Humana Diagnostic Testing of Influenza

Humana Claims Payment Policy

Subject: Laboratory – Diagnostic Testing of Influenza   

Medicare Advantage Payment Policy

As a Medicare Advantage plan, we have developed payment policies to explain coverage more fully for services. The criteria outlined for the Commercial Payment Policy will apply to Medicare Advantage plans except when the procedure(s) has established criteria through the Original Medicare National Coverage Determinations (NCD’s) and Local Coverage Determinations (LCD’s) as outlined below.

In addition to this policy, claims payments are subject to other plan requirements for the processing and payment of claims,

1. Testing for influenza (87804**, 87400**, 87501*, 87502*, 87275**, 87276**) IS ONLY REIMBURSABLE for diagnosis of patients who present with one or more of the following:

• Abdominal Pain
• Acute bronchitis
• Acute sinusitis
• Acute tonsillitis, laryngitis and tracheitis
• Asthma exacerbation
• Chest pain
• Cough
• Dehydration
• Fatigue
• Fever
• Gastritis, unspecified, without bleeding
• Headache
• Infectious mononucleosis
• Influenza
• Nausea, vomiting
• Pharyngitis
• Shortness of breath
• Upper respiratory infection
• Viral infections
• Viral intestinal infection, unspecified
• Viral or bacterial pneumonia
• Whooping cough

2. Testing with infectious agent antigen detection by immunoassay with direct optical observation (87804**) IS NOT REIMBURSABLE with another influenza test (87400**, 87501*, 87502*, 87275**, 87276**).

Applicable procedures for Medicare Advantage plans

*The payment criterion for 87501 and 87502 apply to all Medicare jurisdictions, except those states awarded to CGS Administrators, Noridian Healthcare Solutions, Palmetto GBA and WPS Insurance Corporation.

**The payment criterion for 87804, 87400, 87275, 87276 and 87254 apply to all Medicare jurisdictions, except those states awarded to CGS Administrators, Noridian Healthcare Solutions and Palmetto GBA.