Modifiedblue cross blue shield - louisianaPolicy AHS - G2044

Helicobacter pylori Testing

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Coverage criteria for diagnostic and post-treatment testing for Helicobacter pylori infection, including which test types are covered or not and age- or indication-specific limitations, for Blue Cross Blue Shield of Louisiana members.

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Modifiedblue cross blue shield - louisianaPolicy AHS - G2044

Helicobacter pylori Testing

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Policy Summary

PayerBlue Cross Blue Shield - Louisiana

PolicyHelicobacter pylori Testing

Policy CodePolicy AHS - G2044

Change TypeCoverage criteria modifications and clarifying notes

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review DateAug 1, 2026

Key ActionDocument indication and timing and use UBT or stool antigen testing for diagnosis or post-treatment confirmation per covered indications.

SourceLink

POLICY UPDATE CHANGES

Modifications to coverage criteria on 09/01/2025 included clarity edits to CC1-CC4 and reordering/removing several former criteria; added/renamed criteria items (examples: changed 'dyspeptic' to 'dyspepsia (see Note 1)'; removed former CC2; moved follow-up testing to new CC5).

Added Note 1 (definition of dyspepsia) and Note 2 (alarm features of dyspepsia).

Updated the background, guidelines and evidence-based scientific references; literature review did not necessitate modifications to coverage criteria on 08/01/2026.

Off-cycle coding modification: Added CPT code 87513.

08/01/2026most recent review/approval date

09/01/2025coverage-criteria modifications date

>=4 wksminimum post-treatment interval

Not coveredserology stance

>=6recommended biopsies

Coverage Criteria for H. pylori Testing

Medically necessary / Covered indications

Covered when ALL of the following age- and indication-specific conditions are met (policy separates adult and pediatric criteria):

Adults (>=18) non-endoscopic testing: Urea breath testing or stool antigen testing MEETS COVERAGE CRITERIA when the individual is 18 years of age or older AND one of: dyspepsia (see Note 1); active peptic ulcer disease; past peptic ulcer disease with recurrent symptoms; low-grade gastric MALT lymphoma; history of resection of early gastric cancer; gastric intestinal metaplasia; initiating chronic treatment with or who have been on long-term aspirin or nonsteroidal anti-inflammatory drug (NSAID) therapy; unexplained iron deficiency anemia; idiopathic thrombocytopenic purpura (ITP); family history of gastric cancer; or being a first-generation immigrant from a high-prevalence area.age >= 18

Adults (>=18) endoscopic testing: For individuals 18 years and older undergoing endoscopic examination or who have alarm symptoms (see Note 2), a biopsy-based endoscopic histology test AND either a rapid urease test OR culture with susceptibility testing MEETS COVERAGE CRITERIA for diagnosis of H. pylori infection.age >= 18 + endoscopy or alarm symptoms

Children (<18) non-endoscopic testing: For individuals less than 18 years of age, urea breath testing or stool antigen testing MEETS COVERAGE CRITERIA when the individual has gastric or duodenal ulcers or erosions OR has a family history of gastric cancer.age < 18

Children (<18) endoscopic testing: For individuals less than 18 years of age with refractory iron deficiency anemia, a biopsy-based endoscopic histology test AND either a rapid urease test OR culture with susceptibility testing MEETS COVERAGE CRITERIA for diagnosis of H. pylori infection.age < 18 + refractory iron deficiency anemia

Post-treatment eradication testing: For all individuals who have tested positive for H. pylori, urea breath testing or stool antigen testing to measure eradication MEETS COVERAGE CRITERIA when testing is performed at least four weeks post-treatment.>= 4 weeks post-treatment

Refractory infection: For individuals with refractory H. pylori infection, susceptibility testing (culture or nucleic acid based) MEETS COVERAGE CRITERIA.

Not medically necessary / Not covered

Not covered situations (tests DO NOT MEET COVERAGE CRITERIA):

Not covered: asymptomatic or GERD without PUD: Urea breath testing or stool antigen testing to diagnose H. pylori infection DOES NOT MEET COVERAGE CRITERIA for asymptomatic individuals of all ages OR for adults (>=18) with typical gastroesophageal reflux disease (heartburn, regurgitation) who do not have a history of peptic ulcer disease.

Not covered: serology: Serologic (antibody) testing for H. pylori infection DOES NOT MEET COVERAGE CRITERIA for individuals of all ages.

Not covered: pediatric contexts: For individuals <18 years, biopsy-based endoscopic histology AND rapid urease test or culture with susceptibility testing DOES NOT MEET COVERAGE CRITERIA when performed for children with functional abdominal pain, as part of initial investigation in children with iron deficiency anemia, or when investigating causes of short stature.

Not covered: recent medication use: In individuals with recent use of antibiotics, proton pump inhibitors (PPIs), or bismuth, the urea breath test, stool antigen test, or biopsy-based testing to diagnose H. pylori infection DOES NOT MEET COVERAGE CRITERIA due to risk of false negatives unless appropriate washout intervals have been observed.

Guideline-based indications

Covered when ANY of the following guideline-based indications are present (per ACG/ CAG, AGA, WGO and others):

Indications for testing per guidelines: Peptic ulcer disease (active or prior); gastric MALT lymphoma; uninvestigated dyspepsia below age thresholds specified by guidelines (eg, ACG: under 60 years; AGA: <=55 years without alarm features); prior endoscopic resection of early gastric cancer; unexplained iron deficiency anemia; idiopathic thrombocytopenic purpura; patients initiating or on long-term NSAIDs or low-dose aspirin; household contacts of infected individuals; persons at increased risk for gastric cancer (including certain non-White racial/ethnic groups, immigrants from high-incidence regions, and first-degree relatives of gastric cancer patients); gastric premalignant conditions (eg, intestinal metaplasia); and other guideline-specified high-risk groups.

Compiled from ACG/CAG, AGA, WGO and related guideline statements

Test-of-cure and modalities

Testing to confirm eradication (test-of-cure) and preferred methods:

Test-of-cure recommendations: Use urea breath test (preferably 13C-UBT) or stool antigen test to confirm eradication; NICE limits routine post-treatment retesting but recommends retesting for peptic ulcer patients 6–8 weeks after treatment. Pan-European guidance prefers 13C-UBT for confirmation when endoscopy is not required. Tests for active infection (UBT, stool antigen, or histology if endoscopy performed for other reasons) are recommended for post-treatment confirmation; serology should not be used for test-of-cure.

Includes modality preferences and timing considerations (washout periods)

Susceptibility testing after failed therapies

Actions for treatment-experienced or refractory H. pylori infection:

When to perform susceptibility testing: After two failed eradication therapies with confirmed patient adherence, consider H. pylori susceptibility testing (culture-based) or molecular resistance testing to guide subsequent regimens; molecular testing can be performed on archival gastric biopsy tissue or stool PCR assays that detect clarithromycin resistance mutations.

AGA recommends susceptibility testing after two failed therapies; PCR assays can predict clarithromycin resistance and inform therapy selection

Pediatric diagnostic standards

Pediatric recommendations (ESPGHAN/NASPGHAN):

Pediatric testing and biopsy requirements: For children (<18 years), testing for H. pylori should be performed in children with gastric or duodenal ulcers/erosions via endoscopy with gastric biopsy; obtain at least six gastric biopsies (three from corpus and three from antrum) and use culture or molecular tests plus histopathology per the Sydney system. Noninvasive testing is generally not recommended for many pediatric indications (eg, functional abdominal pain, initial evaluation of iron deficiency anemia, causes of short stature); children with a first-degree relative with gastric cancer may be considered for noninvasive testing. Wait at least 2 weeks after stopping PPIs and 4 weeks after stopping antibiotics and bismuth salts before invasive or noninvasive testing.

Reflects ESPGHAN/NASPGHAN guidance including biopsy count and washout timing

Medically Necessary Testing

Covered when clinical indications or consensus recommendations support testing for active H. pylori infection

Approved indications (consensus): Testing is recommended for patients with active H. pylori infection and for patients with current or past gastric or duodenal ulcers, uninvestigated dyspepsia, MALT lymphoma, family history of gastric cancer, first-generation immigrants from high-prevalence areas, and other situations where testing will inform treatment; expert consensus recommends treating all patients with active infection and using tests for active infection for diagnosis and confirmation of eradication.

Summarizes Houston Consensus and other guideline statements

Pediatric specific: In children, testing is recommended for those with gastric or duodenal ulcers/erosions; diagnostic testing is not indicated for functional abdominal pain/DGBI, short stature, or as routine screening in high-risk racial/ethnic groups living in North America/Europe. Consider testing children with a first-degree relative with gastric cancer and treat/confirm eradication when infection is identified in ulcer cases.

From ESPGHAN/NASPGHAN guidance

Diagnostic Method Criteria

Preferred diagnostic approaches and confirmation

Test selection and confirmation: Use tests for active infection (UBT, stool antigen, or biopsy-based active tests) for initial diagnosis and post-treatment confirmation; UBT (13C) is the recommended noninvasive test and monoclonal stool antigen tests are acceptable alternatives. Do not use serology to detect active infection or for test-of-cure.

From Houston Consensus, Maastricht, and pediatric guidance

Biopsy requirements: When endoscopy is performed, obtain at least six gastric biopsies (three corpus, three antrum) and use culture/molecular testing plus histopathology according to the Sydney system for biopsy-based diagnosis; perform susceptibility testing when indicated (eg, refractory infection).

Reflects ESPGHAN/NASPGHAN and other guideline statements

Not Recommended / Discouraged Testing

Testing that is not indicated or discouraged

Pediatric not recommended tests: Do not perform diagnostic testing (invasive or noninvasive) for H. pylori in children with functional abdominal pain/DGBI; avoid stool molecular tests or culture for detection or susceptibility in children; avoid noninvasive testing as the initial evaluation for iron deficiency anemia in children (unless endoscopy indicated after failed therapy).

ESPGHAN/NASPGHAN recommendations

Serology discouraged: Serological tests (including rapid office serology) are not recommended for detection of active H. pylori infection and should not be used to confirm eradication except when a locally validated laboratory serology is explicitly indicated; avoid serology for diagnosis and test-of-cure.

Houston Consensus, Maastricht, and pediatric guidance

Serologic testing for H. pylori is expressly excluded: serologic (antibody) tests DO NOT MEET COVERAGE CRITERIA for individuals of all ages. The policy further limits coverage for nucleic acid testing: nucleic acid testing (NAAT) for H. pylori does not meet coverage criteria except where specifically described (for example, nucleic acid–based susceptibility testing for refractory infection). Concurrent use of multiple diagnostic modalities (e.g., UBT plus stool antigen and/or biopsy) to diagnose infection is also not covered.

Coverage is limited to the indications and test types listed in the policy; tests ordered outside those indications (including serology and NAAT except as allowed above) may be denied.

Routine testing of asymptomatic individuals is discouraged: guideline statements do not support general population screening, and the policy specifies that urea breath testing (UBT) or stool antigen testing to diagnose H. pylori infection does NOT MEET COVERAGE CRITERIA for asymptomatic individuals of all ages. For pediatric practice, noninvasive testing is limited—ESPGHAN/NASPGHAN recommend testing primarily in children with gastric or duodenal ulcers/erosions and advise against noninvasive testing in many other pediatric contexts (for example, functional abdominal pain and initial evaluation of iron deficiency anemia).

Office-based serologic tests are not recommended by NICE and should be avoided as a routine diagnostic or screening modality.

The policy aligns with pediatric guidance that advises against routine screening of certain high‑risk racial/ethnic pediatric groups living in low‑incidence regions: ESPGHAN/NASPGHAN recommend against screening children from racial/ethnic groups at increased risk for gastric cancer who are living in North America or Europe. Testing in children should be indication‑driven (e.g., ulcers, family history of gastric cancer), not performed as population screening.

Nucleic acid testing (NAAT) for H. pylori is explicitly restricted: NAAT DOES NOT MEET COVERAGE CRITERIA except where specifically described in this policy (for example, nucleic acid–based susceptibility testing is allowed for refractory H. pylori infection). For all other situations not described as covered, nucleic acid testing does not meet coverage criteria and is excluded.

Urea breath test (UBT) or stool antigen testing is not covered for asymptomatic adults or for adults with typical GERD symptoms without a history of peptic ulcer disease: the policy states that UBT or stool antigen testing to diagnose H. pylori infection DOES NOT MEET COVERAGE CRITERIA for asymptomatic individuals and for adults with typical GERD symptoms without a history of PUD. NICE similarly limits retesting and does not recommend routine post‑treatment testing except in selected peptic ulcer cases, reinforcing that non‑indicated testing in low‑risk presentations is not appropriate.

NICE guidance is reflected in the policy: office‑based serological tests are not recommended for diagnosis, and NICE advises limited retesting after treatment rather than routine test‑of‑cure for all patients. The policy therefore restricts routine use of serology for diagnosis or confirmation of eradication and emphasizes use of UBT or stool antigen testing when test‑of‑cure is indicated (with recommended timing and washout intervals described elsewhere in the policy).

Diagnostic testing (invasive or noninvasive) is not indicated for children with functional abdominal pain or disorders of gut–brain interaction (DGBI): ESPGHAN/NASPGHAN recommend against testing for H. pylori in children with functional abdominal pain/DGBI, and the policy lists biopsy‑based histology plus RUT or culture as not meeting coverage in this pediatric subgroup. Testing in children should be reserved for clear indications such as ulcers or a relevant family history.

To restate the policy position: nucleic acid testing for H. pylori is not covered for situations not specifically described as allowed in this document. The policy permits nucleic acid–based susceptibility testing only in the covered circumstance of refractory H. pylori infection; otherwise NAAT is excluded and will not meet coverage criteria.

Selected Covered Indications (referenced in revision history)

Coverage criteria updates and notable covered indications referenced in the revision history include:

Selected covered indications referenced: - Urea breath testing or stool antigen testing meets coverage for individuals (including pediatrics per 01/01/2025 note) with gastric or duodenal ulcers or erosions and for individuals with a family history of gastric cancer. - For individuals <18 years with refractory iron deficiency anemia, biopsy-based endoscopic histology with rapid urease test or culture with susceptibility testing meets coverage. - For all individuals who tested positive for H. pylori, urea breath testing or stool antigen testing to confirm eradication performed at least 4 weeks post-treatment meets coverage. - For refractory H. pylori infection, susceptibility testing (culture or nucleic acid based) meets coverage.

Synthesized from revision history entries (01/01/2025 and 09/01/2025).

Applicable Procedure and Test Codes

Covered CPT Codes (tests, culture, susceptibility)CPTCovered

83009	Helicobacter pylori, blood test analysis for urease activity, non-radioactive isotope (eg, C-13).
83013	Helicobacter pylori; breath test analysis for urease activity, non-radioactive isotope (eg, C-13).
83014	Helicobacter pylori; drug administration.
86677	Antibody; Helicobacter pylori.
87077	Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates.
87149	Culture, typing; identification by nucleic acid (DNA or RNA) probe, direct probe technique, per culture or isolate, each organism probed.
87150	Culture, typing; identification by nucleic acid (DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed.
87153	Culture, typing; identification by nucleic acid sequencing method, each isolate (eg, sequencing of the 16S rRNA gene).
87181	Susceptibility studies, antimicrobial agent; agar dilution method, per agent (eg, antibiotic gradient strip).
87186	Susceptibility studies, antimicrobial agent; microdilution or agar dilution (minimum inhibitory concentration [MIC] or breakpoint), each multi-antimicrobial, per plate.

Covered CPT Codes (stool antigen, NAAT)CPTCovered

87338	Infectious agent antigen detection by immunoassay technique; Helicobacter pylori, stool.
87339	Infectious agent antigen detection by immunoassay technique; Helicobacter pylori.
87513	Infectious agent detection by nucleic acid (DNA or RNA); Helicobacter pylori (H. pylori).

Pathology and Proprietary Testsmixed

Level IV	Surgical pathology, gross and microscopic examination - Stomach biopsy (H. pylori detection).
Proprietary test	AmHPR H. Antibiotic Resistance Panel - NGS for H. pylori resistance (American Molecular Laboratories, Inc).

Added CPT CodesCPT

87513

CPT code added (document notes off-cycle coding modification)

Gastric biopsy count — recommended sampling

Recommended biopsy countObtain at least six gastric biopsies during upper endoscopy: three from the corpus and three from the antrum.

PurposeProvides adequate sampling for histopathology, culture, and molecular testing per Sydney system guidance.

ContextSpecifically recommended for pediatric endoscopic diagnosis of H. pylori (ESPGHAN/NASPGHAN).

PPI/antibiotic hold time — recommended washout intervals before testing

PPI hold timeDiscontinue proton pump inhibitors at least 2 weeks before testing for active H. pylori infection.

Provider Actions, Documentation, and Billing Guidance

Prior Authorization

Coverage limited to listed indications

Coverage is limited to the indications and test types listed in the policy; tests ordered outside those indications — including serologic testing for H. pylori, nucleic acid testing except where specifically allowed (e.g., susceptibility testing for refractory infection), or concurrent use of multiple diagnostic modalities — DO NOT MEET COVERAGE CRITERIA and may be denied.

Serologic testing for H. pylori infection DOES NOT MEET COVERAGE CRITERIA for individuals of all ages (see chunk 5).
Concurrent testing with any combination of UBT, stool antigen, and/or biopsy-based testing to diagnose H. pylori infection DOES NOT MEET COVERAGE CRITERIA (see chunk 5).
Nucleic acid testing for H. pylori DOES NOT MEET COVERAGE CRITERIA except where specifically described as covered (e.g., susceptibility testing for refractory infection) (see chunks 4 and 5).

Note

Guideline-informed utilization (no explicit PA)

The policy does not specify an explicit prior authorization process; utilization expectations are driven by guideline-based indications and the policy's listed coverage criteria, including expectations for sequencing (e.g., susceptibility testing after failed regimens).

Background and Evidence Summary

Background: Helicobacter pylori is a common gram-negative bacterium associated with peptic ulcer disease, chronic gastritis, gastric adenocarcinoma, and mucosa-associated lymphoid tissue (MALT) lymphoma. Testing is performed to identify active infection to guide eradication therapy and to confirm eradication after treatment; appropriate test selection depends on age, clinical presentation, prior medication exposure, and the clinical question (diagnosis versus test-of-cure).

92%QUIK CHEK stool EIA sensitivity

91%H. PYLORI CHEK stool EIA sensitivity

524PCR study sample size (stool samples)

>=6Recommended gastric biopsies (3 antrum + 3 corpus)

A Clinical Advisory Board reviewed the policy on 03/18/2026 and the literature update completed on 08/01/2026 did not necessitate changes to the coverage criteria. The revision history documents the review and confirms that the literature review supported the existing coverage stance.

Notes were added to clarify pediatric guidance and to define alarm features: Note 1 defines dyspepsia symptoms to support coverage decisions, and Note 2 lists alarm features (vomiting, gastrointestinal bleeding, unexplained iron deficiency, or weight loss). These additions provide context for pediatric testing recommendations and for identifying patients who require endoscopic evaluation.

Definitions and Key Terms

Key terms and acronyms

UBTUrea breath test (UBT).

SATStool antigen test (SAT).

RUTRapid urease test (RUT).

PUDPeptic ulcer disease (PUD).

MALTMucosa-associated lymphoid tissue (MALT).

Clarithromycin resistance — mechanism and common mutations

MechanismClarithromycin resistance is most commonly caused by point mutations in the 23S rRNA gene that reduce macrolide binding to the ribosomal subunit.

Policy Revisions and Review Dates

2026-08-01review/approvalLatest

Clinical Advisory Board review and policy approval; updated background, guidelines, and evidence references without changes to coverage criteria.

2025-09-01material_change

Modifications to coverage criteria including clarity edits and reordering/removal of several criteria items (CC1–CC4 edits, removal of former CC2, renumbering and addition of criteria CC5 and CC6; wording changes such as 'dyspeptic' to 'dyspepsia' and other item-specific edits).

2025-01-01

Policy Summary

PayerBlue Cross Blue Shield - Louisiana

PolicyHelicobacter pylori Testing

Policy CodePolicy AHS - G2044

Change TypeCoverage criteria modifications and clarifying notes

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review DateAug 1, 2026

Key ActionDocument indication and timing and use UBT or stool antigen testing for diagnosis or post-treatment confirmation per covered indications.

SourceLink

On This Page

Not covered: concurrent testing: Concurrent testing with any combination of urea breath test, stool antigen testing, and/or biopsy-based testing to diagnose H. pylori infection DOES NOT MEET COVERAGE CRITERIA.

Not covered: nucleic acid testing (general): For all other situations not described as covered, nucleic acid testing for H. pylori DOES NOT MEET COVERAGE CRITERIA (nucleic acid testing is only permitted where specifically described as covered, e.g., susceptibility testing for refractory infection).

Antibiotics and bismuth hold time

Discontinue antibiotics and bismuth-containing compounds at least 4 weeks before testing.

RationaleWashout intervals reduce false-negative results for UBT, stool antigen, and biopsy-based testing.

Guideline recommendations (ACG/AGA) inform which patients should be tested and when susceptibility testing is appropriate (see chunks 27–28).
Providers should follow payer-specific prior authorization processes if the payer requires PA for listed procedure codes (see coding sections).

Billing Rule

Procedure code considerations

When ordering tests, submit the procedure codes listed in the policy that correspond to the performed test(s) or culture/susceptibility method; use the appropriate CPT/HCPCS code(s) from the policy's coding table.

Refer to the policy's applicable CPT/HCPCS codes (e.g., 83009, 83013, 87338, 87339, 87513, 86677, 87077, 87149, 87150, 87153, 87181, 87186) when selecting codes for claims (see chunks 49–50).
Ensure codes reflect the specific modality used (UBT, stool antigen EIA, culture, sequencing, susceptibility testing).

Billing Rule

Coding update — use CPT 87513 where applicable

An off-cycle coding modification added CPT code 87513; providers should use this updated code for nucleic acid detection of H. pylori (and related resistance reporting) when submitting claims.

CPT 87513 is listed in the policy's coding table and noted as added in the revision history (see chunk 63).

Step Therapy

Susceptibility-guided therapy — perform for refractory cases

Susceptibility testing (culture or nucleic-acid–based) is covered for individuals with refractory H. pylori infection and should be considered to guide therapy, particularly when clarithromycin-based therapy is being contemplated.

The policy states susceptibility testing MEETS COVERAGE CRITERIA for refractory H. pylori infection (chunk 4).
PCR and molecular testing can detect clarithromycin resistance and the ACG/other guidelines suggest susceptibility-guided therapy when resistance is suspected or when clarithromycin-based therapy is considered (chunk 19).

Step Therapy

Obtain susceptibility testing after two failed regimens

Follow guideline guidance to perform susceptibility testing after two failed eradication regimens with confirmed adherence; molecular resistance testing on archival biopsy or stool PCR are acceptable approaches to guide subsequent therapy.

AGA recommends H. pylori susceptibility testing after two failed therapies with confirmed adherence (chunk 23).
Molecular resistance testing can be performed on archival formalin-fixed paraffin-embedded gastric biopsy tissue or stool PCR assays to inform treatment selection (chunks 23 and 19).

Prior Authorization

Post-treatment confirmation — test >=4 weeks after therapy

When treatment is given, confirm eradication using tests for active infection — urea breath test, stool antigen test, or histology if endoscopy is performed — with testing performed at least four weeks after completion of therapy.

Policy requires post-treatment testing at least four weeks after therapy to measure success of eradication (chunk 4).
Guidelines (Maastricht V) recommend UBT as the best option for confirmation and monoclonal stool antigen as an alternative, performed at least four weeks after completion of therapy (chunk 39).

Documentation Required

Document indication and patient age

Document the clinical indication that matches a covered situation (e.g., dyspepsia per Note 1, active or past PUD, MALT lymphoma, family history of gastric cancer, first-generation immigrant from high-prevalence area) and record patient age to support coverage.

Coverage criteria list age- and indication-specific scenarios; include the applicable indication and the patient's age on the order or chart (chunks 3–4).
Refer to Note 1 (dyspepsia definition) and Note 2 (alarm features) when documenting dyspepsia or alarm symptoms (see revision history chunks 62–63).

Documentation Required

Document prior therapy, adherence, and test modality

For testing in the context of treatment or prior therapy, document prior eradication regimens, adherence, and the chosen test modality (UBT, stool antigen, biopsy-based), so coverage decisions and susceptibility needs can be supported.

Record prior therapies and adherence when requesting susceptibility testing or repeat testing after treatment failures (chunk 23).
Document the selected noninvasive or biopsy-based test modality (chunk 22).

Documentation Required

Document indication and pre-test preparation

Include documentation of the specific covered indication and any required pre-test preparation (e.g., PPI/antibiotic discontinuation), and note the purpose of testing (diagnosis vs test-of-cure) on orders and reports.

Support indication for testing (active infection, PUD, uninvestigated dyspepsia, family history of gastric cancer, etc.) in clinical notes or test orders (chunk 43).
Record timing of PPI and antibiotic discontinuation prior to testing as part of preparation documentation (chunk 37).

Documentation Required

Reference policy notes (dyspepsia and alarm features) in documentation

When documenting clinical rationale, reference Note 1 (definition of dyspepsia) and Note 2 (alarm features) where applicable, since these notes were added to clarify covered dyspepsia and alarm-feature criteria.

Note 1 defines dyspepsia and was added to support criteria language (chunk 62).
Note 2 lists alarm features (vomiting, GI bleeding, unexplained iron deficiency, weight loss) relevant to endoscopic coverage (chunk 63).

Denial Risk

Denial risk — testing in asymptomatic individuals or typical GERD

Urea breath test or stool antigen testing to diagnose H. pylori infection for asymptomatic individuals (all ages) or adults with typical GERD symptoms without a history of PUD does NOT MEET COVERAGE CRITERIA and may be denied.

The policy explicitly states these diagnostic tests DO NOT MEET COVERAGE CRITERIA for asymptomatic individuals and for adults with typical GERD symptoms without PUD history (chunk 5).

Denial Risk

Washout requirements — ensure PPIs/antibiotics stopped per guidance

Observe recommended washout intervals for PPIs (at least 2 weeks) and antibiotics/bismuth (at least 4 weeks) before noninvasive or biopsy-based testing; failure to do so can invalidate results and may lead to denial or need for repeat testing.

NICE and ESPGHAN/NASPGHAN recommend waiting at least 2 weeks after stopping PPIs and 4 weeks after stopping antibiotics/bismuth before testing (chunks 31 and 37).
Policy notes tests performed in individuals with recent use of antibiotics, PPIs, or bismuth DO NOT MEET COVERAGE CRITERIA due to false-negative risk (chunk 5).

Denial Risk

Defer to applicable government (LCD/NCD) policies when conflicts exist

If there is a conflict between this policy and any applicable government coverage (LCDs/NCDs), the government policy takes precedence; failure to follow an applicable government determination may trigger denial.

The policy states that applicable government policies (LCDs/NCDs) will be used to make determinations when conflicts exist (chunk 46).

Denial Risk

Nucleic acid testing exclusion reminder

Nucleic acid testing for H. pylori is not covered for situations not explicitly described as covered in the policy; use nucleic acid testing only where the policy specifically allows it (e.g., susceptibility testing for refractory infection).

The revision history and policy state that for all other situations not described as covered, nucleic acid testing for H. pylori DOES NOT MEET COVERAGE CRITERIA (chunk 62).

Common mutationsRepresentative 23S rRNA point mutations include A2143G, A2142G, and A2142C.

Clinical impactPredicted clarithromycin resistance is associated with lower success of clarithromycin-based triple therapy, supporting susceptibility-guided treatment decisions.

UBT — definition and role

DefinitionUrea breath test (UBT) is a noninvasive test that detects urease activity indicative of active H. pylori infection.

Role in careRecommended as the preferred noninvasive test for initial diagnosis and for confirmation of eradication after therapy.

Timing for test-of-curePerform UBT at least four weeks after completion of therapy to confirm eradication.

Biopsy-based diagnosis and Sydney system guidance

Biopsy-based diagnosisDiagnosis should be gastric biopsy–based using culture or molecular tests plus histopathology per the Sydney system.

Biopsy sampling guidanceObtain at least six biopsies (three antrum, three corpus) when performing endoscopic diagnosis.

Use of testsWhen endoscopy is indicated, combine histology with RUT or culture (with susceptibility) as appropriate.

Dyspepsia (Note 1) — definition

DefinitionDyspepsia refers to bothersome upper abdominal symptoms often meal related, including postprandial fullness, early satiety, or epigastric pain/burning.

Symptom notesPain is not required for diagnosis; chronic dyspepsia may present with less epigastric pain and more postprandial fullness or early satiety.

Policy useNote 1 defines dyspepsia for coverage criteria where uninvestigated dyspepsia is an indication to test in specified age groups.

Alarm features (Note 2)

Alarm features listVomiting, gastrointestinal bleeding, unexplained iron deficiency, or weight loss.

ContextThese alarm features (Note 2) are used in the policy to identify patients who may require endoscopic evaluation and biopsy-based testing.

ImplicationPresence of any alarm feature supports use of endoscopic testing modalities rather than routine noninvasive testing.

Added/clarified pediatric coverage language and new coverage items for post-treatment eradication testing (test-of-cure at >=4 weeks) and susceptibility testing for refractory infection; added Note 1 (dyspepsia definition) and Note 2 (alarm features).

2024-10-01administrative_update

Literature review performed; policy edited for clarity and consistency without changes to coverage criteria.

2023-06-01administrative_update

Literature review performed; policy edited for clarity and consistency without changes to coverage criteria.

An off-cycle coding modification was recorded in the revision history: CPT code 87513 was added. The entry notes this coding update alongside the documented clinical advisory review.