86409
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation of clinical concern for symptomatic COVID-19 infection (e.g., symptoms consistent with COVID-19) when ordering molecular or antigen testing.
- Documentation of known or suspected exposure to SARS-CoV-2 when that is part of the indication for testing.
- Order must be placed and the test administered by a licensed or authorized healthcare provider (documentation of ordering provider and administration).
- For antibody (serology) testing: documentation of prior molecular or antigen test results that were non-diagnostic, and documentation that the antibody test result will be used to aid in diagnosis of a condition related to COVID-19 (e.g., clinical notes supporting suspicion of MIS or post-acute sequelae).
Key Coverage Criteria
- Molecular or antigen in vitro diagnostic test for SARS-CoV-2 (COVID-19) infection when ALL of the following criteria are met: clinical concern for a symptomatic COVID-19 infection; individual with known or suspected exposure; ordered and administered by a licensed or authorized healthcare provider.
- Antibody (serology) test for SARS-CoV-2 antibodies when: results of a molecular or antigen test is non-diagnostic for COVID-19 AND the results of the antibody test will be used to aid in the diagnosis of a condition related to COVID-19 infection (e.g., Multisystem Inflammatory Syndrome [MIS], post-acute sequelae).
- Molecular/antigen tests (CPT/HCPCS listed in policy) billed with any diagnosis codes other than the specified non-covered screening/administrative codes are considered medically necessary when the above policy clinical criteria are met (policy notes 'All other codes').
- Antibody (serology) testing (CPT codes listed under Antibody Testing) is considered medically necessary for diagnoses M35.81 (Multisystem inflammatory syndrome) and U09.9 (Post COVID-19 condition, unspecified) when applicable clinical criteria are met.
- Infection with human coronavirus 229E (alpha coronavirus).
- Infection with human coronavirus NL63 (alpha coronavirus).
7 Active Policies
CIGNA-0557 — COVID-19: In Vitro Diagnostic Testing - (0557)
BCBSIL-MED207.162 — SARS-CoV-2 (COVID-19) Antibody Testing
BCBSMT-MED207.162 — SARS-CoV-2 (COVID-19) Antibody Testing
BCBSNM-MED207.162 — SARS-CoV-2 (COVID-19) Antibody Testing
BCBSOK-MED207.162 — SARS-CoV-2 (COVID-19) Antibody Testing
Related Codes
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