CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLAB025

Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing

Defines BCBSNM reimbursement criteria for fecal analysis tests related to diagnosis of intestinal dysbiosis and testing prior to FMT, including which organisms/tests are reimbursable or not; applies to providers submitting claims to Blue Cross Blue Shield of New Mexico.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyFecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing

Policy CodePolicy CPCPLAB025

Change TypeNon-material literature review update (reimbursement unchanged)

Effective DateNovember 1, 2023

Next Review Date

Key ActionProviders must submit accurate documentation of services performed and provide additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

Document updated with literature review; reimbursement information unchanged; references revised.

New policy

1.0policy version

Nov 1, 2023effective date

3culture reimbursable

8NAAT reimbursable

≥13

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

non-reimbursable items

Coverage and Medical Necessity Criteria

FMT and intestinal dysbiosis testing coverage criteria

Reimbursement guidance for fecal analysis prior to fecal microbiota transplant (FMT) and diagnostic tests for intestinal dysbiosis/related conditions.

Fecal analysis tests may be reimbursable only as specified below; other tests or organisms not listed are not reimbursable as indicated.

Reimbursable by culture prior to FMT (ANY of the following)

Extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae
Vancomycin-resistant Enterococci (VRE)
Carbapenem-resistant Enterobacteriaceae (CRE)
Methicillin-resistant Staphylococcus aureus (MRSA)
Campylobacter
Shigella
Salmonella

Reimbursable by NAAT prior to FMT (ANY of the following)

Clostridium Difficile
Campylobacter
Salmonella
Shigella
Shiga toxin-producing Escherichia coli
Norovirus
Rotavirus

Not reimbursable by NAAT prior to FMT (ANY of the following)

Extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae
Vancomycin-resistant Enterococci (VRE)
Carbapenem-resistant Enterobacteriaceae (CRE)
Methicillin-resistant Staphylococcus aureus (MRSA)
Any other microorganisms not listed as reimbursable

Fecal components not reimbursable for evaluation of intestinal dysbiosis/IBS/malabsorption/SIBO (ANY of the following)

Triglycerides
Chymotrypsin
Iso-butyrate, iso-valerate, and n-valerate
Meat and vegetable fibers
Long chain fatty acids
Cholesterol
Total short chain fatty acids

Update History

Policy update notes

7/5/2023: Document updated with literature review; reimbursement information unchanged; references revised.

11/1/2022: New policy.

Procedure and Billing Codes

Procedure codes listed (not exhaustive)mixed

82542
82705
82710
82715
83986
84311
87045
87046
87075
87076

1–10 of 20

1/2

No codes listed in this document portionmixed

No codes listed

Provider Responsibilities and Submission Guidance

Documentation Required

Documentation submission responsibility

Providers are responsible for submission of accurate documentation of services performed. Providers must submit claims using valid HIPAA-approved code sets and code appropriately per industry standards (e.g., UB, AMA CPT®, CPT® Assistant, HCPCS, ICD-10 CM/PCS, NDC, DRG guidelines, CMS NCCI Policy Manual and CCI table edits). Claims are subject to code edit protocols and review against benefit coverage, provider contract terms, medical and coding policies, and coding software logic. Upon request, providers must submit any additional documentation to support claims.

Submit claims with valid HIPAA-approved code sets and correct code combinations.
Be prepared to provide additional documentation upon request to support medical necessity and coding.
Claims are subject to claim review and code edit protocols.

Note

Reimbursement information unchanged

Reimbursement information unchanged as of 7/5/2023 — no new authorization actions are specified in this document portion.

Definitions and References

CPCP conflicts with plan documents/provider contracts

Governing documents take precedenceIf a conflict arises between a CPCP and any plan document under which a member is entitled to Covered Services, the plan document will govern.

Provider contract precedenceIf a conflict arises between a CPCP and any provider contract pursuant to which a provider participates in and/or provides Covered Services, the provider contract will govern.

Scope of 'plan documents''Plan documents' include Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.

BCBSNM discretionBCBSNM may use reasonable discretion interpreting and applying this policy to services being delivered in a particular case.

Final authorityBCBSNM has full and final discretionary authority for their interpretation and application to the extent provided under any applicable plan documents.

Policy Update History

2023-07-05updatedLatest

Document updated with literature review; reimbursement information unchanged; references revised.

2022-11-01created

New policy created (policy effective/established).

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyFecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing

Policy CodePolicy CPCPLAB025

Change TypeNon-material literature review update (reimbursement unchanged)

Effective DateNovember 1, 2023

Next Review Date

Key ActionProviders must submit accurate documentation of services performed and provide additional documentation upon request.

SourceLink

On This Page

COVID-19 (SARS-CoV-2)

Levels of Lactobacilli, bifidobacteria, and E. coli and other 'potential pathogens' (Aeromona, Bacillus cereus, Campylobacter, Citrobacter, Klebsiella, Proteus, Pseudomonas, Salmonella, Shigella, S. aureus, Vibrio)

Identification and quantitation of fecal yeast (including C. albicans, C. tropicalis, Rhodoptorul and Geotrichum)

Short chain fatty acid distribution

Policy update 7/5/2023: document updated with literature review; reimbursement information unchanged.

References

Microbiome and pediatric IBDMalham M., et al. (2019). The microbiome reflects diagnosis and predicts disease severity in paediatric onset inflammatory bowel disease. Scand J Gastroenterol.

Intestinal dysbiosis reviewMarietta E., et al. (2020). Intestinal Dysbiosis in, and Enteral Bacterial Therapies for, Systemic Autoimmune Diseases. Front Immunol. 11:2760.

Pediatric FMT position paper addendumMichail S., et al. (2020). Addendum: Fecal Microbiota Transplantation for Recurrent Clostridium difficile Infection and Other Conditions in Children. J Pediatr Gastroenterol Nutr. 70(3).

BSG/HIS guidelines for FMT and CDIMullish BH., et al. (2018). Use of faecal microbiota transplant as treatment for recurrent or refractory Clostridium difficile infection and other potential indications: joint BSG and HIS guidelines. Gut. 67(11):1920.