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Pulmonary Function Testing (PFT) and Polymerase Chain Reaction Respiratory Viral Panel Testing (PCR) Policy Updates

Date: 05/13/26

Thank you for your continued partnership with Ambetter. As you know, we continually review and update our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members. We are writing today to inform you of the revision to existing policies Ambetter from Meridian will be implementing effective 08/01/2026. Posted policy on site contains a revision log explaining the updates that occurred in the annual review.

Policy Number

Policy Name

Policy Description

Lines of Business

CP.MP.242

Pulmonary Function Testing

Pulmonary function tests (PFTs), also known as lung function tests, include a variety of tests to check how well the lungs are working. This policy describes the medical necessity guidelines for pulmonary function testing.

It is the policy of health plans affiliated with Centene Corporation® that pulmonary function testing (PFT) is medically necessary for members/enrollees aged three years and above when meeting the criteria for one of the following tests:

· Spirometry

· Lung Volume Tests

· Diffusion capacity of the lungs for Carbon monoxide (DLCO) tests

· Lung compliance studies when all other PFTs give equivocal results or results which must be confirmed by additional lung compliance testing

· Pulmonary studies during exercise testing

Marketplace

CP.MP.181

Polymerase Chain Reaction Respiratory Viral Panel Testing

Medical necessity criteria for multiplex respiratory polymerase chain reaction (PCR) testing.

Note: For criteria applicable to Medicare plans, please see MC.CP.MP.181 Polymerase Chain Reaction Respiratory Viral Panel Testing.

Marketplace


Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members. We look forward to helping you provide the highest quality of care for our members.

Sincerely,

Ambetter from Meridian