CurrentBlue Cross Blue Shield - IllinoisPolicy CPCPLAB025

Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing

Defines BCBSIL reimbursement criteria for fecal testing related to diagnosis of intestinal dysbiosis and pre-donation screening for fecal microbiota transplantation; applies to providers submitting claims to Blue Cross Blue Shield of Illinois.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyFecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing

Policy CodePolicy CPCPLAB025

Change TypeNo material changes

Effective DateSep 25, 2025

Next Review Date

Key ActionSubmit accurate documentation and appropriate procedure codes when filing claims for fecal testing or FMT donor screening.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7 targetsreimbursable culture organisms

8 targetsreimbursable NAAT organisms

≥14 itemsnon-reimbursable analytes

20 codesexample procedure codes

01/01/2026plan effective date

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage criteria for fecal analyses and FMT donor testing

Coverage criteria for FMT donor testing and diagnostic fecal analyses

Coverage determinations described below apply to donor screening for fecal microbiota transplantation (FMT) and to use of fecal analyses as diagnostic tests for intestinal dysbiosis and related conditions.

ALL of the following

organisms (culture)
- Extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae
- Vancomycin-resistant Enterococci (VRE)
- Carbapenem-resistant Enterobacteriaceae (CRE)
- Methicillin-resistant Staphylococcus aureus (MRSA)
- Campylobacter
- Shigella
- Salmonella

ALL of the following

organisms (NAAT reimbursable)
- Clostridium difficile
- Campylobacter
- Salmonella
- Shigella
- Shiga toxin-producing Escherichia coli
- Norovirus

ALL of the following

NAAT not reimbursable
- Extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae
- Vancomycin-resistant Enterococci (VRE)
- Carbapenem-resistant Enterobacteriaceae (CRE)
- Methicillin-resistant Staphylococcus aureus (MRSA)
- Any other microorganisms not listed as reimbursable

ALL of the following

non-reimbursable diagnostic analytes
- Triglycerides
- Chymotrypsin
- Iso-butyrate, iso-valerate, and n-valerate
- Meat and vegetable fibers
- Long chain fatty acids
- Cholesterol

ALL of the following

Provided procedure and test codes may be used for claim submission but inclusion does not guarantee coverage; claims remain subject to member plan documents, provider contract, clinical payment and coding policies, and code edit protocols.
Not all requirements apply to every product; providers should review specific member plan documents to determine eligible coverage.

Provider actions, prior authorization, and claims submission

Prior Authorization

Prior authorization / pre-donation testing guidance for FMT donor screening

Prior to donation for a fecal microbiota transplant (FMT), providers may seek reimbursement for specific pre-donation bacterial culture and NAAT analyses of donor fecal samples. Bacterial culture may be reimbursed for ESBL-producing Enterobacteriaceae; VRE; CRE; MRSA; Campylobacter; Shigella; and Salmonella. NAAT may be reimbursed for Clostridium difficile; Campylobacter; Salmonella; Shigella; Shiga toxin-producing E. coli; Norovirus; Rotavirus; and COVID-19 (SARS‑CoV‑2). NAAT for ESBL-producing Enterobacteriaceae, VRE, CRE, MRSA, and any organisms not listed as reimbursable is not reimbursable.

Culture reimbursable targets: Extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae; Vancomycin‑resistant Enterococci (VRE); Carbapenem‑resistant Enterobacteriaceae (CRE); Methicillin‑resistant Staphylococcus aureus (MRSA); Campylobacter; Shigella; Salmonella.
NAAT reimbursable targets: Clostridium difficile; Campylobacter; Salmonella; Shigella; Shiga toxin‑producing Escherichia coli; Norovirus; Rotavirus; COVID‑19 (SARS‑CoV‑2).
NAAT not reimbursable for: ESBL-producing Enterobacteriaceae; VRE; CRE; MRSA; and any other microorganisms not listed as reimbursable.

Example relevant procedure and billing codes

Example relevant procedure codesmixed

82542
82705
82710
82715
83986
84311
87045
87046
87075
87076

1–10 of 20

1/2

Definitions — reimbursable targets and non-reimbursable analytes

Reimbursable FMT donor culture targets

ESBL-producing EnterobacteriaceaeReimbursable target for bacterial culture of donor fecal samples prior to FMT

Vancomycin-resistant Enterococci (VRE)Reimbursable target for bacterial culture of donor fecal samples prior to FMT

Carbapenem-resistant Enterobacteriaceae (CRE)Reimbursable target for bacterial culture of donor fecal samples prior to FMT

Methicillin-resistant Staphylococcus aureus (MRSA)Reimbursable target for bacterial culture of donor fecal samples prior to FMT

CampylobacterReimbursable target for bacterial culture of donor fecal samples prior to FMT

ShigellaReimbursable target for bacterial culture of donor fecal samples prior to FMT

Documentation Required

Documentation and claims submission requirements

Providers must submit accurate documentation and appropriate codes for fecal testing claims; claims remain subject to member plan documents, provider contract terms, clinical payment and coding policies, and code edit protocols. Upon request, providers should supply additional documentation to support the claim.

Submit claims using valid HIPAA-approved code sets and code combinations consistent with CPT, HCPCS, ICD-10, and other industry coding guidelines.
Claims are subject to code edit protocols, claim review, plan benefit terms, provider contract language, medical policies, and coding software logic; inclusion of a procedure code does not guarantee coverage.
Be prepared to provide additional documentation upon request to support medical necessity and correct coding.

Non-reimbursable diagnostic fecal analyses

TriglyceridesFecal triglyceride analysis used diagnostically for dysbiosis/IBS/malabsorption is not reimbursable

ChymotrypsinFecal chymotrypsin analysis used diagnostically for dysbiosis/IBS/malabsorption is not reimbursable

Iso-butyrate, iso-valerate, n-valerateThese fecal short/branched chain fatty acids are not reimbursable when used diagnostically

Meat and vegetable fibersAnalysis of meat and vegetable fibers in feces for dysbiosis/IBS evaluation is not reimbursable

Long chain fatty acids / Cholesterol / Total short chain fatty acidsThese lipid and fatty acid measurements in feces are not reimbursable for diagnostic evaluation

Quantification of Lactobacilli, bifidobacteria, E. coli and other potential pathogensMicrobial quantification (including Aeromonas, Bacillus cereus, Campylobacter, Citrobacter, Klebsiella, Proteus, Pseudomonas, Salmonella, Shigella, S. aureus, Vibrio) is not reimbursable

Fecal yeast identification and quantitationIdentification/quantitation of fecal yeast (e.g., C. albicans, C. tropicalis, Rhodotorula, Geotrichum) is not reimbursable

N-butyrate, Beta-glucuronidase, pH, Short chain fatty acid distribution, Fecal secretory IgAThese analytes and distributions used diagnostically for intestinal dysbiosis/IBS are not reimbursable