Download Molecular Tests for Group A Streptococcus

Clinical Policy Title: Molecular tests for group A streptococcus
Clinical Policy Number: 18.01.04
Effective Date:
Initial Review Date:
Most Recent Review Date:
Next Review Date:
July 1, 2016
February 17, 2016
March 16, 2016
March, 2017
Policy contains:
 Group A streptococcus
 Molecular test
Related policies:
None.
ABOUT THIS POLICY: AmeriHealth Caritas Pennsylvania has developed clinical policies to assist with making coverage determinations.
AmeriHealth Caritas Pennsylvania’s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare
& Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and
peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and
regulatory requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation
are considered by AmeriHealth Caritas Pennsylvania when making coverage determinations. In the event of conflict between this clinical policy
and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or
regulatory requirements shall control. AmeriHealth Caritas Pennsylvania’s clinical policies are for informational purposes only and not intended
as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their
patients. AmeriHealth Caritas Pennsylvania’s clinical policies are reflective of evidence-based medicine at the time of review. As medical science
evolves, AmeriHealth Caritas Pennsylvania will update its clinical policies as necessary. AmeriHealth Caritas Pennsylvania’s clinical policies are
not guarantees of payment.
Coverage policy
AmeriHealth Caritas Pennsylvania considers the use of molecular testing for group A streptococcus
(GAS) to be investigational and, therefore, not medically necessary.
Limitations:
All other uses of molecular testing for GAS are not medically necessary.
Note: The following CPT/HCPCS code is not listed in the Pennsylvania Medicaid fee schedule:
87651 - Illumigene for Group A Streptococcus
Alternative covered services:
Rapid strep and throat culture
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Background
Approximately 9,000-11,500 cases of invasive disease (3.2 to 3.9/100,000 populations) occur each year
in the United States; STSS and NF each accounted for approximately 6%-7% of cases. Over 10 million
noninvasive GAS infections (primarily throat and superficial skin infections) occur annually.
Acute pharyngitis, otherwise known as sore throat, results in 15 million primary care consultations each
year in the US, with up to 30 percent of pediatric cases caused by Group A Streptococcus.
GAS is the most common bacterial cause of acute pharyngitis, responsible for 5%–15% of sore throat
visits in adults and 20%–30% in children.
Group A Streptococcus (Group A Strep, or GAS) bacteria spread through contact with droplets from an
infected person's cough or sneeze, and live in a person's nose and throat. Most GAS infections cause
relatively mild (noninvasive) illnesses such as strep throat, scarlet fever, and impetigo (a skin infection).
More than 10 million non-invasive GAS infections (primarily throat and superficial skin infections) occur
annually in the U.S. Occasionally, these bacteria can cause severe and even life-threatening (invasive)
diseases. Cases of invasive GAS infections, such as necrotizing fasciitis and streptococcal toxic shock
syndrome, occur less frequently but are associated with higher rates of deaths.
Acute GAS pharyngitis has certain characteristic epidemiological and clinical features .The disorder is
primarily a disease of children 5–15 years of age, and, in temperate climates, it usually occurs in the
winter and early spring. Patients with GAS pharyngitis commonly present with sore throat (generally of
sudden onset), pain on swallowing, and fever. Headache, nausea, vomiting, and abdominal pain may
also be present, especially in children. On examination, patients have tonsillopharyngeal erythema, with
or without exudates, often with tender, enlarged anterior cervical lymph nodes (lymphadenitis). Other
findings may include a beefy, red, swollen uvula; petechiae on the palate; excoriated nares (especially in
infants); and a scarlatiniform rash. However, none of these findings are specific for GAS pharyngitis.
Conversely, the absence of fever or the presence of clinical features such as conjunctivitis, cough,
hoarseness, coryza, anterior stomatitis, discrete intra-oral ulcerative lesions, viral exanthema, and
diarrhea strongly suggest a viral rather than a streptococcal etiology.
In addition to high sensitivity and specificity, a significant advantage to molecular methods is their
potential utility as rapid diagnostic tests. Results are available within 1 h of setup, enabling physicians to
initiate appropriate treatment promptly. Alternatively, since tests can be batched easily, testing can be
performed several times a day in laboratories with high throughput. Testing can potentially be coupled
with a method of automated physician notification, as described by Uhl et al. This strategy would offer
results with more rapidity than the standard 48-hr. culture.
Rheumatic fever (RF) is an autoimmune disease which affects more than 20 million children in
developing countries. It is triggered by Streptococcus pyogenes throat infection in untreated susceptible
individuals. Carditis, the most serious manifestation of the disease, leads to severe and permanent
valvular lesions, causing chronic rheumatic heart disease (RHD). We have been studying the mechanisms
leading to pathological autoimmunity in RF/RHD for the last 15 years.
Studies allowed a better understanding of the cellular and molecular pathogenesis of RHD, paving the
way for the development of a safe vaccine for a post-infection autoimmune disease. We have focused
on the search for protective T and B cell epitopes by testing 620 human blood samples against
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overlapping peptides spanning 99 residues of the C-terminal portion of the M protein, differing by one
amino acid residue. We identified T and B cell epitopes with 22 and 25 amino acid residues, respectively.
Although these epitopes were from different regions of the C-terminal portion of the M protein, they
showed an identical core of 16 amino acid residues. Antibodies against the B cell epitope inhibited
bacterial invasion/adhesion in vitro. Our results strongly indicated that the selected T and B cell epitopes
could potentially be protective against S. pyogenes. PMCID: PMC2270766 PMID: 17162355 [PubMed indexed for MEDLINE].
US Food and Drug Administration clearance Roche Diagnostics for its cobas Strep A test for detecting
group A streptococcus bacterial DNA in throat swab specimens. According to Roche, The test runs on
Roche's cobas Liat System, a molecular point-of-care diagnostic system scheduled for launch later this
year. The PCR-based test can detect Strep A DNA in 15 minutes when run on the Liat system.
Alere Inc. (NYSE: ALR), a global leader in rapid diagnostic tests, today announced that its Alere™ i Strep A
test has received marketing clearance from the U.S. Food and Drug Administration (FDA). Alere i Strep A
is the first molecular test that detects Group A Streptococcus (GAS) bacteria in throat swab specimens in
8 minutes or less. Other companies offering nucleic acid amplification tests for strep include Focus
Diagnostics, Meridian Bioscience, and Quidel, while firms like Hibergene and Tetracore have assays in
development.
Cultures of a throat swab on a sheep blood agar plate has been the standard for the documentation of
the presence of GAS pharyngitis in the upper respiratory tract and for the confirmation of the clinical
diagnosis of acute streptococcal pharyngitis If performed correctly, culture of a single throat swab on a
blood agar plate is 90%– 95% sensitive for detection of GAS pharyngitis.
The clinical significance of the number of GAS colonies on the throat culture plate is problematic.
Although patients with true acute GAS pharyngitis are likely to have more strongly positive cultures than
patients who are streptococcal carriers (i.e., individuals with chronic GAS colonization of the pharynx),
there is too much overlap in this regard to permit accurate differentiation on this basis alone rapid
antigen detection test (RADTs). A major disadvantage of throat cultures is the delay (overnight or
longer) in obtaining results. RADTs have been developed for the identification of GAS pharyngitis directly
from throat swabs, with shorter turnaround time. Rapid identification and treatment of patients with
GAS pharyngitis can reduce the risk of spread, allowing the patient to return to school or work sooner,
and can reduce the acute associated morbidity.
Diagnosis of GAS Pharyngitis should be established by:
1.
Swabbing the throat and testing for GAS pharyngitis by rapid antigen detection test (RADT)
and/or culture should be performed because the clinical features alone do not reliably
discriminate between GAS and viral pharyngitis except when overt viral features like rhinorrhea,
cough, oral ulcers, and/or hoarseness are present. In children and adolescents, negative RADT
tests should be backed up by a throat culture (strong, high). Positive RADTs do not necessitate a
back-up culture because they are highly specific.
2. 2. Routine use of back-up throat cultures for those with a negative RADT is not necessary for
adults in usual circumstances, because of the low incidence of GAS pharyngitis in adults and
because the risk of subsequent acute rheumatic fever is generally exceptionally low in adults
with acute pharyngitis . Physicians who wish to ensure they are achieving maximal sensitivity in
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diagnosis may continue to use conventional throat culture or to back up negative RADTs with a
culture.
3. 3. Anti-streptococcal antibody titers are not recommended in the routine diagnosis of acute
pharyngitis as they reflect past but not current events. (IDSA 2012)
Searches
AmeriHealth Caritas Pennsylvania searched PubMed and the databases of:
 UK National Health Services Centre for Reviews and Dissemination.
 Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and other
evidence-based practice centers.
 The Centers for Medicare & Medicaid Services (CMS).
We conducted searches on January 28, 2016. Search terms were: “molecular test, pharyngitis,
streptococci, throat culture, rapid streptococcal test, pharyngeal carriers, tonsillectomy, and
streptococcal antibody tests”
We included:
 Systematic reviews, which pool results from multiple studies to achieve larger sample sizes
and greater precision of effect estimation than in smaller primary studies. Systematic
reviews use predetermined transparent methods to minimize bias, effectively treating the
review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies.
 Guidelines based on systematic reviews.
 Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple
cost studies), reporting both costs and outcomes — sometimes referred to as efficiency
studies — which also rank near the top of evidence hierarchies.
Findings
The current gold standard for laboratory diagnosis of GAS pharyngitis is culture of pharyngeal swab
specimens. Cultures are screened for the presence of beta-hemolytic colonies, which are positively
identified as GAS using standard biochemical tests (e.g., catalase, pyrrolidonyl arylamidase, and latex
agglutination for type-specific antigen tests). While sensitive, culture requires up to 48 h of incubation,
which is problematic for physicians considering antibiotic therapy as an option for treating acute
pharyngitis. ( Mitchell MS, 2011).
Although commercial rapid antigen detection tests (RADTs) are more expensive than blood agar plate
(BAP) cultures, the advantage they offer is the speed with which they provide results. Rapid
identification and consequent prompt treatment of patients with pharyngitis due to group A betahemolytic streptococci (GABHS) can reduce the risk of spread of GABHS, can allow patients to return to
school or work sooner, and may reduce the acute morbidity of this illness. In most studies, RADTs have
been compared with BAP cultures as the criterion standard. However, these comparisons are
complicated by the fact that there is no universally accepted procedure for performing a BAP culture.
The great majority of the RADTs that are currently available have a high specificity (i.e., 95% or greater)
and a sensitivity of between 70 and 90% compared with BAP cultures. Few published studies have
compared the performance of various RADTs to each other or examined the performance of various
RADTs in the office setting. There is also relatively little published information about how physicians in
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practice actually use RADTs, but the available information suggests that many physicians do not follow
recommended guidelines. While the development of easy-to-perform RADTs for the diagnosis of GABHS
pharyngitis has altered clinical practice substantially, only limited data about cost-effectiveness are
currently available.
Point-of-care (POC) tests offer potentially substantial benefits for the management of infectious
diseases, mainly by shortening the time to result and by making the test available at the bedside or at
remote care centers. Commercial POC tests are already widely available for the diagnosis of bacterial
and viral infections and for parasitic diseases, including malaria. Infectious diseases specialists and
clinical microbiologists should be aware of the indications and limitations of each rapid test, so that they
can use them appropriately and correctly interpret their results. The clinical applications and
performance of the most relevant and commonly used POC tests are reviewed. Some of these tests
exhibit insufficient sensitivity, and should therefore be coupled to confirmatory tests when the results
are negative (e.g. Streptococcus pyogenes rapid antigen detection test), whereas the results of others
need to be confirmed when positive (e.g. malaria). New molecular-based tests exhibit better sensitivity
and specificity than former immunochromatographic assays (e.g. Streptococcus agalactiae detection). In
the coming years, further evolution of POC tests may lead to new diagnostic approaches, such as panel
testing, targeting not just a single pathogen, but all possible agents suspected in a specific clinical
setting. To reach this goal, the development of serology-based and/or molecular-based
microarrays/multiplexed tests will be needed. The availability of modern technology and new
microfluidic devices will provide clinical microbiologists with the opportunity to be back at the bedside,
proposing a large variety of POC tests that will allow quicker diagnosis and improved patient care. PMID:
20670287 [PubMed - indexed for MEDLINE].
Policy updates:
Summary of clinical evidence:
Citation
Rogo T et al. (2010)
Comparison of the
Inverness Medical Acceava
Strep A test with the
Genzyme OSOM and Quidel
QuickVue Strep A tests.
Content, Methods, Recommendations
Key points:



Schmuziger N et al. (2003)
Reliability and general
practice value of 2 rapid
Streptococcus A tests.
Previous studies of the accuracy of rapid in-office tests for group A Streptococcus had
disparate results, ranging from a sensitivity of 70% to more than 90%. The sensitivity
and specificity of 3 commercially available Strep A tests were determined in 2 private
pediatric office settings.
Acceava Strep A, Genzyme OSOM Strep A, and the Quidel QuickVue Strep A tests
were the representative rapid tests for detection of Streptococcus pyogenes.
Overnight culture on standard 5% sheep blood agar was the reference standard for this
study. All 3 Clinical Laboratory Improvement Amendments-waived tests had sensitivities
and specificities that exceeded 95%.

Key points:
 Results of the optical immunoassay and the conventional immune assay Strep A Plus
were compared in 65 patients with acute pharyngitis. A standard culture was used as
reference and confirmed by enhanced broth culturing and nucleic acid hybridization
assay (Gen-Probe) when the two detection assays produced contradictory results.
While both assays were equally sensitive (78.3%),
 Strep A OIA MAX and Strep A Plus had a similar specificity of 95.2% and 100%,
respectively. Four and nine steps were required for Strep A Plus and for Strep A OIA
MAX test procedures, respectively with results being available in 4-5 min and in 9-10
min, respectively.
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Citation
Content, Methods, Recommendations
 Concluded that both rapid immunoassays have a similar reliability while the handling of
the Strep A Plus is much simpler than the handling of the Strep A OIA MAX.
 Neither rapid immunoassays are sensitive enough to eliminate the need for backup
cultures.
Neuner JM et al. (2003)
Diagnosis and management
of adults with pharyngitis. A
cost-effectiveness analysis.
Key points:
 Five strategies for the management of adult patients with pharyngitis: 1) observation
without testing or treatment, 2) empirical treatment with penicillin, 3) throat culture using
a two-plate selective culture technique, 4) optical immunoassay (OIA) followed by
culture to confirm negative OIA test results, or 5) OIA alone.
 Observation, culture, and two rapid antigen test strategies for diagnostic testing and
treatment of suspected GAS pharyngitis in adults have very similar effectiveness and
costs, although culture is the least expensive and most effective strategy when the GAS
pharyngitis prevalence is 10%.
 Empirical treatment was not the most effective or least expensive strategy at any
prevalence of GAS pharyngitis in adults, although it may be reasonable for individual
patients at very high risk for GAS pharyngitis as assessed by a clinical decision rule.
Le Marechal F et al ( 2012)
Streptococcal pharyngitis in
children: a meta-analysis of
clinical decision rules and
their clinical variables
Key points:
 To identify the best clinical decision rules (CDRs) for diagnosing group A streptococcal
(GAS) pharyngitis in children. A combination of symptoms could help clinicians exclude
GAS infection in children with pharyngitis.
 The rule of Joachim et al could be useful for clinicians who do not use rapid diagnostic
tests and should allow avoiding antibiotic treatment for the 35% of children identified by
the rule as not having GAS pharyngitis. Owing to its poor specificity, such CDR should
be used to focus rapid diagnostic tests to children with high risk of GAS pharyngitis to
reduce the antibiotic consumption.
Mayo Clin Proc.( 2012)
Current concepts in
laboratory testing to guide
antimicrobial therapy.
Key points:
 Antimicrobial susceptibility testing (AST) is indicated for pathogens contributing to an
infectious process that warrants antimicrobial therapy if susceptibility to antimicrobials
cannot be predicted reliably based on knowledge of their identity. Such tests are most
frequently used when the etiologic agents are members of species capable of
demonstrating resistance to commonly prescribed antibiotics. Some organisms have
predictable susceptibility to antimicrobial agents (i.e.,
 Streptococcus pyogenes to penicillin), and empirical therapy for these organisms is
typically used. Therefore, AST for such pathogens is seldom required or performed. In
addition, AST is valuable in evaluating the activity of new and experimental compounds
and investigating the epidemiology of antimicrobial resistant pathogens. Several
laboratory methods are available to characterize the in vitro susceptibility of bacteria to
antimicrobial agents.
 When the nature of the infection is unclear and the culture yields mixed growth or usual
microbiota (wherein the isolates usually bear little relationship to the actual infectious
process), AST is usually unnecessary and results may, in fact, be dangerously
misleading. Phenotypic methods for detection of specific antimicrobial resistance
mechanisms are increasingly being used to complement AST (i.e., inducible
clindamycin resistance among several gram-positive bacteria) and to provide clinicians
with preliminary direction for antibiotic selection pending results generated from
standardized AST (i.e., β-lactamase tests). In addition, molecular methods are being
developed and incorporated by microbiology laboratories into resistance detection
algorithms for rapid, sensitive assessment of carriage states of epidemiologically and
clinically important pathogens, often directly from clinical specimens (i.e., presence of
vancomycin-resistant enterococci in fecal specimens).
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Glossary
The illumigene® Molecular Diagnostic System— Is simple, delivering the power of molecular technology
in a "rapid test" type format; flexible, integrating easily into any facility regardless of volume or
expertise; and cost-effective, allowing addition of molecular assays without the cost of additional labor
or capital expenditures.
References
Professional society guidelines/other:
Infectious Diseases Society of America (IDSA) http://www.idsociety.org/uploadedFiles/IDSA/GuidelinesPatient_Care/PDF_Library/2012%20Strep%20Guideline.pdf
American Society for Microbiology (ASM). Rapid diagnosis of Pharyngitis caused by Group A streptococci
Clinical Microbiology Reviews. doi: 10.1128/CMR.17.3.571-580.2004 Clin. Microbiol. April 2016, volume
29, issue 2 1 April 2016, Rev. July 2004 vol. 17 no. 3 571-580 .1 July 2004.
Clin Microbiol Infect. 2010 Aug; 16(8):1054-61. doi: 10.1111/j.1469-0691.2010.03281.x. Routine use of
point-of care tests: usefulness and application in clinical microbiology. Clerc O, Greub G.
Mayo Clin Proc. 2012 Mar; 87(3):290-308. doi: 10.1016/j.mayocp.2012.01.007. Current concepts in
laboratory testing to guide antimicrobial therapy. Jenkins SG, Schuetz AN. PMCID: PMC3496983 PMID:
22386185 [PubMed - indexed for MEDLINE].
Peer-reviewed references:
Badgett JT, Hesterberg LK. Management of group streptococcus pharyngitis with a second-generation
rapid strep screen: Strep A OIA. Microb Drug Resist. 1996 Fall; 2(3):371-6. Review.PMID:9158797.
Bisno AL, Gerber MA, Gwaltney JM Jr, Kaplan EL, Schwartz RH. Practice guidelines for the diagnosis and
management of group a streptococcal pharyngitis. Infectious Diseases Society of America. Clin Infect Dis
2002; 35:113–25.
Bisno AL. Acute pharyngitis: etiology and diagnosis. Pediatrics 1996; 97:949–54.
BMJ Open. Streptococcal pharyngitis in children: a meta-analysis of clinical decision rules and their
clinical variables 2013; 3:e001482 doi: 10.1136/bmjopen-2012-001482.
http://bmjopen.bmj.com/content/3/3/e001482. Accessed February 4, 2016.
Brien JH, Bass JW. Streptococcal pharyngitis: optimal site for throat culture. J Pediatr 1985; 106:781–3.
Felsenstein S, Faddoul D, Sposto R, Batoon K, et al. Molecular and clinical diagnosis of group A
streptococcal pharyngitis in children. J Clin Microbiol. 2014 Nov; 52(11):3884-9. doi:
10.1128/JCM.01489-14. Epub 2014 Aug 20. PMID: 25143573
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4313219/.
Assessed January 22, 2016.
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Gerber MA. Diagnosis of pharyngitis: methodology of throat cultures.In: Shulman ST, ed. Pharyngitis:
management in an era of declining rheumatic fever. New York: Praeger, 1984:61–72.
Gerber MA. Comparison of throat cultures and rapid strep tests for diagnosis of streptococcal
pharyngitis. Pediatr Infect Dis J 1989; 8:820–4.
Gerber MA, Shulman ST. Rapid diagnosis of pharyngitis caused by group A streptococci. Clin Microbiol
Rev 2004; 17:571–80.
Guilherme L, Faé KC, Higa F, Chaves L, et al. Towards a vaccine against rheumatic fever. Clin Dev
Immunol. 2006 Jun-Dec;13(2-4):125-32.
Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and
strength of recommendations. BMJ 2008; 336:924-6.
Hayes Inc., Hayes Medical Technology Report. Lansdale, Pa. Hayes Inc.; February, 2016.
Kaplan EL, Top FH Jr., Dudding BA, Wannamaker LW. Diagnosis of streptococcal pharyngitis:
differentiation of active infection from the carrier state in the symptomatic child. J Infect Dis 1971;
123:490-501.
Langlois DM, Andreae M. 2011. Group A streptococcal infections. Pediatr. Rev. 32:423–429.
Mitchell MS, Sorrentino A, Centor RM. 2011. Adolescent pharyngitis: a review of bacterial causes. Clin.
Pediatr. (Phila.) 50:1091–1095.
Neuner JM, Hamel MB, Phillips RS, Bona K, et al. Diagnosis and management of adults with pharyngitis.
A cost-effectiveness analysis. .Ann Intern Med. 2003 Jul 15;139(2):113-22.PMID:12859161.
Randolph MF, Gerber MA, DeMeo KK, Wright L. Effect of antibiotic therapy on the clinical course of
streptococcal pharyngitis. J Pediatr 1985; 106:870–5.
Rogo T, Schwartz RH, Ascher DP. Comparison of the Inverness Medical Acceava Strep A tests with the
Genzyme OSOM and Quidel QuickVue Strep A tests. Clin Pediatr (Phila). 2011 Apr; 50(4):294-6. doi:
10.1177/0009922810385675. Epub 2010 Nov 22.PMID: 21098521.
Schmuziger N, Schneider S, Frei R. Reliability and general practice value of 2 rapid Streptococcus A tests
HNO. 2003 Oct; 51(10):806-12. Epub 2003 Apr 11. German. PMID: 1452353.
Schwartz RH, Gerber MA, McCoy P. Effect of atmosphere of incubation on the isolation of group A
streptococci from throat cultures. J Lab Clin Med 1985; 106:88–92.
Schunemann HJ, Oxman AD, Brozek J, et al. Grading quality of evidence and strength of
recommendations for diagnostic tests and strategies. BMJ 2008; 336:1106-10.
Snow V, Mottur-Pilson C, Cooper RJ, Hoffman JR. Principles of appropriate antibiotic use for acute
pharyngitis in adults. Ann Intern Med 2001; 134:506–8.
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Uhl JR, Adamson SC, Vetter EA, Schleck CD, Harmsen WS, Iverson LK, Santrach PJ, Henry NK, Cockerill FR.
2003. Comparison of LightCycler PCR, rapid antigen immunoassay, and culture for detection of group A
streptococci from throat swabs. J. Clin. Microbiol. 41:242–249. Abstract/FREE Full Text.
Clinical trials:
Searched clinicaltrials.gov on February 01, 2016 using terms molecular test, strep A | Open Studies.
None studies found, none relevant.
CMS National Coverage Determinations (NCDs):
No NCDs identified as of the writing of this policy.
Local Coverage Determinations (LCDs):
No LCDs identified as of the writing of this policy
Commonly submitted codes
Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is
not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and
bill accordingly.
CPT Code
Description
87651
Illumigene for Group A Streptococcus
ICD-10
Code
Description
A49.1
Streptococcus infection, unspecified site
HCPCS
Code
Description
Comments
Comments
Comments
N/A
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