CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLABO2S

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

Defines BCBSNM reimbursement criteria for fecal testing related to diagnosis of intestinal dysbiosis and screening/testing related to fecal microbiota transplantation (FMT); applies to providers submitting lab claims under BCBSNM plans.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

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

Policy CodePolicy CPCPLABO2S

Change TypeNo material change

Effective DateJan 1, 2023

Next Review Date

Key ActionProviders must submit accurate documentation and use valid HIPAA‑approved code sets; BCBSNM may request additional documentation and uses discretion interpreting/applying this policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7 organismsReimbursable culture panel

8 organismsReimbursable NAAT panel

Excluded organismsNAAT not reimbursable

MultipleComponent tests excluded

2023Policy effective

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.

Coverage Criteria for Fecal Testing and FMT

FMT and dysbiosis testing coverage

Reimbursement and exclusion criteria for fecal testing related to fecal microbiota transplantation (FMT) and evaluation of intestinal dysbiosis.

ALL of the following

Culture testing reimbursable prior to FMT
- Fecal analysis by culture prior to FMT may be reimbursable for: Extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae.
- Fecal analysis by culture prior to FMT may be reimbursable for: Vancomycin-resistant Enterococci (VRE).
- Fecal analysis by culture prior to FMT may be reimbursable for: Carbapenem-resistant Enterobacteriaceae (CRE).
- Fecal analysis by culture prior to FMT may be reimbursable for: Campylobacter.
- Fecal analysis by culture prior to FMT may be reimbursable for: Methicillin-resistant Staphylococcus aureus (MRSA).
- Fecal analysis by culture prior to FMT may be reimbursable for: Shigella.
- Fecal analysis by culture prior to FMT may be reimbursable for: Salmonella.
NAAT reimbursable prior to FMT
- Fecal analysis by nucleic acid amplification testing (NAAT) prior to FMT may be reimbursable for: Clostridioides difficile (C. difficile).
- Fecal analysis by NAAT prior to FMT may be reimbursable for: Campylobacter.
- Fecal analysis by NAAT prior to FMT may be reimbursable for: Salmonella.
- Fecal analysis by NAAT prior to FMT may be reimbursable for: Shigella.
- Fecal analysis by NAAT prior to FMT may be reimbursable for: Shiga toxin-producing Escherichia coli.
- Fecal analysis by NAAT prior to FMT may be reimbursable for: Norovirus.
NAAT not reimbursable prior to FMT
- NAAT prior to FMT is not reimbursable for: Extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae.
- NAAT prior to FMT is not reimbursable for: Vancomycin-resistant Enterococci (VRE).
- NAAT prior to FMT is not reimbursable for: Methicillin-resistant Staphylococcus aureus (MRSA).
- NAAT prior to FMT is not reimbursable for: Carbapenem-resistant Enterobacteriaceae (CRE).
- NAAT prior to FMT is not reimbursable for: other microorganisms not listed as reimbursable.
Fecal component analyses excluded for dysbiosis/IBS/malabsorption/SIBO
- The following fecal component analyses are not reimbursable as diagnostic tests for evaluation of intestinal dysbiosis, irritable bowel syndrome, malabsorption, or small intestinal bacterial overgrowth: Triglycerides.
- Not reimbursable: Chymotrypsin.
- Not reimbursable: Iso-butyrate, iso-valerate, and n-valerate.
- Not reimbursable: Long chain fatty acids.
- Not reimbursable: Meat and vegetable fibers.
- Not reimbursable: Cholesterol.
Informational: other fecal analytes noted in document
- Identification and quantitation of fecal yeast (including C. albicans, C. tropicalis, Rhodoptorula and Geotrichum); levels of Lactobacilli, bifidobacteria, and E. coli and other potential pathogens; n-butyrate; beta-glucuronidase; pH; fecal secretory IgA; short chain fatty acid distribution.
  Descriptive (informational) list of additional fecal analytes appearing in the document; these are not explicitly identified as reimbursable for dysbiosis testing.

Coding Guidance

Coding guidancemixed

Claims should be coded using HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC etc.) per industry standards.

Documentation and Claims Submission Requirements

Documentation Required

Documentation, coding, and claims submission requirements

Providers must submit accurate documentation of services performed and code claims using valid HIPAA‑approved code sets; BCBSNM may request additional documentation and applies discretion when interpreting and applying this policy.

Submit documentation that accurately reflects services performed.
Use valid code combinations from HIPAA‑approved code sets (CPT, HCPCS, ICD‑10, NDC, UB, DRG, etc.) and follow industry standard coding guidelines.
Be prepared to provide additional documentation upon BCBSNM request; claims are subject to claim review and code edit protocols.

Definitions and Test Lists

inv-04: Culture testing for specified enteric and resistant organisms prior to FMT — Fecal analysis by culture

DefinitionFecal analysis by culture: growth-based laboratory testing of stool to identify specified enteric and resistant organisms prior to fecal microbiota transplant (FMT).

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

Intended usePerformed prior to FMT to screen donor or recipient stool for specified enteric pathogens and antimicrobial-resistant organisms.

Policy noteMay be reimbursable when performed as fecal analysis by culture prior to FMT per BCBSNM reimbursement criteria; review plan documents for coverage applicability.

inv-05: Nucleic acid amplification testing used to detect specific pathogens prior to FMT — NAAT

inv-06: Excluded fecal component analyses — Analyses such as chymotrypsin, triglycerides, certain fatty acids, fibers, cholesterol, and total short chain fatty acids are not reimbursable for dysbiosis/IBS/malabsorption/SIBO evaluation

ScopeAnalyses of specific fecal components are excluded from reimbursement when performed as diagnostic tests for evaluation of intestinal dysbiosis, irritable bowel syndrome, malabsorption, or small intestinal bacterial overgrowth (SIBO).

Excluded fecal component testsChymotrypsin; Triglycerides; Iso-butyrate, iso-valerate, n-valerate; Long-chain fatty acids; Meat and vegetable fibers; Cholesterol; Total short chain fatty acids.

Policy implicationThese component analyses are not reimbursable for dysbiosis/IBS/malabsorption/SIBO evaluation under BCBSNM lab management reimbursement criteria.

Additional analytes (informational)Document lists other descriptive fecal analytes (yeast identification, Lactobacilli, bifidobacteria, E. coli, pH, fecal secretory IgA, SCFA distribution) but these are presented descriptively and are not explicitly marked reimbursable for dysbiosis testing.