ModifiedWellCarePolicy CP.MP.181

Clinical Policy: Polymerase Chain Reaction Respiratory Viral Panel Testing

Customize your policy alerts

Sign up for WellCare Policy CP.MP.181 alerts

Get alerted when Policy CP.MP.181 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Medical necessity criteria and coding guidance for multiplex respiratory PCR (RVP) testing across inpatient and outpatient settings for WellCare members; applies to providers ordering and billing these tests.

Policy Summary

PayerWellCare

PolicyPolymerase Chain Reaction Respiratory Viral Panel Testing

Policy CodePolicy CP.MP.181

Change TypeCriteria replacement, coding updates, POS and table additions

Effective Date

Next Review Date

Key ActionDocument required clinical indications, reasons for panel testing, provider type and place of service in the medical record to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Replaced prior criteria in sections I. and II. with current criteria and removed policy statement III.

Added Table 4, Table 5, and Table 6 which include ICD-10 diagnosis codes supporting medical necessity.

Split medical necessity statements to address panels of 5 pathogens or less and panels of 6 or more separately; added outpatient criteria that testing will influence plan of care and specified indications (e.g., immunocompromised, ID-ordered).

Removed criteria specific to COVID-19 testing in section I.A.

3-5CPT code 87631 target range

6-11

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.

ModifiedWellCarePolicy CP.MP.181

Clinical Policy: Polymerase Chain Reaction Respiratory Viral Panel Testing

Customize your policy alerts

Sign up for WellCare Policy CP.MP.181 alerts

Get alerted when Policy CP.MP.181 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerWellCare

PolicyPolymerase Chain Reaction Respiratory Viral Panel Testing

Policy CodePolicy CP.MP.181

Change TypeCriteria replacement, coding updates, POS and table additions

Effective Date

Next Review Date

Key ActionDocument required clinical indications, reasons for panel testing, provider type and place of service in the medical record to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Replaced prior criteria in sections I. and II. with current criteria and removed policy statement III.

Added Table 4, Table 5, and Table 6 which include ICD-10 diagnosis codes supporting medical necessity.

Removed criteria specific to COVID-19 testing in section I.A.

3-5CPT code 87631 target range

6-11

CPT code 87632 target range

12-25CPT code 87633 target range

18+20115U panel composition

≤5 vs ≥6Panel distinction

Coverage Criteria for Respiratory Viral Panels

Medical necessity criteria for panels with <=5 targets

RVP testing for five pathogens or fewer is considered medically necessary when ALL of the following are met:

Section I: Member has an appropriate clinical indication as defined in I.A (immunocompetent with presumption of active infection or infection-associated complications requiring identification of causative organism, or immunocompromised persons including HIV/AIDS, those on immunosuppressive medications, or inherited immune disorders; testing may be performed once as part of pre-transplant evaluation regardless of symptoms).

See sub-items in policy I.A for definitions of immunocompromised and appropriate clinical indications.

Section I: The results of testing will impact clinical management in a manner demonstrated in peer-reviewed published literature to improve outcomes.

Policy requirement I.B.

Section I: Testing is performed according to the intended use of the test in the intended population for which the test was developed and validated.

Policy requirement I.C.

Section I: Targeted testing is not appropriate (i.e., targeted testing will not provide sufficient information for appropriate clinical management).

Policy requirement I.D.

Section I: The panel performed includes at least the minimum pathogens required for clinical decision making for its intended use that can be reasonably detected by the test.

Policy requirement I.E.

Section I: The registered test demonstrates equivalent or superior analytic and clinical validity compared to established standard-of-care methods for the majority of targets included on the panel.

Policy requirement I.F.

Section I: Documentation in the medical record must clearly state: specific clinical indications for testing, specific reasons for performing panel testing, provider type/specialty, and place of service.

Policy requirement I.G (documentation items 1-3).

Medical necessity criteria for panels with >=6 targets

RVP testing for six pathogens or more is considered medically necessary when the Section I criteria are met AND any one of the following applies:

Section II additional criteria: Performed in a healthcare setting that cares for critically ill individuals (e.g., emergency department, inpatient hospital, or observation status).

Section II.A.1; all Section I requirements also apply.

Section II additional criteria: Member/enrollee is immunocompromised as defined in section I.A.2 (including HIV/AIDS, receipt of immunosuppressive medications, or inherited immune disorders).

Section II.A.2; all Section I requirements also apply.

Section II additional criteria: Member/enrollee is immunocompetent and both: (a) has a severe and established underlying respiratory pathology (e.g., severe asthma, COPD, cystic fibrosis, pulmonary fibrosis, prior lung radiation), and (b) treatment with antibiotics may be indicated according to established guidelines.

Section II.A.3 (parts a and b); all Section I requirements also apply.

Medical necessity criteria by panel size

Coverage depends on panel size and clinical context; panels of 5 or fewer pathogens in the outpatient setting require that testing will influence the plan of care and meet specific indications.

Outpatient, panels ≤5 pathogens: Test is medically necessary when ALL outpatient criteria are met: (1) the ordered panel includes five pathogens or fewer; (2) the result will influence the plan of care; and (3) one of the specified indications is present (examples added in revisions include testing for other pathogens when COVID-19 is suspected and COVID-19 testing is not available soon enough to influence care, testing when the member is immunocompromised, or testing when ordered by an infectious disease (ID) specialist or when an ID is not available).<=5 pathogens

Derived from policy revisions adding outpatient criteria (see Reviews, Revisions, and Approvals).

Panels ≥6 pathogens: Separate medical necessity statements apply for panels of six or more pathogens; criteria for large panels are addressed in Section II (Section I criteria plus one of the Section II conditions).>=6 pathogens

Policy split of criteria by panel size noted in revisions; exact outpatient text for large panels is in Sections I and II.

The policy notes that multiplex PCR respiratory viral panels (RVPs) can detect multiple viral targets from a single upper respiratory swab and have high analytic sensitivity and specificity, but emphasizes that the diagnostic role is limited when identification of a specific pathogen rarely alters clinical management. Clinicians and billers should recognize that while RVPs can confirm viral infection and occasionally guide antiviral use or infection control, many results do not change patient treatment decisions and coverage is therefore tied to clinical scenarios where test results will meaningfully influence care.

The revision log documents that criteria specific to COVID-19 testing were removed from section I.A of the policy in the 08/21 update; subsequent reviews retained that removal while other criteria and tables were revised.

Per the revision history, COVID-19–specific criteria that previously appeared in section I.A were deleted in the August 2021 revision, and those criteria are no longer part of the policy's Section I requirements.

Although the policy emphasizes the limited clinical utility of broad multi-pathogen panels in many settings, the provided text does not include explicit single-line non-medically necessary (NMN) statements listing tests or indications as universally not covered. Instead, the document uses clinical-context language and structured criteria to define when testing is considered medically necessary.

The policy's code history shows that certain temporary or recently added U-codes were subsequently removed: CPT codes 0098U, 0099U, and 0100U were deleted effective 04/21, and therefore these codes are not retained in the policy's medically necessary code lists after that revision.

Covered Indications and Clinical Scenarios

Symptomatic patients, immunocompromised, critically ill, and scenarios where results impact management

Covered indications where testing is appropriate include symptomatic patients, immunocompromised individuals, critically ill patients, and scenarios where results will impact management:

Covered indications: Symptomatic patients (immunocompetent) with a presumption of active infection or infection-associated complications requiring identification of a causative organism for appropriate management; atypical presentations (e.g., elderly) are included.

I.A.1 describes immunocompetent symptomatic indications.

Covered indications: Immunocompromised patients as defined in I.A.2 (including HIV/AIDS, those on immunosuppressive medications, and inherited immune deficiencies); testing may be performed once as part of pre-transplant evaluation regardless of symptoms.

I.A.2 and laboratory covered indications note pre-transplant testing allowance.

Covered indications: Patients who are critically ill or in healthcare settings that manage critically ill individuals (e.g., ED, inpatient, observation) where identification of pathogens would influence acute management decisions.

Coding Guidance and Code Tables

Covered CPT Codes (any place of service)CPTCovered

87631

Infectious agent detection by nucleic acid; respiratory virus, multiplex, 3-5 targets

Covered CPT Codes (place/diagnosis-restricted)CPTCovered

0115U	Respiratory infectious agent detection by nucleic acid (DNA and RNA), 18 viral types and subtypes and 2 bacterial targets
87632	Infectious agent detection by nucleic acid; respiratory virus, multiplex, 6-11 targets
87633	Infectious agent detection by nucleic acid; respiratory virus, multiplex, 12-25 targets

Example ICD-10 diagnosis codes that support medical necessityICD-10

A37.00	Whooping cough due to Bordetella pertussis without pneumonia
J06.9	Acute upper respiratory infection, unspecified
J12.9	Viral pneumonia, unspecified

Medically necessary CPT/HCPCS/U-codes tied to POSmixedCovered

87632	Noted in document as moved to medically necessary table when billed with specified POS
87633	Noted in document as moved to medically necessary table when billed with specified POS
0098U	Added as medically necessary when billed with POS codes in Table 3 (later deleted 04/21 per log)
0099U	Added as medically necessary when billed with POS codes in Table 3 (later deleted 04/21 per log)
0100U	Added as medically necessary when billed with POS codes in Table 3 (later deleted 04/21 per log)
0115U	Added as medically necessary when billed with POS codes in Table 3

ICD-10 diagnosis codes that support medical necessity (Tables 4-6)ICD-10Covered

B20	Human immunodeficiency virus [HIV] disease
C46.0	Kaposi's sarcoma of skin
D57.01	Hb-SS disease with acute chest syndrome
D61.09	Other constitutional aplastic anemia
D70.1	Agranulocytosis secondary to cancer chemotherapy
D80.0	Hereditary hypogammaglobulinemia
D81.0	Severe combined immunodeficiency [SCID] with reticular dysgenesis
D83.0	Common variable immunodeficiency with predominant abnormalities of B-cell numbers and function
D84.821	Immunodeficiency due to drugs
D89.0	Polyclonal hypergammaglobulinemia

1–10 of 18

1/2

Document references to coding and place of servicemixed

No codes listed

Panel target counts

CPT 87631 target range3-5 targets

CPT 87632 target range6-11 targets

CPT 87633 target range12-25 targets

Proprietary assay (0115U) composition18 viral types/subtypes + 2 bacterial targets

Panel size definitions

Small panel definitionPanels of 5 pathogens or less

Provider Actions, Documentation, and Billing Reminders

Prior Authorization

Confirm POS/diagnosis for restricted CPT/U-codes

Certain CPT codes (87631, 87632, 87633, 0115U) support medical necessity only when billed with required place of service codes or specified diagnosis codes as detailed in Tables 2–6; ensure the claim includes the supported POS or diagnosis combination before billing these codes.

See Table 1 and Table 2 for code lists and Table 3 for permitted Place of Service codes.
Codes in Table 2 (e.g., 87632, 87633, 0115U) require billing with a Table 3 POS or diagnosis codes from Tables 4–6.

Billing Rule

Bill POS-dependent codes only with Table 3 POS

Some CPT and U-codes (including 87632, 87633, and select U-codes such as 0115U) are designated medically necessary only when billed with the place-of-service codes listed in Table 3; verify the POS on the claim matches Table 3 before submission.

Ordering Requirements and Limitations

Documentation Required

Document POS and provider type; confirm POS/diagnosis requirements for specific CPTs

Place of service and provider type must be documented on the medical record; certain CPT codes require specific POS or diagnosis code combinations as described in the policy tables.

Documentation must include provider type/specialty and where the service was performed (POS).
Some CPT codes (see Table 2) are only medically necessary when billed with POS codes enumerated in Table 3 or with appropriate diagnosis codes.

Documentation Required

Note ID specialist orders or lack thereof when applicable

When testing is ordered by an Infectious Disease (ID) specialist, outpatient criteria reference this as an indication; ordering clinicians should note if an ID specialist ordered the test or if an ID was not available and this influenced the decision.

Outpatient criteria include testing ordered by an ID or when an ID is not available as a listed indication supporting medical necessity.

Frequency Limits

Panels with >=6 targets — frequency / use notes

Applies to panels with >=6 targetsPanels with six or more targets (CPT 87632, 87633) have separate criteria requiring Section I plus at least one Section II condition (e.g., performed in ED/inpatient/observation, immunocompromised, or severe underlying respiratory disease with possible antibiotic indication)

Frequency limits presentNo explicit numeric repeat-frequency limit specified in policy text for panels >=6 targets; policy describes clinical indications and setting-based use

Billing implicationsCodes for larger panels are placed in Table 2 and require appropriate place-of-service or diagnosis linkage per Table 3-6

Frequency limits (placeholder)

Inventory placeholderPolicy includes frequency/follow-up considerations for multiplex panels but does not provide a labeled numeric frequency limit in the extracted text

Not Covered / Exclusions

The document does not provide a discrete list of tests or indications labeled as universally not covered; instead it notes that multi-pathogen panels have limited diagnostic value when identification of a pathogen rarely alters management, and coverage decisions are structured around specific clinical criteria where results will affect patient care.

As recorded in the revision notes, U-codes 0098U, 0099U, and 0100U were deleted from the policy on 04/21. These deleted U-codes therefore are no longer supported by this policy as medically necessary.

The revision history shows that COVID-19–specific testing criteria were removed from this policy (section I.A) in the August 2021 update, and those COVID-19–focused items are not present in the current criteria.

Definitions and Background

Background: Multiplex PCR respiratory viral panels (RVPs) detect nucleic acid (RNA or DNA) from multiple respiratory viruses using nasal, nasopharyngeal, or oropharyngeal swabs. Viral pathogens cause the majority of respiratory tract infections, and while PCR testing is highly sensitive and specific and can support antiviral stewardship and infection control, the policy highlights that identifying the specific virus often does not change individual patient management. Immunocompromised patients are noted as a subgroup at higher risk for severe disease in whom testing may have greater clinical importance.

Respiratory viral panel (RVP) — definition

DefinitionMultiplex PCR test that detects RNA or DNA of multiple respiratory viruses from nasal, nasopharyngeal, or oropharyngeal swabs

Typical pathogens detectedExamples include adenovirus, influenza, coronavirus, metapneumovirus, parainfluenza, RSV, rhinovirus

Clinical roleUsed to identify causative viral agents when results will influence management; utility may be limited when identification does not change care

Immunocompromised — definition

Policy Summary

PayerWellCare

PolicyPolymerase Chain Reaction Respiratory Viral Panel Testing

Policy CodePolicy CP.MP.181

Change TypeCriteria replacement, coding updates, POS and table additions

Effective Date

Next Review Date

Key ActionDocument required clinical indications, reasons for panel testing, provider type and place of service in the medical record to support medical necessity.

SourceLink

On This Page

Section II.A.1 supports use in critically ill settings.

Covered indications: Patients with severe underlying respiratory disease where results may change management (see Section II.A.3 for examples such as severe asthma, COPD, cystic fibrosis, pulmonary fibrosis) and where antibiotic therapy may be indicated per guidelines.

Section II.A.3 describes severe underlying respiratory pathology plus antibiotic consideration.

When results will influence plan of care in outpatient setting

Outpatient testing is covered when results will influence the plan of care and specific conditions are met:

Outpatient plan-of-care requirement: Results are expected to influence the plan of care in a manner demonstrated to improve outcomes.

Revision language added criteria specifying the test must influence plan of care for outpatient small panels (see Reviews, Revisions).

Outpatient allowed indications (examples): Testing is appropriate when: (a) testing for other pathogens is needed when COVID-19 is suspected and COVID-19 testing is not available soon enough to influence care; (b) the member is immunocompromised; or (c) the test is ordered by an infectious disease (ID) specialist or when an ID is not available.

Examples were added in the policy revisions describing outpatient indications for small panels.

Outpatient documentation requirement: Provider documents specific clinical indication, reason for panel testing, provider type/specialty, and place of service in the medical record.

Documentation requirements per I.G apply to outpatient testing as well.

Additional referenced indications

Additional referenced indications and supporting literature include acute respiratory infection, influenza, bronchiolitis, suspected pneumonia, and guidance for immunocompromised adults:

Referenced indications: Acute respiratory infection and suspected influenza where rapid identification may affect antiviral use or infection control measures.

Supported by IDSA influenza guideline reference (Uyeki et al.) and studies on rapid molecular detection (references in policy).

Referenced indications: Bronchiolitis in pediatric populations where multiplex panels have been studied; use should align with bronchiolitis guidance.

Pediatric bronchiolitis guideline and multiplex platform assessments cited in references.

Referenced indications: Suspected pneumonia in outpatients with acute cough where pathogen identification may influence management per CHEST guidelines.

CHEST guideline referenced in policy references.

Referenced indications: Immunocompromised adults where consensus statements recommend initial diagnostic strategies that may include multiplex molecular testing.

Consensus statement on immunocompromised adults cited in references.

Large panel definitionPanels of 6 or more pathogens

Coverage depends on contextPolicy applies different medical necessity criteria for small vs large panels (outpatient vs inpatient/critically ill contexts)

Table 3 lists POS codes that support medical necessity for codes in Table 2 (see chunk 10 for POS examples including code 19).
Revision history moved 87632 and 87633 to the POS-dependent medically necessary table.

Note

Check member plan and Medicare requirements before ordering/billing

Coverage decisions are subject to Health Plan-level administrative policies and applicable legal/regulatory requirements; review the member's plan and any relevant Medicare NCDs/LCDs prior to ordering or billing.

This policy is a guide to medical necessity and does not guarantee payment; check the member’s contract, state/federal requirements, and plan administrative policies.
For Medicare members, review applicable NCDs, LCDs, and Medicare Coverage Articles prior to applying criteria (see chunk 44).

Step Therapy

No step-therapy required

No step-therapy requirements are specified in this policy for respiratory viral panels; none are mandated by the clinical criteria.

The policy’s step therapy section lists no prerequisites or step edits for panel testing.

Note

No additional administrative actions specified

No additional provider action is specified in the policy beyond the stated documentation, coding, and POS requirements.

Revision notes and criteria describe code placement and POS linkage but do not impose extra ordering steps.

Prior Authorization

Prior authorization: follow medical necessity criteria

No additional provider action is specified in the policy for prior authorization beyond meeting the medical necessity criteria and billing rules described.

Providers must meet Section I (and Section II where applicable) medical necessity criteria when ordering.

Documentation Required

Document indications, rationale, provider type and POS in the medical record

Medical records must clearly state the specific clinical indications for testing, the specific reasons for performing panel testing, the provider type/specialty, and the Place of Service.

Document the clinical suspicion or indication that justifies a multiplex panel rather than targeted testing.
Include provider specialty and the POS on the medical record to support coverage determinations.

Billing Rule

Use ICD-10 codes from Tables 4–6 when required

When billing PCR respiratory viral panel CPT codes that require supporting diagnoses, include an ICD-10 code from the policy’s Tables 4, 5 or 6 that supports medical necessity.

Use one of the ICD-10 diagnosis codes listed in Tables 4–6 (e.g., codes for immunocompromised status, acute respiratory infections) when required by the CPT code rule.

Documentation Required

Ensure documentation aligns with policy and member coverage

Follow documentation practices consistent with the medical necessity criteria in this clinical policy and the member’s coverage documents; this policy does not guarantee payment and coverage is subject to contract terms and administrative policies.

Ensure documentation aligns with Section I (and Section II where applicable) criteria to support medical necessity.
Verify member coverage, exclusions, and any plan-specific requirements before expecting payment.

Denial Risk

Denial risk if required documentation is missing

Claims may be denied if documentation of clinical indications, reasons for panel testing, provider specialty, or Place of Service is missing or insufficient to meet the policy’s criteria.

Failure to document the specific clinical indication or reason for a multiplex panel (versus targeted testing) can trigger denial.
Omit provider type/specialty or POS in the record risks denial during claims review.

Denial Risk

Claims denial risk for unsupported code/POS/diagnosis combinations

Claims may be denied if CPT codes are billed without the supported Place of Service codes or without the appropriate diagnosis codes listed in the policy tables; confirm coding and POS alignment prior to claim submission.

Codes in Table 2 require being billed with POS codes in Table 3 or with diagnosis codes from Tables 4–6 to support medical necessity.
Review revisions that moved certain codes to POS-dependent lists prior to billing.

Note

State Medicaid and Medicare NCD/LCD precedence — verify before billing

For Medicaid members, state Medicaid provisions take precedence over this clinical policy where conflicts exist; for Medicare members, review applicable NCDs, LCDs, and Medicare Coverage Articles prior to applying the policy.

Refer to the state Medicaid manual for any coverage provisions that pertain to this policy.
Consult CMS resources for Medicare NCDs/LCDs and coverage articles that may affect applicability.

Document the ordering clinician’s specialty (ID) or rationale if an ID was not available.

Note

Order based on professional judgment and member coverage

Providers must exercise professional medical judgment when ordering RVP testing; this policy does not dictate clinical practice and orders should align with member coverage and the policy’s medical necessity criteria.

Use the Section I (and Section II where applicable) criteria to guide ordering decisions rather than relying solely on the policy as a treatment directive.
Ensure orders align with the member’s coverage documents and plan administrative policies.

Action for providers

Document clinical indication and place of service; ensure criteria in Section I (and Section II for >=6 targets) are met before repeat testing

Coding noteLarger-panel CPT codes moved to medically necessary table when billed with required POS codes (see Table 3)

DefinitionPersons with weakened immune systems, including HIV/AIDS; those on immunosuppressive medications (chemotherapy, biologics, transplant-related immunosuppressives, high‑dose systemic corticosteroids); and inherited immune disorders

Policy usage noteTesting in immunocompromised patients may be performed once as part of pre‑transplant evaluation regardless of symptoms

Clinical implicationImmunocompromised status qualifies for larger-panel testing under Section II when combined with Section I criteria

Small panel (≤5 pathogens)

ThresholdSmall panel = panels of 5 pathogens or less

Coverage contextOutpatient small panels require that testing will influence the plan of care and meet specified indications

Associated CPT rangeTypically represented by CPT 87631 (3–5 targets)

Large panel (≥6 pathogens)

ThresholdLarge panel = panels of 6 or more pathogens

Associated CPT codesCPT 87632 (6–11 targets) and CPT 87633 (12–25 targets) represent larger panels

Clinical criteriaLarge panels require Section I criteria plus at least one Section II condition (e.g., ED/inpatient use, immunocompromised, or severe underlying respiratory disease with potential antibiotic indication)

References

CMS MolDX guidanceLocal coverage articles: MolDX molecular syndromic panels for infectious disease pathogen identification testing (A58710, A58720, A58726, A58747, A58761)

IDSA and ATS guidelinesInfectious Diseases Society of America (Uyeki et al.) and ATS/IDSA community‑acquired pneumonia guideline (Metlay et al.) cited

Platform assessments and reviewsFilmArray respiratory panel assessments and multiplex platform reviews (Hayes, FilmArray evaluations) included

Additional clinical reviewsGuidelines and reviews addressing influenza, bronchiolitis, antimicrobial stewardship, and management of immunocompromised adults cited