Coverage Policies

Please Note:

QualChoice reserves the right to conduct audits on any provider and/or facility to ensure compliance with the guidelines stated in this policy. Services that are provided outside of following guidelines may not meet coverage criteria and may lead to recoupment of payment.

It is better and often less costly to get care from doctors who are in QualChoice network. If the member gets care from an out-of-network Health care provider, even if care is given at a network doctor’s office or facility, the member’s cost may be higher.

Public Statement:

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Respiratory viral panels (RVPs) testing for five (5) pathogens or less are considered medically necessary and are covered without prior authorization.

2)    Respiratory viral panels (RVPs) testing for 6 or more pathogens are considered medically necessary in a healthcare setting that cares for critically ill patients, such as the emergency department or inpatient hospital, including those in observation status.

3)    RVPs are considered not medically necessary for all other indications.

The diagnostic role and importance of the multi-pathogen panels in identifying specific viruses in the setting of a respiratory infection is limited because the care and management of the patient is not altered based upon the pathogen identified.

1)    Respiratory viral panels (CPT 87631) testing for 5 or less pathogens are considered medically necessary and are covered without prior authorization.

2)    Respiratory viral panels (CPT 87632 and 87633) testing for 6 or more pathogens are considered medically necessary for critically ill members only when performed in an inpatient facility, observation or emergency room settings.

3)    RVPs testing for 6 or more pathogens are considered not medically necessary for any other places of service.

Codes Used In This BI:

87631   Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (e.g., adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets.

87632   Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets.

87633   Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse.

Respiratory viral panels PCR testing in an outpatient place of service is reimbursable only when performed as part of the diagnostic work-up for a patient admitted for Observation.

Polymerase chain reaction (PCR) respiratory viral panels (RVP) may detect the RNA or DNA of multiple types of respiratory viruses as a single test, often through a nasal, nasopharyngeal, or oropharyngeal swab. Viral pathogens are the most common cause of respiratory tract infections. PCR testing is effective for confirming respiratory viral infections with very high sensitivity and specificity. Rhinovirus, parainfluenza virus, coronavirus, adenovirus, respiratory syncytial virus, Coxsackie virus, human metapneumovirus, and influenza virus account for most cases of viral respiratory infections.

Multiplex PCR testing can detect numerous respiratory viruses; that number varies with the type and brand of testing being performed. However, the diagnostic role and importance of these multi-pathogen panels in identifying specific viruses in the setting of a respiratory infection is quite limited because the care and management of the patient is not altered based upon the pathogen identified, if any. For example, the child with a URI, cough, and wheezing who might be positive for RSV would not be managed any differently than the child with parainfluenza virus, adenovirus, rhinovirus, human metapneumovirus, enterovirus, Coxsackie virus, or coronavirus.

Infectious Disease Society of America (IDSA)

The IDSA recommends that “clinicians should use multiplex RT-PCR assays targeting a panel of respiratory pathogens, including influenza viruses, in hospitalized immunocompromised patients.” Further, “clinicians can consider using multiplex RT-PCR assays targeting a panel of respiratory pathogens, including influenza viruses, in hospitalized patients who are not immunocompromised if it might influence care (e.g., aid in cohorting decisions, reduce testing, or decrease antibiotic use).”

1)    Hill AT, et al. and the CHEST Expert Cough Panel. Adult Outpatients with Acute Cough Due to Suspected Pneumonia or Influenza: CHEST Guideline and Expert Panel Report. CHEST 2019; Volume 155, Issue 1, Pages 155–167.

2)    Noridian Local Coverage Determination. L37315 MolDX: Multiplex Nucleic Acid Amplified Tests for Respiratory Viral Panels. Revision effective 10/1/2019.

3)    Hayes Precision Medicine Research Brief, “FilmArray Respiratory Panel and FilmArray Respiratory Panel 2 (BioFire Diagnostics LLC),” September 2019

4)    Uyeki TM, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenza. Clin Inf Dis 2019; Volume 68, Issue 6, Pages e1–e47, https://doi.org/10.1093/cid/ciy866.

5)    Ralston SL, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. American Academy of Pediatrics. Pediatrics 2014; Volume 134, Issue 5, Pages e1474- 502. doi: 10.1542/peds.2014-2742.

6)    Esposito S, et al. Multiplex Platforms for the Identification of Respiratory Pathogens: Are They Useful in Pediatric Clinical Practice? Front Cell Infect Microbiol. 2019 Jun 4;9:196. doi: 10.3389/fcimb.2019.00196.

7)    Busson L, et al. Contribution of the FilmArray Respiratory Panel in the management of adult and pediatric patients attending the emergency room during 2015–2016 influenza epidemics: An interventional study. Int J Infect Dis. 2019 Jun;83:32-39. doi: 10.1016/j.ijid.2019.03.027.

8)    Echavarria M, et al. Clinical impact of rapid molecular detection of respiratory pathogens in patients with acute respiratory infection. J Clin Virol. 2018 Nov;108:90-95. doi: 10.1016/j.jcv.2018.09.009.