Anthem Blue Cross Connecticut CG-LAB-14 Respiratory Viral Panel Testing in the Outpatient Setting Form

This document addresses the use of respiratory viral panel (RVP) testing in the outpatient setting. RVPs are multiplexed nucleic acid tests used to detect respiratory viruses including, but not limited to: adenovirus, coronavirus (229E, HKU1, NL63, OC43, severe acute respiratory syndrome coronavirus 2), human bocavirus, human metapneumovirus, human rhinovirus/enterovirus, influenza A (A, H1, H1-2009, H3), influenza B, parainfluenza (1, 2, 3, 4), respiratory syncytial virus (A, B). This document does not address RVP testing in the inpatient setting.

Note: This document does not address tests that detect only the following:

• Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and influenza virus types A and B.
• SARS-CoV-2 and influenza virus types A and B and respiratory syncytial virus.

Note: Please see the following related document for additional information:

• ADMIN.00007 Immunizations

Clinical Indications

Medically Necessary:

Respiratory viral panel testing in the outpatient setting is considered medically necessary when all of the following criteria have been met:

1. Use of limited panels involving 5 targets or less; and
2. Testing is for individuals who are at high risk for complications of respiratory viral infection including, but not limited to, individuals who are immunocompromised (for example, lung transplant recipients); and
3. The results of testing will be used to guide or alter management.

Not Medically Necessary:

Respiratory viral panel testing in the outpatient setting is considered not medically necessary when the criteria above have not been met and for all other indications, including but not limited to:

1. Testing average risk individuals;
2. Use of large panels involving 6 or more targets.