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    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyProvidence Respiratory Panels Coverage | OpenPayer
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    ModifiedProvidence Health PlanPolicy 256

    Respiratory Viral Panels

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    This policy governs coverage of respiratory viral panels for Providence Health Plan, Providence Health Assurance, and Providence Plan Partners members in commercial and Medicaid/OHP products. It establishes medical-necessity criteria for panels testing 3–5 pathogens and identifies panels testing 6 or more pathogens as not medically necessary.

    Policy Summary
    PayerProvidence Health Plan
    PolicyRespiratory Viral Panels
    Policy CodePolicy 256
    Change TypeModified
    Effective DateOct 1, 2026
    Last ReviewSep 1, 2026
    Next Review DateJul 1, 2027
    Key ActionObtain prior authorization before submitting an unlisted code for a potentially covered service addressed by this policy.
    SourceLink
    POLICY UPDATE CHANGES

    The October 2026 Q4 code set update revised the respiratory testing code configuration, including termination of code 0528U effective October 1, 2026.

    3–5

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Eligible panel size
    6+Not medically necessary
    2Product lines
    High-riskSupported population
    ≤5Supported target limit
    0528UTerminated code

    Medical Necessity Criteria

    3–5 Pathogen Panel — Medically Necessary

    Covered when ALL of the following criteria are met:

    ALL of the following

    • Testing is for a diagnosis listed in the policy; see the Billing Guidelines for the complete list of diagnosis codes.
    • Testing is for an individual at high risk for complications of respiratory viral infection.
    • Testing will be used to guide or alter management.

    3–5 Pathogen Panel — Not Medically Necessary

    Respiratory viral panels of 3–5 pathogens are considered not medically necessary when the medical-necessity requirements below are not all met:

    Any of the following

    • Testing is not for a diagnosis listed in the policy.
    • The individual is not at high risk for complications of respiratory viral infection.
    • Testing will not be used to guide or alter management.

    Panels of 6 or More Pathogens

    Panels testing for 6 or more pathogens are not medically necessary.

    ALL of the following

    • The test is a multiplex PCR respiratory viral panel testing for 6 or more pathogens.
    • The panel is determined not medically necessary regardless of individual risk status or intended management use.

    High-Risk Individuals

    Evidence supports respiratory viral panel testing of 5 or fewer targets when ALL of the following criteria are met:

    ALL of the following

    • The individual is at high risk for complications of respiratory viral infection, including an immunocompromised individual.
    • The clinical presentation and diagnosis support respiratory viral testing under the policy.
    • The test result will be used to guide or alter clinical management.

    Average-Risk Individuals

    Routine respiratory viral panel testing is not supported for average-risk individuals.

    All of the following describe the evidence limitation

    • The individual is at average risk for complications of respiratory viral infection.
    • The testing is being considered as routine respiratory viral panel testing.
    • Improved clinical outcomes have not been demonstrated in this population.

    Large Panels With 6 or More Targets

    Use of large respiratory viral panels is not supported by sufficient evidence.

    ALL of the following

    • The panel contains 6 or more pathogen targets.
    • Evidence is insufficient to establish the clinical utility of the large panel.
    • Additional large diagnostic cohort studies are needed to establish clinical utility.

    Influenza Testing Indications

    Influenza testing is supported or may be considered when the result is expected to influence clinical management, including the following situations:

    ONE or more of the following

    • ALL of the following

      • The patient is at high risk for influenza complications, including an immunocompromised person.
      • The patient presents with influenza-like illness, pneumonia, or nonspecific respiratory illness, such as cough without fever.
      • The test result will influence clinical management.

    • ALL of the following

      • The patient presents with acute-onset respiratory symptoms, with or without fever.

    Multiplex PCR respiratory viral panels testing for 6 or more pathogens are excluded from coverage because they are considered not medically necessary under this policy. The policy identifies the applicable large-panel CPT codes as 87632, 87633, 0115U, 0202U, 0223U, and 0225U.

    Routine respiratory viral panel testing is not supported in average-risk individuals because studies to date have not demonstrated improved clinical outcomes in this population.

    Evidence is insufficient to support large viral panels containing 6 or more pathogen targets. Additional large diagnostic cohort studies are needed to establish their clinical utility.

    A respiratory viral panel testing 3–5 pathogens is not medically necessary when criterion I is not met—that is, when the testing is not for a policy-listed diagnosis, the individual is not at high risk for complications of respiratory viral infection, or the result will not guide or alter management.

    Multiplex PCR respiratory viral panels testing for 6 or more pathogens are considered not medically necessary, including panels billed with CPT codes 87632, 87633, 0115U, 0202U, 0223U, and 0225U.

    Testing in average-risk individuals is unsupported when clinical utility has not been demonstrated, because available studies have not shown improved clinical outcomes in this population.

    Covered Testing Indications

    Testing for a Listed Diagnosis in a High-Risk Individual

    Testing may be considered medically necessary when all of the following conditions are met.

    Covered high-risk testing

    • Testing is for a diagnosis listed in the policy's Billing Guidelines
    • The individual is at high risk for complications of respiratory viral infection
    • Results will be used to guide or alter management

    Respiratory Viral Panel Testing in High-Risk or Immunocompromised Individuals

    Evidence is sufficient to support respiratory viral panel testing when all of the following conditions are met.

    High-risk small-panel testing

    Billing and Code Reference

    Covered CPT CodesCPTCovered
    87631Respiratory viral panel of 3-5 pathogens
    87636Respiratory viral panel of 3-5 pathogens
    87637Respiratory viral panel of 3-5 pathogens
    87812Respiratory viral panel of 3-5 pathogens
    0240URespiratory viral panel of 3-5 pathogens
    0241URespiratory viral panel of 3-5 pathogens
    Not-Covered CPT CodesCPTNot Covered
    87632Multiplex PCR respiratory viral panel of 6 or more pathogens
    87633Multiplex PCR respiratory viral panel of 6 or more pathogens
    0115UMultiplex PCR respiratory viral panel of 6 or more pathogens
    0202UMultiplex PCR respiratory viral panel of 6 or more pathogens
    0223UMultiplex PCR respiratory viral panel of 6 or more pathogens
    0225UMultiplex PCR respiratory viral panel of 6 or more pathogens
    Covered CPT and HCPCS CodesCPTCovered
    87631Respiratory virus nucleic acid detection, multiplex, 3-5 targets
    87636Respiratory pathogen nucleic acid detection including SARS-CoV-2 and influenza A and B
    87637Respiratory pathogen nucleic acid detection including SARS-CoV-2, influenza A and B, and respiratory syncytial virus
    87812SARS-CoV-2 and influenza A and B antigen detection by immunoassay
    0240URespiratory infectious agent detection code listed in the billing guideline
    0241URespiratory infectious agent detection code listed in the billing guideline
    Additional Respiratory Infectious Disease CodesCPT
    0115URespiratory infectious agent detection by nucleic acid, 18 viral types and subtypes and 2 bacterial targets
    0202UInfectious disease pathogen-specific nucleic acid testing, 22 targets including SARS-CoV-2, qualitative RT-PCR
    0223UInfectious disease pathogen-specific nucleic acid testing, 22 targets including SARS-CoV-2, qualitative RT-PCR
    0225UInfectious disease pathogen-specific DNA and RNA testing, 21 targets including SARS-CoV-2
    0528ULower respiratory tract infectious agent detection including bacteria, viruses, and antimicrobial resistance genes; termed 10/1/2026
    Respiratory Virus and SARS-CoV-2/Influenza Testing CodesCPT
    87631Respiratory virus nucleic acid detection, 3-5 targets
    87636SARS-CoV-2 and influenza A and B nucleic acid detection
    87367Respiratory pathogen nucleic acid detection code shown in the billing section
    87812SARS-CoV-2 and influenza A and B antigen detection
    ICD-10 Diagnosis Codes in Billing Diagnosis MappingICD-10
    A37.00ICD-10 diagnosis code in billing diagnosis mapping
    A37.01ICD-10 diagnosis code in billing diagnosis mapping
    A37.10ICD-10 diagnosis code in billing diagnosis mapping
    A37.11ICD-10 diagnosis code in billing diagnosis mapping
    A37.80ICD-10 diagnosis code in billing diagnosis mapping
    A37.81ICD-10 diagnosis code in billing diagnosis mapping
    A37.90ICD-10 diagnosis code in billing diagnosis mapping
    A37.91ICD-10 diagnosis code in billing diagnosis mapping
    A41.81ICD-10 diagnosis code in billing diagnosis mapping
    A41.89ICD-10 diagnosis code in billing diagnosis mapping
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    Respiratory Viral Panel Size
    Panel size3–5 pathogens
    Coverage statusMay be considered medically necessary when all policy criteria are met
    Required conditionsQualifying diagnosis, high risk for complications, and results used to guide or alter management
    Large Multiplex Respiratory Viral Panel Size
    Panel size6 or more pathogens
    Coverage status

    Provider, Authorization, and Claim Guidance

    Prior Authorization

    Prior Authorization for Unlisted Codes

    For a potentially covered respiratory viral panel service, obtain prior authorization before submitting an unlisted code to help avoid a post-service denial.

    • Applies when the unlisted code represents a potentially covered service addressed by this policy.
    Billing Rule

    Link Testing to a Qualifying Diagnosis

    Bill CPT 87631, 87636, 87637, 87812, 0240U, or 0241U with a qualifying ICD-10 diagnosis from the policy’s listed diagnosis set. The diagnosis must support the respiratory testing service and be reported with the applicable testing code.

    • Qualifying respiratory testing codes: 87631, 87636, 87637, 87812, 0240U, and 0241U.

    Key Definitions

    Respiratory Viral Panels
    Test typeRespiratory viral panel
    FunctionDetects and identifies specific viral nucleic acids
    対象 individualsIndividuals exhibiting symptoms of respiratory viruses
    Multiplex PCR Respiratory Viral Panels
    DefinitionA respiratory viral panel that tests for six or more pathogens using multiplex polymerase chain reaction
    Panel size6 or more pathogens
    Medical necessityNot medically necessary under this policy

    Ordering Guidance

    Note

    Order testing according to clinical guidance

    The cited guideline addresses clinicians ordering influenza testing. No narrower provider-specialty ordering restriction is stated in this policy.

    Excluded Services and Situations

    Not covered: multiplex PCR respiratory viral panels testing for 6 or more pathogens; 3–5 pathogen panels when the qualifying diagnosis, high-risk status, or management-impact criterion is not met; testing in average-risk individuals when clinical outcome benefit has not been established; and large panels containing 6 or more pathogen targets when evidence is insufficient to support clinical utility.

    Policy Summary
    PayerProvidence Health Plan
    PolicyRespiratory Viral Panels
    Policy CodePolicy 256
    Change TypeModified
    Effective DateOct 1, 2026
    Last ReviewSep 1, 2026
    Next Review DateJul 1, 2027
    Key ActionObtain prior authorization before submitting an unlisted code for a potentially covered service addressed by this policy.
    SourceLink
    On This Page
    Medical Necessity CriteriaCovered Testing IndicationsBilling and Code ReferenceProvider, Authorization, and Claim GuidanceClinical BackgroundKey DefinitionsOrdering GuidanceExcluded Services and Situations
  1. The patient has an exacerbation of a chronic medical condition, such as asthma, COPD, or heart failure, or a known complication of influenza, such as pneumonia.
  2. The test result will influence clinical management.

  3. ALL of the following

    • The patient is not at high risk for influenza complications and presents with influenza-like illness, pneumonia, or nonspecific respiratory illness, such as cough without fever.
    • The patient is likely to be discharged home.
    • The result may influence antiviral treatment decisions, reduce unnecessary antibiotics or further diagnostic testing, reduce time in the emergency department, or influence antiviral treatment or chemoprophylaxis decisions for high-risk household contacts.
  4. For outpatients, use a rapid molecular assay (nucleic acid amplification test) rather than a rapid influenza diagnostic test (RIDT) to improve detection of influenza virus infection; use targeted panel testing when appropriate.
  5. The respiratory viral panel tests for 5 or fewer targets5 or fewer targets
  6. The individual is at high risk for complications of respiratory viral infection, including being immunocompromised

    7. Influenza Testing in High-Risk Patients

    Influenza testing is recommended when all of the following conditions are met.

    High-risk influenza testing

    • The patient is at high risk for influenza complications

    • Respiratory presentation

      • Influenza-like illness
      • Pneumonia
      • Nonspecific respiratory illness, such as cough without fever
    • The testing result will influence clinical management

    Influenza Testing With Chronic-Condition Exacerbation or Known Complications

    Influenza testing may be considered when all of the following conditions are met.

    Acute respiratory symptoms with chronic-condition exacerbation or complication

    • The patient has acute-onset respiratory symptoms, with or without fever

    • Qualifying chronic condition or complication

      • Exacerbation of asthma
      • Exacerbation of chronic obstructive pulmonary disease (COPD)
      • Exacerbation of heart failure
      • Known influenza complication, such as pneumonia
    • The testing result will influence clinical management
    Not medically necessary
    Test categoryMultiplex PCR respiratory viral panel
    Small Respiratory Viral Panel
    DefinitionA respiratory viral panel containing 5 or fewer pathogen targets
    Evidence-supported populationIndividuals at high risk for complications of respiratory viral infection, including immunocompromised individuals
    Average-risk populationRoutine testing is not supported because improved clinical outcomes have not been demonstrated
    Large Respiratory Viral Panel
    DefinitionA respiratory viral panel containing 6 or more pathogen targets
    Evidence statusEvidence is insufficient to support use
    Clinical utilityAdditional large diagnostic cohort studies are needed to establish clinical utility
  7. A qualifying ICD-10 diagnosis is required for these listed codes to be considered medically necessary.
    8. Documentation Required

    Unlisted-Code Documentation

    Unlisted codes are reviewed at the claim level for medical necessity, correct coding, and pricing. Submit complete supporting documentation and obtain prior authorization before service when the unlisted code represents a potentially covered service.

    • Document the service, clinical indication, and information needed to evaluate medical necessity and correct coding.
    • Prior authorization is recommended before service to avoid a post-service denial.
    Denial Risk

    3–5 Pathogen Criteria Required

    Respiratory viral panels testing 3–5 pathogens are considered not medically necessary when the policy criteria are not met.

    • Testing must be for a listed diagnosis.
    • The individual must be at high risk for complications of respiratory viral infection.
    • Results must be used to guide or alter management.
    Denial Risk

    Large Multiplex Panels Not Medically Necessary

    Multiplex PCR respiratory viral panels testing 6 or more pathogens are not medically necessary under this policy.

    • CPTs include 87632, 87633, 0115U, 0202U, 0223U, and 0225U.
    Denial Risk

    Average-Risk Testing

    Respiratory viral panel testing in average-risk individuals is not supported by sufficient evidence to demonstrate improved clinical outcomes and may be denied as not medically necessary.

    • Coverage support is limited to individuals at high risk for complications of respiratory viral infection, including immunocompromised individuals, when other criteria are met.
    Denial Risk

    Insufficient Evidence for Large Panels

    Evidence is insufficient to establish the clinical utility of large respiratory viral panels containing 6 or more pathogen targets, creating a potential denial risk.

    • Additional large diagnostic cohort studies are needed to establish clinical utility.
    Denial Risk

    Unlisted Code for Non-Covered Services

    If an unlisted code is submitted for a non-covered service addressed by this policy, the claim will be denied as not covered.

    • Unlisted-code review does not create coverage for a service excluded by the policy.
    Billing Rule

    Claim and Coding Edits Apply

    Code lists are not all-inclusive and do not guarantee reimbursement or coverage. Claims remain subject to applicable benefits, member eligibility, provider contracts, utilization audit, NCCI procedure-to-procedure edits, CMS medically unlikely edits, and other CMS coding rules.

    • The policy does not take precedence over CMS-published NCCI or MUE edits.
    • Review applicable code combinations, daily maximums, and coding guidance before submitting the claim.
    Small Respiratory Viral Panel
    DefinitionA respiratory viral panel containing 5 or fewer pathogen targets
    Supported useUse is supported in individuals at high risk for complications of respiratory viral infection, including immunocompromised individuals
    Evidence limitationRoutine testing in average-risk individuals is not supported by demonstrated improvement in clinical outcomes
    Large Respiratory Viral Panel
    DefinitionA respiratory viral panel containing 6 or more pathogen targets
    Evidence statusEvidence is insufficient to support use
    Research needAdditional large diagnostic cohort studies are needed to establish clinical utility
    Rapid Molecular Assay
    DefinitionA nucleic acid amplification test used for rapid molecular detection of influenza
    Guideline preferenceClinicians should use rapid molecular assays over rapid influenza diagnostic tests (RIDTs) in outpatients
    PurposeTo improve detection of influenza virus infection