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    v1.0.28
    OpenPayerPolicy UpdatesInfectious DiseaseAmbetter Nevada GI Testing Coverage | OpenPayer
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    ModifiedAmbetter NevadaPolicy CG.CP.MP.04

    Concert Infectious Disease: Gastroenterologic Testing

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    This outpatient clinical policy governs medical necessity for syndromic or multiplex gastrointestinal pathogen panels and Helicobacter pylori urea breath, stool antigen, and antibody tests submitted by providers for health plan members and enrollees in Nevada.

    Policy Summary
    PayerAmbetter Nevada
    PolicyConcert Infectious Disease: Gastroenterologic Testing
    Policy CodePolicy CG.CP.MP.04
    Change TypeModified
    Effective DateNot specified
    Last ReviewNov 1, 2024
    Next Review DateNot specified
    Key ActionDocument the outpatient presentation, applicable qualifying feature, and how the gastrointestinal pathogen test result will influence clinical management.
    SourceLink
    POLICY UPDATE CHANGES

    For syndromic or multiplex gastrointestinal pathogen panels with 11 or fewer targets, the policy statement was changed from “may be considered medically necessary” to “are considered medically necessary.”

    CPT code 87650 and code 0369U were added to the coding table during the annual review.

    The policy title and coding sections were revised and reorganized.

    CPT coding descriptions were corrected, code 0369U was removed in an earlier revision, and the policy number was corrected from CG.CP.MP.104 to CG.CP.MP.04.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    ≤11 targetsPanel category
    ≥12 targetsPanel category
    Every 14 daysRepeat testing limit
    7 daysQualifying diarrhea duration
    InvestigationalH. pylori antibody status

    Medical Necessity Criteria

    Syndromic/multiplex gastrointestinal pathogen panels with 11 or fewer targets

    Covered as medically necessary when ALL of the following are met:

    Required criteria

    • Clinical presentation

      • Outpatient suspected infectious gastroenteritis: The member/enrollee presents in the outpatient setting with suspected infectious gastroenteritis.

      • At least one qualifying clinical feature

        • Immunocompromised status, such as HIV/AIDS, immunosuppression therapy, or primary immunodeficiency.
        • Recent travel to, or contact with travelers from, an infectious diarrheal disease-endemic area.
        • Dysentery, defined as blood or mucus in the stool.
        • Fever.
        • Dehydration.
        • Abdominal pain or tenderness.
        • Bacteremia.
        • Diarrhea persisting longer than 7 days.> 7 days
        • Symptoms of enteric fever, including typhoid or paratyphoid fever.

    • Management impact

      • Results of the testing will influence the member/enrollee's clinical management.

    Frequency for panels with 11 or fewer targets

    Frequency limitation:

    Permitted frequency: The panel is performed once per incident of diarrheal disease, or no more than once per 14-day period.Once per incident or ≤ once per 14 days

    Applies to panels with 11 or fewer targets.

    Syndromic/multiplex gastrointestinal pathogen panels with 12 or more targets

    Covered as medically necessary when ALL of the following are met:

    Required criteria

    • Clinical presentation

      • Outpatient suspected infectious gastroenteritis: The member/enrollee presents in the outpatient setting with suspected infectious gastroenteritis.

      • At least one qualifying clinical feature

        • Immunocompromised status, such as HIV/AIDS, immunosuppression therapy, or primary immunodeficiency.
        • Recent travel to, or contact with travelers from, an infectious diarrheal disease-endemic area.

    Frequency for panels with 12 or more targets

    Frequency limitation:

    Permitted frequency: The panel is performed once per incident of diarrheal disease, or no more than once per 14-day period.Once per incident or ≤ once per 14 days

    Applies to panels with 12 or more targets.

    H. pylori urea breath or stool antigen tests

    Covered as medically necessary when the member/enrollee meets ANY ONE of the following indication pathways:

    Qualifying indication pathway

    • Ulcer, lymphoma, or gastric cancer pathway

      • Active peptic ulcer disease (PUD).
      • Low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma.
      • History of endoscopic resection of early gastric cancer (EGC).

    • Past PUD pathway

      • The member/enrollee has a past history of peptic ulcer disease.

    H. pylori urea breath or stool antigen testing is investigational for evaluation of GERD, lymphocytic gastritis, hyperplastic gastric polyps, or hyperemesis gravidarum; for asymptomatic individuals with a family history of gastric cancer; and for children or adolescents with functional abdominal pain or short stature. These indications do not meet the policy’s coverage criteria.

    H. pylori antibody tests are considered investigational for all indications.

    Coding Implications

    CPT codes referenced in coding implicationsCPT
    83013Helicobacter pylori, blood test analysis for urease activity, non-radioactive isotope (eg, C-13).
    83014Helicobacter pylori; drug administration.
    86677Antibody; Helicobacter pylori.
    87493Infectious agent detection by nucleic acid (DNA or RNA); Clostridium difficile, toxin gene(s), amplified probe technique.
    87498Infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique, includes reverse transcription when performed.
    87500Infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique.
    87505Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse
    CPT and other codes listed under Coding ImplicationsCPT
    83013Helicobacter pylori, blood test analysis for urease activity, non-radioactive isotope (eg, C-13).
    83014Helicobacter pylori; drug administration.
    86677Antibody; Helicobacter pylori.
    87493Infectious agent detection by nucleic acid (DNA or RNA); Clostridium difficile, toxin gene(s), amplified probe technique.
    87498Infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique, includes reverse transcription when performed.
    87500Infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique.
    87505Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or
    87506Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets
    87507Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets
    87561Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, amplified probe technique.
    1–10 of 20
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    Repeat gastrointestinal pathogen panel frequency
    Repeat frequencyOnce per incident of diarrheal disease
    Time-based limitNo more than once per 14-day period
    Applies toSyndromic/multiplex gastrointestinal pathogen panels
    Diarrhea duration
    Qualifying durationPersisting longer than 7 days
    Clinical conditionDiarrhea
    Qualifying feature

    Documentation and Denial Risk

    Documentation Required

    Document criteria for panels with 11 or fewer targets

    Document that the member/enrollee presents in the outpatient setting with suspected infectious gastroenteritis, identify at least one qualifying clinical feature, and explain how the test results will influence clinical management.

    • Qualifying features include immunocompromised status; recent travel to or contact with travelers from an infectious diarrheal disease-endemic area; dysentery; fever; dehydration; abdominal pain or tenderness; bacteremia; diarrhea persisting longer than 7 days; or symptoms of enteric fever.
    Documentation Required

    Document criteria for panels with 12 or more targets

    Document that the member/enrollee presents in the outpatient setting with suspected infectious gastroenteritis, identify the applicable qualifying clinical feature, and explain how the test results will influence clinical management.

    • Qualifying features are immunocompromised status; recent travel to or contact with travelers from an infectious diarrheal disease-endemic area; bacteremia; or symptoms of enteric fever.

    Clinical Background

    Gastrointestinal infections may be caused by bacteria, viruses, fungi, or parasites. Diagnostic methods include culture, microscopy, immunoassays, and molecular testing. Multiplex panels can evaluate multiple pathogens simultaneously, but testing should be targeted to clinical presentations in which identifying an infectious etiology will affect management. H. pylori testing is used for selected ulcer-related, dyspepsia, medication-related, anemia, gastric cancer, lymphoma, and adult idiopathic thrombocytopenic purpura indications.

    Terms and Clinical Definitions

    Uninvestigated dyspepsia
    Core definitionDyspepsia that has not already been evaluated through investigations
    Example investigationUpper GI endoscopy
    Classification statusNot already classified as functional or organic dyspepsia
    Dyspepsia alarm features
    VomitingVomiting
    Bleeding or anemiaBleeding or anemia
    Mass or weight lossAbdominal mass or unintended weight loss
    Policy Summary
    PayerAmbetter Nevada
    PolicyConcert Infectious Disease: Gastroenterologic Testing
    Policy CodePolicy CG.CP.MP.04
    Change TypeModified
    Effective DateNot specified
    Last ReviewNov 1, 2024
    Next Review DateNot specified
    Key ActionDocument the outpatient presentation, applicable qualifying feature, and how the gastrointestinal pathogen test result will influence clinical management.
    SourceLink
    On This Page
    Medical Necessity CriteriaCoding ImplicationsDocumentation and Denial RiskClinical BackgroundTerms and Clinical Definitions
    Bacteremia.
  1. Symptoms of enteric fever, including typhoid or paratyphoid fever.

  2. Management impact

    • Results of the testing will influence the member/enrollee's clinical management.
    3. Previous cure of H. pylori infection has not been documented.

  3. Uninvestigated dyspepsia pathway

    • The member/enrollee has dyspepsia.
    • The member/enrollee is younger than 60 years of age.< 60 years
    • The member/enrollee does not have dyspepsia alarm features.
    • The member/enrollee has not undergone previous investigation for dyspepsia; the dyspepsia is uninvestigated.

  4. Medication-initiation pathway

    • The member/enrollee is initiating prophylactic low-dose aspirin.
    • The member/enrollee is initiating chronic treatment with a non-steroidal anti-inflammatory drug (NSAID).

  5. Other clinical pathways

    • The member/enrollee has unexplained iron deficiency anemia despite an appropriate evaluation.
    • The member/enrollee is an adult with idiopathic thrombocytopenic purpura (ITP).

      Adult status is required for the ITP pathway.

    6. Diarrhea persisting longer than 7 days
    Age for dyspepsia-based H. pylori testing
    Age thresholdYounger than 60 years of age
    Testing contextH. pylori urea breath or stool antigen testing
    Associated conditionDyspepsia
    Syndromic/Multiplex Gastrointestinal Pathogen Panels
    Panel categorySyndromic/multiplex gastrointestinal pathogen panels
    Target threshold11 or fewer targets
    Related higher-target category12 or more targets
    Documentation Required

    Document the qualifying H. pylori indication

    Document the applicable H. pylori indication and the associated required conditions before billing a urea breath or stool antigen test.

    • Qualifying indications include active peptic ulcer disease, low-grade gastric MALT lymphoma, history of endoscopic resection of early gastric cancer, or past peptic ulcer disease without documented prior cure of H. pylori infection.
    • For dyspepsia, document age younger than 60 years, no dyspepsia alarm features, and no previous investigation for dyspepsia.
    • Other qualifying indications include initiating prophylactic low-dose aspirin, initiating chronic NSAID treatment, unexplained iron deficiency anemia despite appropriate evaluation, or adult idiopathic thrombocytopenic purpura (ITP).
    Denial Risk

    Avoid non-qualifying use of smaller panels

    A syndromic/multiplex gastrointestinal pathogen panel with 11 or fewer targets is investigational and subject to denial when used for indications other than suspected infectious gastroenteritis in the outpatient setting with a qualifying clinical feature and when results will influence clinical management.

    • The panel is also considered investigational when performed more than once per incident of diarrheal disease or more frequently than once per 14-day period.
    Denial Risk

    Avoid non-qualifying use of larger panels

    A syndromic/multiplex gastrointestinal pathogen panel with 12 or more targets is investigational and subject to denial when used for indications other than suspected infectious gastroenteritis in the outpatient setting with immunocompromised status, recent relevant travel or contact, bacteremia, or symptoms of enteric fever, and when results will influence clinical management.

    • The panel is also considered investigational when performed more than once per incident of diarrheal disease or more frequently than once per 14-day period.
    Denial Risk

    Do not use H. pylori antigen testing for investigational indications

    H. pylori urea breath or stool antigen testing is investigational for other indications and may be denied when it does not meet a covered indication pathway.

    • Examples include evaluation of GERD, lymphocytic gastritis, hyperplastic gastric polyps, or hyperemesis gravidarum; testing asymptomatic individuals with a family history of gastric cancer; and testing children or adolescents with functional abdominal pain or short stature.
    Denial Risk

    H. pylori antibody testing is investigational

    H. pylori antibody tests are considered investigational for all indications.

    • This applies to antibody testing regardless of the clinical indication.
    Billing Rule

    Follow the repeat-testing frequency limit

    Repeat syndromic/multiplex gastrointestinal pathogen panel testing more than once per incident of diarrheal disease or more frequently than once in a 14-day period does not meet the stated frequency criterion.

    • The frequency limitation applies to panels with 11 or fewer targets and panels with 12 or more targets.
    Swallowing symptomDysphagia
    Symptoms of enteric fever
    FeverHigh fever
    Abdominal symptomsAbdominal pain
    Bowel patternConstipation followed by diarrhea, sometimes bloody
    Skin findingFlat rose-spot rash on the abdomen and chest
    Neurologic symptomConfusion due to fever
    Organ enlargementHepatosplenomegaly
    Serious gastrointestinal findingsGastrointestinal bleeding or perforation
    Gastroenteritis
    DefinitionA condition characterized by vomiting and/or diarrhea
    VomitingVomiting
    DiarrheaDiarrhea