Blue Cross Blue Shield NM Helicobacter pylori Coverage | OpenPayer

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Blue Cross Blue Shield NM Helicobacter pylori Coverage | OpenPayer

inv-01: Noninvasive testing — Adult

Covered when ANY of the following adult clinical indications are present (one noninvasive test - urea breath OR stool antigen):

Adult indications: dyspeptic symptoms

One noninvasive test (UBT or stool antigen) reimbursable

Adult indications: active peptic ulcer disease (PUD)

One noninvasive test (UBT or stool antigen) reimbursable

Adult indications: past peptic ulcer disease without known H. pylori history

One noninvasive test (UBT or stool antigen) reimbursable

Adult indications: history of endoscopic resection of early gastric cancer (EGC)

One noninvasive test (UBT or stool antigen) reimbursable

Adult indications: low-grade gastric MALT lymphoma

One noninvasive test (UBT or stool antigen) reimbursable

Adult indications: gastric intestinal metaplasia (GIM)

One noninvasive test (UBT or stool antigen) reimbursable

Adult indications: uninvestigated dyspepsia in patients <60 years without alarm features

One noninvasive test (UBT or stool antigen) reimbursable

Adult indications: unexplained iron deficiency anemia

One noninvasive test (UBT or stool antigen) reimbursable

Adult indications: initiating chronic NSAID therapy

One noninvasive test (UBT or stool antigen) reimbursable

Adult indications: evaluation of chronic immune thrombocytopenic purpura (ITP) with suspected H. pylori

One noninvasive test (UBT or stool antigen) reimbursable

Adult indications: first-generation immigrants from high-prevalence areas

One noninvasive test (UBT or stool antigen) reimbursable

Adult indications: family history of gastric cancer

One noninvasive test (UBT or stool antigen) reimbursable

inv-02: Noninvasive testing — Eradication confirmation

Covered for re-evaluation to confirm eradication or for persistent symptoms after treatment:

Eradication follow-up: Re-evaluation to measure success of eradication of H. pylori infection at least 4 weeks post-treatment>=4 weeks post-treatment

Use Urea Breath Test (UBT) or stool antigen

Follow-up indications: Follow-up of persistent dyspepsia after appropriate antibiotic treatment for H. pylori

Use UBT or stool antigen

Follow-up indications: Evaluation of patients with H. pylori–associated ulcer

Use UBT or stool antigen

inv-03: Biopsy-based testing

Covered biopsy-based indications:

Biopsy-based covered: Adult patients (>18 y) undergoing endoscopic examination or those with alarm symptoms

Use endoscopic histology with Rapid Urease Test or culture with susceptibility testing

Biopsy-based covered: Pediatric patients (<18 y) with gastric or duodenal ulcers

Use endoscopic histology with Rapid Urease Test or culture with susceptibility testing

Biopsy-based covered: Pediatric patients with refractory iron deficiency anemia when other causes have been ruled out

Use endoscopic histology with Rapid Urease Test or culture with susceptibility testing

inv-04: Pediatric testing

Pediatric noninvasive testing covered when:

Pediatric covered: Re-evaluation to measure success of eradication at least 4 weeks post-treatment>=4 weeks post-treatment

UBT or stool antigen may be reimbursable

Pediatric covered: Diagnosis in selected clinical scenarios as noted (see biopsy-based testing for certain pediatric diagnostic indications)

UBT or stool antigen may be reimbursable

Urea breath test (UBT) and stool antigen testing are reimbursable only when performed for listed, clinically indicated purposes. These tests are not reimbursable for asymptomatic pediatric (<18 years) or adult (>18 years) patients outside the indications described in this policy, and are not reimbursable for adult patients with typical GERD symptoms who do not have a history of peptic ulcer disease. Providers should order a single noninvasive test (UBT OR stool antigen) per clinical evaluation episode consistent with the covered indications and frequency limits.

Serologic testing for Helicobacter pylori is not reimbursable for adult or pediatric patients because it cannot distinguish active infection from past exposure or a cured infection. Nucleic acid–based methods (including PCR, 16S rRNA, 23S rRNA, and next‑generation sequencing) are also not reimbursable for routine diagnosis. When using UBT or stool antigen testing for diagnosis or to confirm eradication, ensure testing is performed in accordance with the timing and clinical indications in this policy.