CurrentBlue Cross Blue Shield - MassachusettsPolicy BCBSA Reference Number: 2.04.69

Fecal calprotectin testing

Defines medical necessity criteria, coding, prior authorization, and investigational exclusions for fecal calprotectin testing for Commercial and Medicare members, including use for diagnosis when endoscopy is being considered and for management/monitoring of inflammatory bowel disease; home-based and concurrent lactoferrin testing positions are specified.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyFecal calprotectin testing

Policy CodePolicy BCBSA Reference Number: 2.04.69

Change TypeRevised (3/1/2024)Coding clarified (10/2025)

Effective Date3/1/2024

Next Review Date

Key ActionWhen CPT code 83993 is billed, include an ICD-10 diagnosis from the policy list that supports medical necessity and follow product-specific prior authorization requirements (inpatient precertification required).

SourceLink

POLICY UPDATE CHANGES

Policy revised to include medically necessary indications for fecal calprotectin testing in the management of bowel disease, active inflammatory bowel disease and surveillance for relapse of disease in remission.

Coding information clarified.

3Covered indications

1Investigational indications

1CPT codes listed

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This policy addresses medical necessity, coding, and prior authorization for fecal calprotectin testing to evaluate and manage inflammatory bowel disease (IBD). It applies to diagnostic use when the differential includes IBD versus noninflammatory conditions and endoscopy with biopsy is being considered, and to management/monitoring of bowel disease including active IBD and surveillance for relapse. A commonly used cutoff is 50 µg/g, and this threshold is the usual lower bound for adults and children older than 4 years.

Policy quick facts

Policy numberBCBSA Reference Number: 2.04.69

StatusCURRENT

Last review date2024-03-01

Effective dateEffective 3/1/2024

Scope summaryDefines medical necessity criteria, coding, prior authorization, and investigational exclusions for fecal calprotectin testing including diagnosis when endoscopy is being considered and for management/monitoring of IBD; home-based and concurrent lactoferrin testing positions specified.

Fecal calprotectin cutoff50 µg/g (commonly used lower bound for adults and children >4 years)

Moderate increase in older adults (>65 years)Up to 100 µg/g

Diagnostic accuracy studies using a cutoff near 50 µg/g report high sensitivity (about 93%–99%) and a wide negative predictive value (73%–100%), supporting its use to triage patients for endoscopy. Incorporating fecal calprotectin into workups has been shown in analyses to reduce the need for colonoscopy by about two-thirds in some studies. Meta-analyses report pooled sensitivity around 78% for predicting relapse in patients with quiescent IBD, supporting use in surveillance/monitoring.

Medical-Necessity Criteria

Medically Necessary - Diagnostic Evaluation

Fecal calprotectin testing is considered MEDICALLY NECESSARY when ALL of the following are met:

ALL of the following

Differential diagnosis includes inflammatory bowel disease (IBD) versus noninflammatory bowel disease (including irritable bowel syndrome) AND endoscopy with biopsy is being considered

Medically Necessary - Management / Monitoring

Fecal calprotectin testing is considered MEDICALLY NECESSARY for the management of bowel disease when ANY of the following apply:

ANY of the following

Management of active inflammatory bowel disease
Surveillance for relapse of disease in remission (predicting relapse / monitoring disease activity)

Concurrent Testing

Fecal calprotectin testing concurrent with lactoferrin testing

Considered not indicated per policy (concurrent testing with lactoferrin is not medically necessary).

Not Medically Necessary / Investigational

Fecal calprotectin testing is considered INVESTIGATIONAL or NOT MEDICALLY NECESSARY when the following apply:

ANY of the following

Any indication other than those specified as medically necessary (diagnostic when endoscopy is being considered, management of active IBD, surveillance for relapse)
explicitly considered INVESTIGATIONAL
Home-based fecal calprotectin testing
explicitly considered INVESTIGATIONAL

Any indication for fecal calprotectin testing that is not specified as medically necessary—i.e., other uses beyond diagnosis when endoscopy is being considered, management of active IBD, or surveillance for relapse—is considered investigational or not medically necessary under this policy.

Coding

Covered CPTCPTCovered

83993

Calprotectin, fecal

Relevant ICD-10 Diagnoses (medically necessary when submitted with CPT 83993 if criteria met)ICD-10Covered

K50.00	Crohn's disease of small intestine without complications
K50.011	Crohn's disease of small intestine with rectal bleeding
K50.012	Crohn's disease of small intestine with intestinal obstruction
K50.013	Crohn's disease of small intestine with fistula
K50.014	Crohn's disease of small intestine with abscess
K50.018	Crohn's disease of small intestine with other complication
K50.019	Crohn's disease of small intestine with unspecified complications
K50.10	Crohn's disease of large intestine without complications
K50.111	Crohn's disease of large intestine with rectal bleeding
K50.112	Crohn's disease of large intestine with intestinal obstruction

1–10 of 93

1/10

When billing CPT code 83993, submit an appropriate ICD-10 diagnosis from the policy list that supports medical necessity (for example, suspected IBD when endoscopy is being considered or active IBD management); see provider actions/documentation for coding requirements and inpatient precertification rules.

Provider Actions

Prior Authorization

Precertification for inpatient services

Precertification/preauthorization is required for all products if the procedure is performed inpatient.

Prior Authorization

Outpatient prior authorization - commercial managed care

For Commercial Managed Care (HMO and POS) outpatient services, prior authorization is not required; review product-specific requirements for other outpatient products as indicated in policy.

Documentation Required

Submit appropriate diagnosis with CPT 83993

When CPT code 83993 (calprotectin, fecal) is billed, include an ICD-10 diagnosis from the policy list that supports medical necessity (examples include suspected IBD when endoscopy is being considered or active IBD management).

83993

Billing Rule

Use most up-to-date codes

Report services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

Background & Definitions

Fecal calprotectin is a neutrophil-derived stool protein marker of intestinal inflammation used to distinguish IBD from noninflammatory conditions and to monitor disease activity and predict relapse. The protein is stable in feces at room temperature for up to about 1 week, allowing for sample collection and transport. A 50 µg/g fecal calprotectin concentration is usually recommended as the cutoff for normal in adults and children older than 4 years, though concentrations are higher in neonates, infants, and young children and may be modestly elevated in older adults or after certain medications (eg, NSAIDs, proton pump inhibitors).

Term	Definition
Fecal calprotectin	A calcium- and zinc-binding protein released from neutrophils; marker of intestinal inflammation stable in feces.
Home-based fecal calprotectin testing	At-home collection/testing methods; considered investigational per policy.

Revision History

2024-03-01material_revision

Policy revised and effective 3/1/2024 to include medically necessary indications for fecal calprotectin testing for management of bowel disease: management of active inflammatory bowel disease and surveillance for relapse of disease in remission; policy statements otherwise unchanged during prior annual reviews.

2025-10administrative_clarificationLatest

Administrative action dated 10/2025 clarifying coding information (coding information clarified).