ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPLAB035

Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease

Defines BCBSNM reimbursement policy for laboratory serologic and algorithm-based tests used in the diagnosis and monitoring of inflammatory bowel disease (IBD); applicable to providers submitting claims to Blue Cross Blue Shield of New Mexico.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyLaboratory Testing for the Diagnosis of Inflammatory Bowel Disease

Policy CodePolicy CPCPLAB035

Change TypeRevised — reimbursement info and references updated

Effective DateJanuary 15, 2025

Next Review Date

Key ActionDo not bill for listed serologic markers or diagnostic algorithm-based tests (e.g., ibs-smart™, Prometheus®) for IBD workup or monitoring; verify plan documents for product-specific coverage.

SourceLink

POLICY UPDATE CHANGES

Document updated with literature review and reimbursement information revised to include ibs-smart™.

Document updated with literature review (02/01/2024 entry).

Document updated with literature review (11/01/2023 entry) and reimbursement information revised for clarity.

Policy created as new policy on 11/1/2022.

1.0policy version

2024-10-30approval date

2025-01-15plan effective date

≥11non-reimbursable tests

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Coverage Criteria

Non-reimbursable serologic markers

Not reimbursable for workup and monitoring of individuals with IBD:

Non-reimbursable serologic markers: The following serologic markers are not reimbursable for the workup and monitoring of inflammatory bowel disease (IBD): Anti-neutrophil cytoplasmic antibody (ANCA); AntiSaccharomyces cerevisiae antibody (ASCA); Perinuclear anti-neutrophilic cytoplasmic antibody (pANCA); Antibody to Escherichia coli outer membrane porin C (anti-OmpC); Antibody to Pseudomonas fluorescens-associated sequence I2 (anti-I2); Antichitobioside antibodies (ACCA IgA); Anti-CBir1 flagellin antibody (anti-cBir1); Antilaminaribioside antibodies (ALCA IgG); Antimannobioside antibodies (AMCA IgG); Pyruvate kinase M2 (PKM2).

Exact list as provided in policy

Non-reimbursable diagnostic algorithm-based testing

Not reimbursable for diagnosis or monitoring of individuals with IBD:

Non-reimbursable diagnostic algorithm-based tests: Diagnostic algorithm-based testing (e.g., ibs-smart™, Prometheus® testing) is not reimbursable for the diagnosis or monitoring of individuals with inflammatory bowel disease (IBD).

Applies to diagnostic algorithm/algorithm-based commercial panels

Coverage and reimbursement for laboratory management tests vary by Blue Cross Blue Shield of New Mexico product. Not all lab management reimbursement criteria apply to each product; providers must review the member's specific Plan documents to determine eligibility and coverage prior to ordering or billing for these services.

A review of the policy update history and related documentation shows no explicit exclusion conditions specified in the referenced policy sections. Providers should nonetheless consult the applicable Plan documents for product-specific exclusions.

The referenced policy materials do not contain explicit statements labeling the listed tests as not medically necessary. The document instead specifies reimbursement scope and updates; clinical determinations and Plan coverage specifics should be confirmed in the member's Plan documentation.

Coding

Procedure Codes (illustrative — not exhaustive)mixed

No codes listed

Provider Actions and Billing

Note

Coverage May Vary by Product

Coverage varies by product. Providers should review member plan documents (Certificates of Benefits, benefit booklets, Summary Plan Descriptions, etc.) to confirm eligibility and coverage for laboratory services prior to rendering services.

Not all lab management reimbursement criteria apply to every product — check the member's plan documents for coverage specifics.

Documentation Required

Claims Documentation and Coding

Providers are responsible for submission of accurate documentation and correct coding. Claims are subject to edits and review against benefit coverage, provider contract language, medical and coding policies, and coding software logic. Upon request, providers should submit additional documentation to support medical necessity and coding.

Submit claims using valid HIPAA-approved code sets (CPT, HCPCS, ICD-10-CM/PCS, NDC, etc.).
Coding should follow industry-standard guidelines (AMA CPT, UB, CMS NCCI, etc.).

Background

Inflammatory bowel disease (IBD) refers primarily to Crohn's disease and ulcerative colitis, chronic disorders characterized by intestinal inflammation with variable clinical courses. Serologic markers and multi‑marker algorithm‑based panels (for example, commercially available tests like ibs‑smart™ and Prometheus® panels) have been evaluated to aid in diagnosis, differentiation of IBD from non‑IBD conditions, and characterization of disease phenotype or activity. This policy defines Blue Cross Blue Shield of New Mexico's reimbursement approach for such serologic markers and algorithm‑based diagnostic tests when used in the diagnosis or monitoring of IBD, and notes specific tests that are not reimbursable for IBD workup and monitoring.

Definitions

Diagnostic algorithm-based testing (e.g., ibs-smart™, Prometheus® testing)

DefinitionDiagnostic algorithm-based testing refers to multi-analyte laboratory panels that apply algorithmic interpretation for diagnosis or monitoring (examples named in policy: ibs-smart™, Prometheus® testing).

Policy stanceNot reimbursable for the diagnosis or monitoring of individuals with inflammatory bowel disease (IBD).

ScopeApplies to diagnostic algorithm–based tests used specifically for IBD workup and monitoring as identified in reimbursement information.

Provider actionClaims for these tests submitted for IBD diagnosis or monitoring will not be reimbursed — review plan documents for product-specific coverage details.

Example tests listedibs-smart™; Prometheus® testing.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyLaboratory Testing for the Diagnosis of Inflammatory Bowel Disease

Policy CodePolicy CPCPLAB035

Change TypeRevised — reimbursement info and references updated

Effective DateJanuary 15, 2025

Next Review Date

SourceLink

On This Page

Denial Risk

Denial Triggers — Non‑Reimbursable Tests

The following tests and test strategies are denial triggers and are not reimbursable for the diagnosis or monitoring of inflammatory bowel disease (IBD): single serologic markers and diagnostic algorithm–based panel testing. Claims for these services will be denied.

Non-reimbursable serologic markers include, but are not limited to: ANCA; ASCA; pANCA; anti‑OmpC; anti‑I2; ACCA (IgA); anti‑CBir1; ALCA (IgG); AMCA (IgG); PKM2.
Diagnostic algorithm–based tests (examples): ibs‑smart™ and Prometheus® testing — not reimbursable for diagnosis or monitoring of IBD.

Prior Authorization

Prior Authorization / Step Therapy

No explicit prior authorization or step therapy requirements are stated in this section. Providers should still verify any product-specific prior authorization requirements in the member's plan documents before performing services.

If a plan requires prior authorization for laboratory testing, that requirement will supersede this policy and must be followed.

Note

Reimbursement Update Note

Reimbursement information was revised to include ibs‑smart™ in the list of non‑reimbursable diagnostic algorithm–based tests. Providers should consider this when ordering and billing for IBD workup and monitoring.

Document updates effective 01/15/2025 include adding ibs‑smart™ to non‑reimbursable tests.

IBD biomarkers and serologic panels — serologic antibodies, fecal markers, and multi‑marker commercial panels

Included biomarkersSerologic antibodies listed: Anti-neutrophil cytoplasmic antibody (ANCA); AntiSaccharomyces cerevisiae antibody (ASCA); Perinuclear anti-neutrophilic cytoplasmic antibody (pANCA); Anti-CBir1 flagellin antibody (anti-cBir1).

Additional non-reimbursable serologic testsAntibody to Escherichia coli outer membrane porin C (anti-OmpC); Antibody to Pseudomonas fluorescens–associated sequence I2 (anti-I2); Antichitobioside antibodies (ACCA IgA); Antilaminaribioside antibodies (ALCA IgG); Antimannobioside antibodies (AMCA IgG); Pyruvate kinase M2 (PKM2).

Fecal markers and multi-marker panels (context)Policy definition references fecal markers (e.g., calprotectin, lactoferrin) and multi-marker commercial panels (e.g., Prometheus IBD sgi, Monitr Crohn's) as components of IBD biomarker strategies, though the reimbursement exclusions specifically list serologic markers and algorithm-based tests.

Clinical roleThese biomarkers and panels have been studied for diagnosis, differentiation, and prognostication in IBD; however, reimbursement is restricted per policy.