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CurrentBlue Cross Blue Shield - NebraskaPolicy M.80

MA Specialty Testing: Gastroenterology (Preauthorization Required)

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Medical policy governing preauthorization and medical necessity criteria for specialty laboratory and genetic tests used in non-malignant gastroenterologic conditions (e.g., hereditary hemochromatosis, pancreatitis, inflammatory bowel disease, and noninvasive liver disease). Affects providers requesting these tests for Blue Cross Blue Shield - Nebraska members.

Policy Summary

PayerBlue Cross Blue Shield - Nebraska

PolicyMA Specialty Testing: Gastroenterology (Preauthorization Required)

Policy CodePolicy M.80

Change TypeMinor or no material changes

Effective DateMay 1, 2026

Next Review DateJan 1, 2027

Key ActionObtain preauthorization for specialty gastroenterology genetic and molecular tests and document clinical history supporting the indication (e.g., abnormal iron indices, pancreatitis episodes, age of onset, or FIB-4/NFS scores).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

RequiredPreauthorization required

Not coveredIBD algorithmic tests

Under 6 yrsMonogenic IBD testing

MultipleGuidelines cited

CPT/molecularCodes listed

Coverage Criteria for Specialty Gastroenterology Testing

HFE C282Y and H63D genotyping

HFE C282Y and H63D genotyping is reasonable and necessary when ONE of the following is present:

HFE testing indications: Abnormal serum iron indices (e.g., elevated serum transferrin-iron saturation and/or elevated serum ferritin concentration, indicating iron overload)

Family history indication: First-degree relative with a diagnosis of hereditary hemochromatosis

Hereditary pancreatitis multigene panel

Hereditary pancreatitis multigene panel analysis is reasonable and necessary when ALL of the following are met:

Pancreatitis panel overall

Specific clinical/family criteria: Unexplained acute pancreatitis in childhood (<=18 yrs) OR recurrent (>=2) unexplained acute pancreatitis episodes OR chronic pancreatitis of unknown cause with onset before age 35 without heavy alcohol use OR at least one close relative with recurrent/chronic/childhood pancreatitis of unknown cause
Panel content requirement: Panel includes at a minimum PRSS1, SPINK1, CFTR, and CTRC

IBD algorithmic diagnostic and prognostic tests

Algorithmic diagnostic and prognostic IBD tests

IBD algorithmic tests: Inflammatory bowel disease diagnostic algorithmic tests are considered not reasonable and necessary.

IBD prognostic tests: Inflammatory bowel disease prognostic algorithmic tests are considered not reasonable and necessary.

Evidence reviews (Concert) published 06/01/2025 concluded insufficient evidence to support coverage.

Hereditary IBD / Crohn's disease multigene panels

Genetic multigene panel testing for IBD may be reasonable and necessary when ONE of the following is met:

Infantile IBD: Member was diagnosed with infantile-onset inflammatory bowel disease before age 2 yearsage <2 years

VEO-IBD: Member was diagnosed with very early onset inflammatory bowel disease (VEO-IBD) before age 6 yearsage <6 years

Testing recommended for children under 2 and for those under 6 with additional features suggesting monogenic disease

Blood-based non-invasive liver fibrosis tests (FIB-4, NFS, APRI)

Blood-based non-invasive liver fibrosis serum tests (e.g., FIB-4, NFS, APRI) may be considered reasonable and necessary when ALL of the following apply:

Eligibility - at least one condition: Member has at least one of: signs/symptoms or a diagnosis of chronic liver disease; abnormal liver chemistries; hepatic steatosis on imaging; prediabetes/type 2 diabetes; features of metabolic syndrome (e.g., dyslipidemia, obesity); significant alcohol consumption; first-degree relative with MASH (NASH) cirrhosis.

Use FIB-4 as first-line risk stratification per guidelines; not reasonable and necessary for other indications.

Blood-based noninvasive liver disease algorithmic tests (rule-out fibrosis)

Blood-based noninvasive liver disease algorithmic tests may be considered reasonable and necessary when ALL of the following are met:

Algorithmic test overall requirements: Member does NOT have a confirmed diagnosis of liver fibrosis AND this test has NOT been performed within the last year AND the member meets BOTH condition groups 1 and 2 below.

Condition group 1: One of: untreated chronic HCV infection OR suspected/confirmed MASLD (formerly NAFLD).

Member must NOT have chronic cholestatic liver disease.

Condition group 2 - risk score or metabolic features: Either an intermediate/high-risk FIB-4 score (>=1.3 if <65 yrs; >=2.0 if >=65 yrs) OR a low-risk FIB-4 score combined with prediabetes/diabetes OR two or more features of metabolic syndrome OR an indeterminate/high-risk NAFLD fibrosis score (NFS).FIB-4 and NFS thresholds referenced

Inflammatory Bowel Disease / Crohn’s Diagnostic Algorithmic Tests

Concert evidence review conclusions for algorithmic diagnostic tests

Coverage conclusion: There is INSUFFICIENT EVIDENCE in peer-reviewed publications to support clinical validity and utility of IBD Crohn’s diagnostic algorithmic tests (e.g., Prometheus IBD sgi Diagnostic) to improve health outcomes compared to standard care; available evidence does not support health plan coverage.

Concert Evidence Review published 06/01/2025

Inflammatory Bowel Disease / Crohn’s Prognostic Algorithmic Tests

Concert evidence review conclusions for prognostic tests

Coverage conclusion: There is INSUFFICIENT EVIDENCE in peer-reviewed publications to support clinical validity and utility of Crohn’s prognostic algorithmic tests (e.g., PredictSURE-IBD) to improve health outcomes; current evidence does not support health plan coverage.

Concert Evidence Review published 06/01/2025; randomized trial cited showing no significant clinical utility

HFE (hereditary hemochromatosis) genetic testing

Professional guidance for appropriate use

Recommended testing conditions: Test for p.C282Y is recommended; p.H63D may be offered sequentially or simultaneously per local practice; population screening is not recommended. Confirm elevated transferrin saturation before HFE genetic testing is considered good practice.TS >=45% or elevated serum ferritin per ACG algorithm referenced

EMQN and ACG guidance cited

Hereditary pancreatitis genetic testing

When to consider genetic testing

Indications: Molecular genetic testing for hereditary pancreatitis is indicated in a proband with pancreatitis and at least one of: unexplained documented childhood acute pancreatitis; recurrent acute pancreatitis of unknown cause; chronic pancreatitis of unknown cause (onset <35 years without heavy alcohol use); or a family history of recurrent/chronic/childhood pancreatitis.

ACG and GeneReviews recommendations

Hereditary IBD / monogenic IBD genetic testing

Population and phenotype-based recommendations

Recommended populations: Genomic/panel testing is recommended for all children with infantile-onset IBD (onset <2 years) and for children with VEO-IBD (<6 years) especially when additional features suggesting monogenic disease are present; testing may be offered in exceptional circumstances after age 6.age <2 (strong recommendation); age <6 with features (strong recommendation)

NASPGHAN and British Society guidance cited

Coverage logic — diagnostic and staged testing

Coverage aligned with clinical guidance when tests are used for diagnostic evaluation or risk stratification in at-risk populations

Genetic panel testing for pediatric IBD: Targeted genetic panel testing is recommended for infantile-onset IBD or when phenotype is consistent with monogenic pediatric IBD, in presence of immunologic abnormalities, or with family consanguinity.

NASPGHAN position paper recommendation

Liver function panel testing: Liver chemistry panels are appropriate to confirm abnormal results or evaluate suspected liver disease or contributing conditions; not appropriate for routine screening without signs/symptoms.

ACG guideline and CMS LCD support

Blood-based NILDA initial staging: Use FIB-4 as first-line noninvasive blood-based test to stratify risk for advanced fibrosis in patients with hepatic steatosis or suspected MASLD and in high-risk groups (eg, type 2 diabetes).FIB-4 <1.3 exclusion; adjust threshold to <2.0 for age >65

AGA and AASLD guidance

The policy identifies specific indications where testing is considered reasonable and necessary and explicitly states that testing performed outside those indications is considered not reasonable and necessary. Examples in this excerpt include: HFE C282Y/H63D genotyping for members without abnormal serum iron indices or without a first-degree relative with hereditary hemochromatosis; hereditary pancreatitis multigene panels when the member does not meet the listed personal or family history criteria; algorithmic IBD diagnostic or prognostic tests when used for routine or unsupported indications; and blood-based liver algorithmic tests when the patient does not meet the multi-branch clinical and risk-score requirements. (See HFE genotyping criteria, hereditary pancreatitis panel criteria, IBD algorithmic test statements, and blood-based algorithmic test criteria.)

The policy further clarifies that many tests are considered not reasonable and necessary "for all other indications" when the specific criteria are not met. Providers should document clinical findings that satisfy the stated entry conditions (for example, abnormal iron indices or qualifying pancreatitis history) before requesting testing to avoid coverage denials.

Prometheus IBD sgi Diagnostic and similar algorithmic blood-based tests for inflammatory bowel disease are addressed directly by concert evidence reviews cited in the policy. The evidence reviews conclude there is insufficient evidence of clinical validity and utility for diagnostic tests (e.g., Prometheus IBD sgi Diagnostic) and for prognostic tests (e.g., PredictSURE-IBD), and therefore these algorithmic tests are not supported for health plan coverage.

As a result, algorithmic IBD diagnostic and prognostic assays are categorized in the policy as not reasonable and necessary, and requests for these tests should be expected to face denial unless new, guideline-changing evidence is available.

The policy references CMS local coverage guidance noting that hepatic panel testing performed as part of routine annual physicals or population-based screening without signs, symptoms, or illness indicating medical necessity is considered not medically reasonable or necessary. The policy therefore aligns with this guidance: liver function panels should be ordered to confirm abnormal prior results or to evaluate suspected liver disease or contributing conditions, not for routine screening of asymptomatic individuals.

Providers should document the clinical signs, symptoms, abnormal results, or specific risk factors that justify ordering a hepatic panel to support medical necessity and coverage.

This medical policy is used by Blue Cross Blue Shield of Nebraska to determine scientific validity and to administer plan benefits, but it does not itself define plan benefits. Coverage and payment for any service are determined by the member’s applicable benefit contract. The policy excerpt does not list explicit contractual exclusions; therefore, actual benefit determination should be confirmed against the terms and conditions of the member’s plan.

Providers should verify member coverage and any plan-specific limitations or authorizations before ordering tests, and use the policy criteria to document medical necessity when requesting preauthorization.

Illustrative examples of requests likely to be denied under the policy include: ordering HFE genotyping when the member does not have confirmatory abnormal serum iron indices (e.g., elevated transferrin saturation or ferritin) and there is no first-degree relative with diagnosed hereditary hemochromatosis; requesting Prometheus IBD sgi Diagnostic or other IBD algorithmic diagnostic/prognostic tests despite the policy’s evidence-based determination that these tests are not reasonable and necessary; and submitting a hereditary pancreatitis multigene panel when the member lacks the required personal history (e.g., unexplained childhood pancreatitis, recurrent unexplained pancreatitis, chronic pancreatitis with early onset) or relevant family history.

These examples reflect the policy’s requirement that testing requests meet the specific, documented clinical criteria to be considered reasonable and necessary.

The policy states that routine population-based liver chemistry screening or hepatic panel testing without clinical indications is not medically necessary, consistent with CMS LCD wording. For blood-based algorithmic liver tests, the policy requires specific clinical context and risk-score thresholds (for example, appropriate FIB-4 or NFS results and relevant risk factors) before testing is considered reasonable and necessary; absent those indications, testing to screen an asymptomatic population is not supported.

Order hepatic panels and algorithmic liver tests only when documentation supports clinical indications (abnormal prior results, signs/symptoms of liver disease, imaging showing steatosis, metabolic risk factors, or qualifying FIB-4/NFS scores).

Within the provided excerpt the policy clearly identifies many specific tests and scenarios that are considered not reasonable and necessary, but it does not present a separate general statement explicitly labeled as a universal "not medically necessary" clause beyond these itemized exclusions. The document does include CMS and evidence-review conclusions that certain routine or unsupported uses (e.g., routine hepatic panel screening; Prometheus/PredictSURE IBD assays) are not medically reasonable or necessary.

For any coverage determination, absence of an explicit universal NMN statement in this excerpt does not alter the policy’s guidance that individual test requests must meet the listed clinical criteria and evidence-based conclusions to be considered for coverage.

Relevant CPT and Molecular Pathology Codes

Hereditary Hemochromatosis / example codesmixed

81256	HFE C282Y and H63D genotyping (HFE hematochromatosis gene analysis, common variants)
E83.110	Iron overload disorder
E83.118	Other hemochromatosis
E83.119	Hemochromatosis, unspecified
R79.0	Abnormal iron studies
E83.19	Other disorders of iron metabolism
R16.0	Hepatomegaly

Hereditary Pancreatitis / example codesmixed

81220	Hereditary pancreatitis / related gene testing
81222	CFTR gene analysis - duplication/deletion variants
81223	CFTR gene analysis - full gene sequence
81404	Molecular pathology procedure, Level 5
81405	Molecular pathology procedure, Level 6
81479	Unlisted molecular pathology procedure

Inflammatory Bowel Disease / Crohn's Disease codesmixed

81479	Unlisted molecular pathology procedure
82397	Assay code listed in IBD diagnostic table
83520	Assay code listed in IBD diagnostic/prognostic table
86140	Assay code listed in IBD diagnostic table
88346	Pathology code listed in IBD table
88350	Pathology code listed in IBD table
0203U	PredictSURE IBD / Autoimmune IBD mRNA profile (mRNA gene expression profiling, 17 genes, whole blood)
81401	Molecular pathology procedure, Level 2

Blood-based noninvasive liver disease algorithmic test codesCPT

81596	FibroSURE / FibroTest (BioPredictive)
81517	Enhanced Liver Fibrosis (ELF) Test (analysis of 3 biomarkers: HA, PIIINP, TIMP-1)
0002M	LIVER DIS 10 ASSAYS SERUM ALGORITHM W/ASH
0003M	LIVER DIS 10 ASSAYS SERUM ALGORITHM W/NASH

Codes (excerpt)CPT

0002M	LIVER DIS 10 ASSAYS SERUM ALGORITHM W/ASH
0003M	LIVER DIS 10 ASSAYS SERUM ALGORITHM W/NASH
81222	CFTR GENE ANALYSIS DUPLICATION/DELETION VARIANTS
81223	CFTR GENE ANALYSIS FULL GENE SEQUENCE
81256	HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS
81321	PTEN GENE ANALYSIS FULL SEQUENCE ANALYSIS
81401	MOLECULAR PATHOLOGY PROCEDURE LEVEL 2

Molecular pathology CPT levels (examples and gene list excerpts)CPT

81404	MOLECULAR PATHOLOGY PROCEDURE LEVEL 5
81405	MOLECULAR PATHOLOGY PROCEDURE LEVEL 6

Molecular pathology CPT groupingsCPT

81405	Molecular pathology procedure level 6
81406	Molecular pathology procedure level 7
81407	Molecular pathology procedure level 8
81479	Unlisted molecular pathology procedure

Covered CPT Codes (biomarker panels listed)CPT

81517

Liver disease, analysis of 3 biomarkers (HA, PIIINP, TIMP-1), serum, prognostic algorithm reported as a risk score and risk of liver fibrosis and liver-related clinical events within 5 years

Other test-specific codesCPT

0203U

Autoimmune (inflammatory bowel disease), mRNA, gene expression profiling by quantitative RT-PCR, 17 genes, whole blood, reported as a continuous risk score and classification of IBD aggressiveness

FIB-4 index (FIB-4) risk thresholds

FIB-4 intermediate/high-risk thresholds>= 1.3 for individuals younger than 65 years; >= 2.0 for individuals 65 years of age or older

FIB-4 low-risk threshold< 1.3 for individuals younger than 65 years; < 2.0 for individuals 65 years of age or older

Use contextIndicates need for secondary NIT or further evaluation when intermediate/high-risk

NAFLD Fibrosis Score (NFS) threshold

NFS indeterminate/high-risk threshold referenced

Provider Actions, Authorization & Documentation Requirements

Prior Authorization

Prior authorization required

Preauthorization is required for specialty gastroenterology testing; when national or local coverage determinations (NCD/LCD) exist they take precedence and should be applied first.

Prior Authorization

IBD algorithmic tests — PA not supported by evidence

Concert evidence reviews concluded there is insufficient evidence to support clinical validity or utility of IBD Crohn’s diagnostic and prognostic algorithmic tests; these findings effectively discourage prior authorization for these algorithmic tests because coverage is not supported.

Examples cited include Prometheus IBD sgi Diagnostic and PredictSURE‑IBD.

Prior Authorization

PA required for listed molecular/specialty CPT codes

Background and Scope

Background: This policy addresses specialty laboratory testing used in non-malignant gastroenterologic conditions, including genetic testing for hereditary hemochromatosis (HFE C282Y/H63D), hereditary pancreatitis multigene panels, genetic testing for infantile and very early onset inflammatory bowel disease, and blood-based algorithmic and noninvasive tests for liver fibrosis risk stratification. It ties coverage to specific clinical criteria, family history, validated risk scores (such as FIB-4 and NFS), and evidence reviews for novel algorithmic assays.

The policy emphasizes preauthorization requirements for specialty gastroenterology testing, recommends confirmatory laboratory evidence or relevant family history prior to genetic testing, and cites Concert evidence reviews and professional society guidance when concluding that certain algorithmic IBD tests lack sufficient evidence to support coverage.

Definitions and Key Terms

Close relatives — definition

First-degree relativesParents, siblings, and children

Second-degree relativesGrandparents, aunts/uncles, nieces/nephews, grandchildren, and half siblings

Third-degree relativesGreat grandparents, great aunts/uncles, great grandchildren, and first cousins

Infantile-IBD and VEO-IBD — age-based definitions

Infantile-onset IBDOnset or diagnosis younger than 2 years of age

Very early onset IBD (VEO-IBD)Onset or diagnosis younger than 6 years of age

Testing recommendation

Policy Summary

PayerBlue Cross Blue Shield - Nebraska

PolicyMA Specialty Testing: Gastroenterology (Preauthorization Required)

Policy CodePolicy M.80

Change TypeMinor or no material changes

Effective DateMay 1, 2026

Next Review DateJan 1, 2027

SourceLink

On This Page

Sequential testing for indeterminate/high risk: For FIB-4 >=1.3 (or >=2.0 if older than 65) or in patients with metabolic risk factors, perform a second NIT (ELF, FibroTest, or imaging elastography) for secondary risk assessment.

AGA best practice advice and AASLD suggestion

Use of proprietary tests: Proprietary tests (ELF, FibroTest, FibroMeter) may be used as secondary tests where available; they have higher specificity but higher cost and varied validation across etiologies.

ACG/AASLD/Canivet review

NAFLD Fibrosis Score (NFS) indeterminate or high-risk noted (threshold referenced as less than -1.455)

NFS inputsCalculated from AST, ALT, albumin, age, BMI, platelet count, and presence of impaired fasting glucose or diabetes

Action on indeterminate/high-riskConsider second NIT (ELF, FibroTest) or imaging-based assessment

FIB-4 cutoff for exclusion of advanced fibrosis

FIB-4 cutoff to exclude advanced fibrosisFIB-4 < 1.3 excludes advanced hepatic fibrosis for patients younger than 65 years; for patients older than 65 years use < 2.0

Repeat testing guidanceFor FIB-4 below cutoff without diabetes/metabolic features, repeat every 1-2 years

If diabetes or metabolic features presentPerform a second NIT even if FIB-4 is below the exclusion cutoff

ALT abnormal threshold cited in AGA workup

ALT abnormal threshold (AGA workup)> 20 U/L for women; > 30 U/L for men

Context of useThese ALT cutoffs are part of suggested clinical workup for suspected NAFLD

Follow-up implicationElevated ALT per these thresholds prompts further NIT-based risk assessment

The molecular and specialty CPT codes listed in the policy (e.g., 0002M, 0003M, 81222, 81223, 81256, 81321, 81401) are subject to the plan's preauthorization requirements.

Submit prior authorization requests when ordering any listed molecular pathology or specialty gastroenterology CPT codes.

Prior Authorization

PA required for listed specialty gastroenterology tests

Certain molecular pathology and biomarker panel CPT codes specifically listed in the policy (for example 81517, 0203U, 81405–81407, 81479) require preauthorization per the policy title.

Prior authorization should be obtained for listed biomarker panels and molecular pathology level codes before testing.

Note

General provider responsibilities

Providers must follow the policy’s stated actions: obtain preauthorization when required, document clinical indications, and ensure testing meets the policy criteria to avoid denial.

Include evidence of meeting the specific clinical criteria described in the policy for the test ordered.
Ensure prior authorization is requested for CPTs listed in the policy before testing.

Step Therapy

Sequential HFE testing — p.C282Y first

For HFE genotyping a stepwise approach is acceptable: test for p.C282Y first; p.H63D may be offered sequentially or simultaneously per local practice.

Confirm elevated transferrin saturation (TS) before genetic testing when possible, as good practice per EMQN/ACG guidance.

Step Therapy

No step therapy required (excerpt)

The policy excerpt does not specify any step therapy requirements for ordering these tests.

No mandated step-therapy sequence is described in this document excerpt.

Documentation Required

Documentation — include clinical history and prior testing

Documentation should include clinical history supporting the indication (for example serum iron indices, documented pancreatitis episodes, age of onset for IBD, and FIB‑4/NFS/APRI scores) and prior testing history (e.g., that the algorithmic test has not been performed within the last year when applicable).

For liver algorithmic tests document prior test dates and supporting risk scores (FIB‑4, NFS) per policy thresholds.
Provide clinical details ruling out alternate causes when ordering hereditary pancreatitis panels.

Documentation Required

HFE testing — documentation expectations

For HFE (hereditary hemochromatosis) genotyping, documentation is expected to confirm elevated transferrin saturation (TS) and/or elevated serum ferritin prior to genetic testing when possible; family screening of first‑degree relatives is recommended.

ACG algorithm suggests HFE genotyping if TS ≥45% and/or serum ferritin is elevated.
Document family history details for first‑degree relatives when relevant.

Documentation Required

Genetic panel testing — documentation required

When ordering hereditary pancreatitis or monogenic IBD genetic panels, document the clinical criteria that justify testing (e.g., unexplained childhood pancreatitis, recurrent idiopathic pancreatitis, chronic pancreatitis onset <35 without heavy alcohol use, infantile‑onset IBD <2 years, or VEO‑IBD <6 years with suggestive phenotype).

Confirm the panel includes required genes for pancreatitis (PRSS1, SPINK1, CFTR, CTRC) per policy.
For pediatric IBD panels document features suggesting monogenic disease (early onset, family history, immunologic abnormalities, consanguinity).

Documentation Required

Liver panel — document clinical indication

Document the clinical indication when ordering liver function panels; these tests are appropriate to confirm prior abnormal results or evaluate suspected liver disease and contributing conditions, but are not appropriate for routine screening without signs/symptoms.

CMS LCD states hepatic panel testing performed during routine annual physicals without signs/symptoms is not medically necessary — document clinical signs or abnormal prior results.

Note

Policy disclaimer — not an authorization or contract

The Medical Policy Disclaimer states these policies are used to administer plan benefits and do not constitute authorization, certification, or a contract for benefits; benefits are determined by the terms of the applicable benefit contract.

Obtaining prior authorization per this policy does not by itself guarantee coverage — confirm member benefits under the applicable contract.

Denial Risk

Denial risk — tests not meeting clinical criteria

Requests for testing that do not meet the policy’s clinical criteria (for example HFE genotyping without abnormal iron indices or without a first‑degree relative with HH; hereditary pancreatitis panel when the required personal/family history criteria are not met; IBD algorithmic/prognostic tests which are deemed not reasonable and necessary) may be denied.

Ensure submitted clinical documentation clearly demonstrates the specific criteria in the policy are satisfied to reduce risk of denial.

Denial Risk

Denial risk — IBD algorithmic diagnostic/prognostic tests

Algorithmic Crohn’s diagnostic and prognostic blood‑based tests (e.g., Prometheus IBD sgi Diagnostic, PredictSURE‑IBD) are not supported by sufficient peer‑reviewed evidence and therefore are not supported for health plan coverage; requests for these tests are at high risk of denial.

Prior authorization is discouraged because the Concert evidence reviews found insufficient evidence of clinical utility.

Denial Risk

Denial risk — routine screening without indications

Hepatic panel testing performed as part of an annual physical or routine screening without signs, symptoms, or illness indicating medical necessity may be denied per CMS local coverage guidance.

Document any abnormal prior results or clinical signs that justify ordering a hepatic panel to avoid routine‑screening denials.

Denial Risk

No other explicit denial triggers listed

The policy excerpt does not list additional explicit denial triggers beyond the described clinical‑criteria failures and the IBD algorithmic test exclusions.

Denial decisions remain subject to the member’s benefit contract and the reviewer’s assessment of documented clinical need.

Targeted genetic panel testing recommended for all children <2 years and for children <6 years with suggestive features

FIB-4 index — definition and inputs

DefinitionFIB-4 is a blood test that estimates probability of advanced liver fibrosis using AST, ALT, platelet count, and age

InputsAST (SGOT), ALT (SGPT), platelet count, and patient age

Clinical roleRecommended as first-line noninvasive test (NILDA) for initial fibrosis risk stratification

NAFLD Fibrosis Score (NFS) — definition and inputs

DefinitionNAFLD Fibrosis Score (NFS) estimates probability of advanced liver fibrosis using AST, ALT, albumin, age, BMI, platelet count, and presence of impaired fasting glucose or diabetes

InputsAST, ALT, albumin, age, BMI, platelet count, impaired fasting glucose or diabetes status

Interpretation noteAn indeterminate or high-risk NFS (threshold example referenced) supports further noninvasive assessment

Signs/symptoms of liver dysfunction — examples

Examples of signs/symptomsJaundice; right upper quadrant abdominal pain/tenderness; fatigue; abdominal swelling; itching; anorexia; nausea/vomiting

Hematologic/lab manifestationsAnemia; thrombocytopenia; unexplained bleeding or bruising

Gastrointestinal manifestationsLoose/fatty stools

Infantile-IBD and VEO-IBD (redundant) — age-based definitions

Infantile-IBDOnset/diagnosis before 2 years of age

VEO-IBDOnset/diagnosis before 6 years of age

Clinical implicationConsider targeted genetic panel testing when infantile or VEO-IBD phenotypes present

Infantile-onset IBD / Very Early-onset IBD — phenotypic guidance and genetic testing

Phenotypic guidanceTargeted genetic panel testing is recommended for infantile-onset IBD and for patients whose phenotype is consistent with known monogenic pediatric IBD (eg, immunologic abnormalities, consanguinity)

Recommended actionRefer infants/young children with suggestive features to immunology and consider panel, exome, or genome sequencing

Age-based strong recommendationTesting recommended for all children <2 years and for children <6 years with concerning features

NILDA / NIT / noninvasive tests — examples

Examples of NILDA/NIT testsAPRI; FIB-4; Enhanced Liver Fibrosis (ELF); FibroTest/FibroSURE

PurposeNoninvasive assessment of liver fibrosis without biopsy; used for initial risk stratification and sequential testing

Role in pathwayFIB-4 recommended as first-line; ELF or FibroTest used as secondary assessment when FIB-4 is indeterminate or high

Liver disease 3 biomarker panel (CPT 81517)

Biomarkers includedHyaluronic acid (HA); Procollagen III amino-terminal peptide (PIIINP); Tissue inhibitor of metalloproteinase 1 (TIMP-1)

MethodImmunoassays on serum reported as a prognostic algorithmic risk score

CPT code81517

0203U Autoimmune IBD mRNA profile — description

Test descriptionmRNA gene expression profiling by qRT-PCR of 17 genes from whole blood, reported as a continuous risk score and classification of IBD aggressiveness

Genes reported17 genes (15 target and 2 reference genes)

CPT code0203U