Provide PA/supporting documentation to demonstrate medical necessity

Prior authorization or supporting documentation may be required to show that the requested test meets the policy's medically necessary criteria for the listed CPT/PLA codes for GI pathogen panels and H. pylori testing. Ensure PA (or accompanying documentation) demonstrates outpatient presentation, the applicable clinical features (e.g., immunocompromised status, recent travel, dysentery, fever, dehydration, abdominal pain, bacteremia, diarrhea >7 days, or symptoms of enteric fever) and that test results will influence management.

• PA should reference the specific CPT/PLA code(s) applicable to the ordered test.
• Include clinical details that map to the policy criteria (see criteria for ≤11-target, ≥12-target panels and H. pylori indications).

Select CPT/unique codes from the updated CPT code table for PA and claims

Use CPT and unique codes from the policy's CPT code table on prior authorization requests and claims; do not rely on codes removed from the reference table. Select codes that match the panel target count (e.g., codes describing 3–5 targets versus 12–25 targets) and the specific test type.

• Match panel target count to the CPT code description (≤11 targets vs 12+ targets guidance in the policy).
• Reference the policy's CPT code table and coding implications when submitting PA or claims.

Document outpatient presentation and qualifying clinical indication

Document the outpatient clinical presentation and the specific clinical indication(s) that meet the policy criteria when ordering multiplex GI panels or H. pylori antigen/urea breath tests to support coverage decisions.

• For GI panels, document setting (outpatient), at least one qualifying clinical feature and that results will influence management.
• For H. pylori antigen/urea breath tests, document the applicable indication group (A–G) per policy.

Record test details and clinical impact in the medical record

Include exact test details and code-selected descriptions on the request and in the medical record so reviewers can confirm the ordered test aligns with policy criteria and the CPT table.

• State the specific test performed (e.g., multiplex GI panel with X targets or H. pylori urea breath/stool antigen).
• When applicable, state how results will influence clinical management.

Retain clinical documentation supporting indication and allowable testing frequency

Maintain documentation showing the outpatient setting, the clinical features that satisfy the applicable coverage criteria, and that testing frequency adheres to policy limits (once per incident or ≤14 days for panels).

• For panels: document that testing is being done for an outpatient with suspected infectious gastroenteritis and at least one qualifying clinical feature; record that test results will impact management.
• For repeat testing: document incident timing to show testing is no more than once per incident or within a 14-day period.

Use the updated CPT code table and coding implications section when selecting codes

Reference and use the policy's updated CPT code table and the 'Coding Implications' section for accurate code descriptions and submission guidance; providers and laboratories should rely on the updated table when selecting codes.

• The policy reorganized coding into a CPT code table and moved the coding implications section—use these updated sections for code selection.
• Verify code descriptions against the policy's CPT table before submitting claims or PA requests.

Ordering tests for indications outside criteria risks denial as investigational

Tests ordered for indications outside the policy's listed medically necessary criteria (for multiplex GI panels and H. pylori urea breath/stool antigen tests) are considered investigational and may be denied.

• Examples of non-covered uses include multiplex panels for indications not listed in the policy and H. pylori antibody testing (investigational for all indications).
• Repeat testing more frequently than once per incident or within 14 days may also trigger denial.

Using removed or mismatched codes may trigger denials or coding corrections

Claims submitted with CPT/unique codes that are not listed in the policy's updated CPT table or that use removed/deprecated codes (for example, codes removed or corrected in the policy such as 0369U) may be denied or returned for coding correction.

• Do not submit claims using codes removed from the policy's coding table; verify the current accepted codes in the policy before billing.
• If a lab or provider previously used a removed code, update to the corresponding current CPT/PLA code in the policy table.