CurrentAmbetter NevadaPolicy CP.MP.153

Helicobacter Pylori Serology Testing

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This policy governs medical-necessity determinations for H. pylori antibody and serology testing, which is not medically necessary for diagnosing infection or evaluating treatment effectiveness.

Policy Summary

PayerAmbetter Nevada

PolicyHelicobacter Pylori Serology Testing

Policy CodePolicy CP.MP.153

Change TypeAnnual reviewreferences updated

Effective DateNot provided

Last ReviewSep 1, 2023

Next Review DateNot provided

Key ActionDo not request H. pylori serology testing to diagnose infection or evaluate treatment effectiveness.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not medically necessarySerology coverage stance

3Noninvasive testing modalities discussed

4–6 weeksUrea breath test confirmation interval

2 weeksPPI discontinuation before urea breath testing

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CurrentAmbetter NevadaPolicy CP.MP.153

Helicobacter Pylori Serology Testing

Customize your policy alerts

Sign up for Ambetter Nevada Policy CP.MP.153 alerts

Get alerted when Policy CP.MP.153 changes without checking for updates manually.

Monitor payer policy activity

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This policy governs medical-necessity determinations for H. pylori antibody and serology testing, which is not medically necessary for diagnosing infection or evaluating treatment effectiveness.

Policy Summary

PayerAmbetter Nevada

PolicyHelicobacter Pylori Serology Testing

Policy CodePolicy CP.MP.153

Change TypeAnnual reviewreferences updated

Effective DateNot provided

Last ReviewSep 1, 2023

Next Review DateNot provided

Key ActionDo not request H. pylori serology testing to diagnose infection or evaluate treatment effectiveness.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not medically necessarySerology coverage stance

3Noninvasive testing modalities discussed

4–6 weeksUrea breath test confirmation interval

2 weeksPPI discontinuation before urea breath testing

H. pylori Serology Coverage Criteria

H. pylori Serology Not Medically Necessary

H. pylori serology testing is not medically necessary for either of the following purposes:

Not medically necessary

Diagnosis of infection: Testing is requested to diagnose H. pylori infection.
Evaluation of treatment effectiveness: Testing is requested to evaluate the effectiveness of H. pylori treatment.
Serology cannot be used as a test of cure.

H. pylori serology testing is excluded as medically necessary coverage when used to diagnose H. pylori infection or evaluate treatment effectiveness. Antibody testing cannot be used as a test of cure.

H. pylori serology is not medically necessary when ordered to diagnose H. pylori infection or to evaluate the effectiveness of H. pylori treatment.

Coding Information

CPT CodesCPT

86677

Antibody; Helicobacter pylori

Provider Actions and Coverage Coordination

Note

Review State Medicaid Coverage Provisions

For Medicaid member/enrollees, state Medicaid coverage provisions take precedence when they conflict with this clinical policy. Review the applicable state Medicaid manual for coverage provisions before applying this policy.

Note

Review Applicable Medicare Coverage Guidance

For Medicare member/enrollees, review all applicable Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles before applying the criteria in this clinical policy. Refer to the CMS website for additional guidance.

Denial Risk

H. pylori Serology Is Not Medically Necessary

H. pylori serology testing is determined to be not medically necessary for diagnosing infection or evaluating treatment effectiveness. Providers should account for this determination when selecting diagnostic or treatment-evaluation tests and when submitting claims.

Clinical Background

H. pylori infection is associated with peptic ulcer disease, chronic gastritis, gastric adenocarcinoma, and gastric MALT lymphoma. Serologic antibody testing detects IgG antibodies but cannot distinguish active infection from prior exposure or confirm eradication. Urea breath testing and stool antigen testing are more accurate noninvasive options and can be used to confirm cure.

Testing Modality Definitions

H. pylori Serologic Antibody Testing

SpecimenSerum

What it detectsImmunoglobulin G (IgG) antibodies specific to H. pylori

LimitationCannot distinguish active infection from past infection

Test-of-cure useCannot be used as a test of cure

Urea Breath Test

Test typeNoninvasive

MethodIngestion of urea labeled with the nonradioactive isotope carbon 13 or carbon 14

Not Covered Services

The following are not covered as medically necessary: H. pylori serology or antibody testing for diagnosing infection, and H. pylori serology or antibody testing for evaluating treatment effectiveness or confirming cure.