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Clinical Payment Policy: Polymerase Chain Reaction Respiratory Viral Panel Testing Effective - January 15, 2021

Date: 10/09/20

Superior HealthPlan presents a revised clinical payment policy to communicate the medical necessity criteria for multiplex respiratory polymerase chain reaction (PCR) testing for applicable services and procedure codes.  As a result, the following policy has been added:

Policy

Effective Date

Applicable Products

New Policy Overview or Updated Policy Revisions

Polymerase Chain Reaction Respiratory Viral Panel Testing (CP.MP.181)*

 

 

 

 

January 15, 2021

Allwell (HMO and HMO SNP) and Ambetter

I.      It is the policy of Superior HealthPlan that respiratory viral panels (RVPs) testing for five pathogens or less are considered medically necessary when meeting one of the following:

A.    Performed in the outpatient setting, will influence the plan of care, and any of the following:

1.     To assess for infection by other pathogens when COVID-19 is suspected and a COVID-19-specific test result will not be available soon enough to influence the plan of care;

2.     The member is immunocompromised;

3.     The test is ordered by an infectious disease specialist, or an infectious disease specialist is not available;

B.    Performed in a healthcare setting that cares for critically ill patients, such as the emergency department or inpatient hospital, including those in observation status.

 

II.     It is the policy of Superior HealthPlan that respiratory viral panels (RVPs) testing for six pathogens or more 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.

 

III.   It is the policy of Superior HealthPlan that RVPs are considered not medically necessary for all other indications.

 

Polymerase Chain Reaction Respiratory Viral Panel Testing (TX.CP.MP.181)*

 

 

 

 

January 15, 2021

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP

I.      It is the policy of Superior HealthPlan that respiratory viral panels (RVPs) testing for five pathogens or less are considered medically necessary when meeting one of the following:

A.    Performed in the outpatient setting, will influence the plan of care, and any of the following:

1.     To assess for infection by other pathogens when COVID-19 is suspected and a COVID-19-specific test result will not be available soon enough to influence the plan of care;

2.     The member is immunocompromised;

3.     The test is ordered by an infectious disease specialist, or an infectious disease specialist is not available;

C.    Performed in a healthcare setting that cares for critically ill patients, such as the emergency department or inpatient hospital, including those in observation status.

 

II.     It is the policy of Superior HealthPlan that respiratory viral panels (RVPs) testing for six pathogens or more 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.

 

III.   It is the policy of Superior HealthPlan that RVPs are considered not medically necessary for all other indications.

 

* REPLACES Current PCR Policy, Polymerase Chain Reaction Respiratory Viral Panel Testing (TX.PP.150)

To review all Clinical policies, please visit Superior’s Clinical and Payment Polices webpage.

Prior to updates, Medical Clinical policies are reviewed and approved by the Utilization Management Committee.

For questions or additional information, please contact Superior HealthPlan Prior Authorization department at 1-800-218-7508.