0098U
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation of immunocompromised status (e.g., diagnosis codes, medication list showing immunosuppressive therapy, or documentation of congenital immunodeficiency) and indication for testing (e.g., pre‑transplant evaluation).
- Documentation or citation/evidence that test results will impact clinical management and improve outcomes (peer‑reviewed literature) and that the test is used per its intended/validated population.
- Specific clinical indications for testing (clinical suspicion of a pathogen as the cause of the medical condition).
- Specific reasons for performing panel testing.
Key Coverage Criteria
- Respiratory viral panel (RVP) testing for five pathogens or fewer when the member has a clinical indication for infectious disease testing and meets all specified criteria
- Member is immunocompetent with a clinical suspicion of active infection or infection-associated complications that require identification of a causative organism for appropriate management.
- Atypical clinical presentations (e.g., elderly or other special populations who may not present with classic symptoms) are considered appropriate indications for testing to identify a causative organism.
- Member is immunocompromised (e.g., HIV/AIDS, on immunosuppressive medications such as chemotherapy, biologics, transplant-related immunosuppressives, high‑dose systemic corticosteroids, or inherited immunodeficiencies); atypical clinical presentations are appropriate for testing.
- In immunocompromised members, testing may be performed once as part of a pre‑transplant evaluation regardless of presence of symptoms.
- Testing when the results will impact clinical management in a manner demonstrated in peer‑reviewed published literature to improve outcomes.
1 Active Policy
AMBETTER-CP.MP.181 — Polymerase Chain Reaction Respiratory Viral Panel Testing
Related Codes
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