ModifiedBlue Cross Blue Shield - New MexicoPolicy CPCPLABO3S

Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease

This reimbursement and coding policy governs when the Plan may reimburse certain laboratory tests used to diagnose or monitor inflammatory bowel disease (IBD) for Blue Cross and Blue Shield of New Mexico members; it applies to providers submitting claims to BCBSNM. Providers should consult specific plan documents for product-level applicability.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyLaboratory Testing for the Diagnosis of Inflammatory Bowel Disease

Policy CodePolicy CPCPLABO3S

Change TypeMaterial updates: merged prior policy, added reimbursable rules, clarified exclusions

Effective DateSep 26, 2025

Next Review Date

Key ActionWhen submitting claims, provide documentation; fecal calprotectin is preferred and only it will be approved if ordered with fecal lactoferrin.

SourceLink

POLICY UPDATE CHANGES

Combined CPCPLABO26 Fecal Calprotectin Testing in Adults into this policy, resulting in new #1 and #2 specifying reimbursable uses for fecal calprotectin or fecal lactoferrin testing.

Added Note 1 that fecal calprotectin is the preferred biomarker and if both fecal calprotectin and fecal lactoferrin are ordered simultaneously, only fecal calprotectin will be approved.

Former #2 was renumbered to #4 and revised to state that multianalyte serum biomarker panels designed to distinguish between IBD and non-IBD or to diagnose/monitor IBD are not reimbursable (examples: ibs-smart, IBSchek, Prometheus).

Added CPT/HCPCS code 0598U effective 10/01/2025.

2New reimbursable situations

1Preferred biomarker mandated

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MultipleExcluded serologic markers

YesExcluded multianalyte panels

Coverage Criteria for IBD Laboratory Testing

IBD lab testing coverage criteria

Reimbursement information and coverage stance for laboratory tests related to IBD:

ALL of the following

ANY of the following
- ALL of the following
  - For the differential diagnosis between non-inflammatory gastrointestinal disease (e.g., IBS) and inflammatory gastrointestinal disease (e.g., IBD).
    See Note 1 regarding preferred biomarker.
- ALL of the following
  - To monitor individuals with IBD to assess response to therapy or relapse.
ALL of the following
- Fecal calprotectin and fecal lactoferrin testing are not reimbursable for situations other than the two uses listed above.
- Serologic markers are not reimbursable for the workup and monitoring of IBD. Examples include: ANCA, pANCA, ASCA, anti-OmpC, anti-I2, anti-CBir1, ACCA IgA, AMCA IgG, ALCA IgG, PKM2.
  List is not necessarily exhaustive; see policy for full list.
- Multianalyte serum biomarker panels (with or without algorithmic analysis) designed to distinguish IBD from non-IBD or to diagnose/monitor IBD are not reimbursable (examples: ibs-smart, IBSchek, Prometheus).
ALL of the following
- Not all requirements apply to every product; providers must review specific plan documents for eligible coverage.
- Procedure code inclusion does not guarantee coverage or reimbursement eligibility.

ALL of the following

Note 1: Fecal calprotectin is the preferred biomarker; if fecal calprotectin and fecal lactoferrin are ordered at the same time, only fecal calprotectin will be approved.
BCBSNM added CPT/HCPCS code 0598U effective 10/01/2025; inclusion of a code does not by itself guarantee coverage.

Fecal biomarker coverage criteria

Reimbursable uses

ALL of the following

ONE OF
- Differential diagnosis: Fecal calprotectin or fecal lactoferrin testing is reimbursable to distinguish non-inflammatory gastrointestinal disease (e.g., IBS) from inflammatory gastrointestinal disease (e.g., IBD).
- Monitoring: Fecal calprotectin or fecal lactoferrin testing is reimbursable to monitor individuals with IBD to assess response to therapy or to detect relapse.
ALL of the following
- Tests not listed above are not reimbursable: fecal calprotectin and fecal lactoferrin are not reimbursable for other situations not described in the two covered uses.

Procedure Codes and Code Updates

Procedure codes guidancemixed

No codes listed

New/updated codesHCPCS

0598U

Added code effective 10/01/2025 (specific description not provided in source)

Provider Responsibilities, Prior Authorization, and Reimbursement Rules

Documentation Required

Submit accurate documentation and respond to claims review requests

Providers are responsible for submission of accurate documentation of services performed and must submit claims using valid, industry-standard code sets and guidelines. Claims are subject to code edit protocols and may be reviewed for benefit, contract, policy, and code-edit compliance; upon request, providers should submit any additional documentation to support the claim.

Submit claims using valid HIPAA-approved code sets and appropriate coding guidelines (CPT, HCPCS, ICD-10-CM/PCS, NDC, DRG, CMS NCCI/CCI guidance).
Be prepared to provide additional documentation upon request during claim review for benefit, contract, policy, or coding edits.

Prior Authorization

Reimbursement rules for fecal biomarker testing (prior authorization summary)

Fecal calprotectin or fecal lactoferrin testing is reimbursable only for: 1) differential diagnosis between non-inflammatory GI disease (e.g., IBS) and inflammatory GI disease (e.g., IBD); and 2) monitoring individuals with IBD to assess response to therapy or relapse. If both fecal calprotectin and fecal lactoferrin are ordered simultaneously, only fecal calprotectin will be approved.

Definitions and Test Descriptions

inv-08: fecal calprotectin / fecal lactoferrin — definitions of these stool biomarkers and their clinical role

DefinitionFecal calprotectin and fecal lactoferrin are stool biomarkers used to differentiate inflammatory versus non‑inflammatory gastrointestinal disease and to monitor individuals with IBD for response to therapy or relapse.

Clinical roleDifferential diagnosis: helps distinguish non‑inflammatory GI disease (e.g., IBS) from inflammatory GI disease (e.g., IBD).

Monitoring roleUsed to monitor individuals with known IBD to assess response to therapy or detect relapse.

inv-09: serologic markers (not reimbursable) — list of serologic markers excluded from reimbursement for IBD workup/monitoring

Scope of exclusionSerologic markers are not reimbursable for the workup and monitoring of individuals with IBD.

Examples (non‑exhaustive)

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyLaboratory Testing for the Diagnosis of Inflammatory Bowel Disease

Policy CodePolicy CPCPLABO3S

Change TypeMaterial updates: merged prior policy, added reimbursable rules, clarified exclusions

Effective DateSep 26, 2025

Next Review Date

Key ActionWhen submitting claims, provide documentation; fecal calprotectin is preferred and only it will be approved if ordered with fecal lactoferrin.

SourceLink

On This Page

If both fecal calprotectin and fecal lactoferrin are ordered at the same time, only fecal calprotectin will be approved (preferred biomarker).

Operational preference mandated by policy Note 1.

Multianalyte serum biomarker panels (with or without algorithmic analysis) designed to distinguish between IBD and non-IBD or to diagnose/monitor IBD (e.g., ibs-smart, IBSchek, Prometheus) are not reimbursable.

ALL of the following

New/updated code: 0598U was added (effective 10/01/2025); inclusion of a code does not guarantee coverage eligibility—claims remain subject to plan, contract, policy, and code edit review.

Tests are not reimbursable for situations other than the two listed above.
Note: CPT/HCPCS code 0598U was added effective 10/01/2025.

Denial Risk

Serum multianalyte biomarker panels are not reimbursable

Multianalyte serum biomarker panels—whether with or without algorithmic analysis—intended to distinguish between IBD and non-IBD or to diagnose or monitor IBD are not reimbursable.

Examples include ibs-smart, IBSchek, and Prometheus testing.
Claims for such serum multianalyte panels will be denied as non-reimbursable under this policy.

Anti‑neutrophil cytoplasmic antibody (ANCA); perinuclear ANCA (pANCA); Anti‑Saccharomyces cerevisiae antibody (ASCA).

Additional examplesAntibody to Escherichia coli outer membrane C (anti‑OmpC); antibody to Pseudomonas fluorescens‑associated sequence I2 (anti‑I2); Anti‑CBir1 flagellin antibody (anti‑CBir1).

Other listed markersAntichitobioside antibodies (ACCA IgA); Antimannobioside antibodies (AMCA IgG); Antilaminaribioside antibodies (ALCA IgG); Pyruvate kinase M2 (PKM2).

inv-10: multianalyte serum biomarker panels (not reimbursable) — definition and scope of excluded serum panel tests

DefinitionMultianalyte serum biomarker panels are serum‑based tests, with or without algorithmic analysis, intended to distinguish between IBD and non‑IBD or to diagnose or monitor IBD.

Reimbursement stanceThese multianalyte serum biomarker panels are not reimbursable when designed to distinguish IBD from non‑IBD or to diagnose/monitor IBD.

Examples noted in policyExamples include tests marketed as ibs‑smart, IBSchek, and Prometheus (listed as illustrative, not exhaustive).

inv-11: Preferred biomarker — Note 1 stating fecal calprotectin is preferred and only it will be approved when both calprotectin and lactoferrin are ordered

Policy NoteFecal calprotectin is the preferred biomarker; if fecal calprotectin and fecal lactoferrin are ordered at the same time, only fecal calprotectin will be approved.

Operational effectWhen both tests are submitted simultaneously, claims for fecal lactoferrin will not be approved in favor of fecal calprotectin.

SourceThis preference was added to the policy during the 09/26/2025 update and is effective per the policy update history.

inv-12: Multianalyte serum biomarker panels — additional definitional detail on panels intended to distinguish IBD vs non-IBD

Expanded definitionMultianalyte serum biomarker panels refer to serum‑based tests, with or without algorithmic or proprietary analytic algorithms, intended to distinguish IBD from non‑IBD or to diagnose or monitor IBD.

Policy exclusion detailThe policy explicitly states these panels are not reimbursable when designed for IBD vs non‑IBD differentiation or for diagnosing/monitoring IBD; examples provided include ibs‑smart, IBSchek, Prometheus.

Implication for orderingProviders should not expect reimbursement for serum multianalyte panel testing used for IBD differential diagnosis or monitoring, regardless of analytic method.