcription, when performed, and amplified probe technique, each type or subtype.
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.
87804	Infectious agent antigen detection by immunoassay with direct optical (i.e., visual) observation; Influenza.

No CPT/HCPCS/ICD codes listed in this partmixed

No codes listed

Provider Action Items & Billing Impact

Documentation Required

Document symptomatic status and local influenza activity

Document in the medical record that the patient is symptomatic (see Note 1 for typical signs/symptoms) and that influenza activity has been documented in the community or geographic area to qualify for reimbursable testing.

Billing Rule

Limit to one reimbursable influenza test per symptomatic episode

Reimbursement is limited to one single rapid flu test (rapid NAAT or rapid antigen) OR one single traditional NAAT (but not both) per symptomatic episode when community influenza activity is documented. Affected CPT codes: 87804, 87400, 87501, 87502.

87804
87400
87501

Clinical Rationale & Evidence

Background/rationale: RIDTs are useful for rapid, point‑of‑care detection in outpatient settings but have lower sensitivity compared with molecular assays; a pooled meta‑analysis reported RIDT sensitivity ~62.3% and specificity ~98.2%. NAATs and real‑time RT‑PCR are substantially more sensitive and specific and are preferred when higher analytical performance or hospitalization decisions are required (real‑time RT‑PCR sensitivity reported ~96.5% versus viral culture in comparative studies). Viral culture is time‑consuming (average ~7 days turnaround) and is not appropriate for initial clinical management. Serologic testing is not useful for outpatient diagnosis because single‑sample serology cannot reliably diagnose acute infection. National guidance (CDC, IDSA, AAP, ACOG, FDA, NIH) supports using molecular assays over RIDTs when clinical decisions depend on accurate results, reserving RIDTs for rapid screening or outbreak detection while recognizing their limited sensitivity.

Key diagnostic performance metrics

RIDT pooled sensitivity62.3% sensitivity

RIDT pooled specificity98.2% specificity

RT-PCR sensitivity vs viral cultureReal-time RT-PCR sensitivity 96.5% vs viral culture

Policy Changes & Effective Dates

2025-10-14policy_approval

New policy approved October 14, 2025 and added to Routine Test Management Policy section. (Change detail: Added to Routine Test Management Policy section.)

2026-02-06policy_effectiveLatest

Policy effective for dates of service on or after February 6, 2026 following 90-day provider notification. (Change detail: Added to Routine Test Management Policy section.)

2025-10-14

Policy Summary

PayerPremera Bluecross

Policy15.01.018 Diagnostic Testing of Influenza

Policy CodePolicy 15.01.018

Change TypeNew routine test management policy

Effective DateFeb 6, 2026

Next Review Date

Key ActionProviders must document that the patient is symptomatic and that influenza activity is documented in the community to qualify for reimbursable testing.

SourceLink

On This Page

Viral culture for influenza

Serology testing for influenza

Influenza testing for asymptomatic individuals

Examples include rapid antigen tests, rapid NAAT or RT-PCR tests, traditional RT-PCR tests, and viral culture testing.

Denial Risk

Tests likely to be denied

Claims for viral culture, serology, or testing for asymptomatic individuals will be denied/not reimbursed under this policy. Affected CPT codes included in coding list for related non-reimbursable modalities: 87254, 86710.

87254
86710

Billing Rule

Limit one reimbursable influenza test per symptomatic episode during documented activity

For symptomatic individuals during documented influenza activity, only one rapid flu test (rapid NAAT or rapid antigen) or one traditional nucleic acid amplification test is reimbursable per symptomatic episode (i.e., limit of one reimbursable test during that episode).

Denial Risk

Claims for non-reimbursable influenza tests risk denial

Claims for viral culture, serology, or influenza testing for asymptomatic individuals are not reimbursable and may be denied under this policy.

Documentation Required

Symptom and activity documentation required

Medical record documentation must support that the patient was symptomatic (see Note 1 Typical Influenza Signs and Symptoms) and that there was documented influenza activity in the community or geographic area at the time of testing.

Billing Rule

Addition to Routine Test Management Policy

This guidance has been added to the Routine Test Management Policy section and applies to reimbursement determinations for influenza diagnostic testing (effective Feb. 6, 2026; approved Oct. 14, 2025).

Specifies reimbursable test modalities and limits to one test: For symptomatic individuals during documented influenza activity, one rapid flu test (rapid NAAT or rapid antigen) or one traditional nucleic acid amplification test is reimbursable. (Change detail: Specifies reimbursable test modalities and limits to one test.)

2025-10-14coverage_change

Explicit exclusions for non-reimbursable testing types and populations: Viral culture, serology, and influenza testing for asymptomatic individuals are not reimbursable. (Change detail: Explicit exclusions for non-reimbursable testing types and populations.)