CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLABO18

Helicobacter pylori Testing

Defines Blue Cross Blue Shield of New Mexico reimbursement criteria for diagnostic and test-of-cure testing for Helicobacter pylori across age groups and test modalities; applies to providers submitting claims to BCBSNM for covered members.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyHelicobacter pylori Testing

Policy CodePolicy CPCPLABO18

Change TypeRevised with additions

Effective DateAug 8, 2025

Next Review Date

Key ActionSubmit claims with accurate documentation and appropriate codes; BCBSNM may request additional documentation and exercises discretion in policy application.

SourceLink

POLICY UPDATE CHANGES

Reimbursement criteria reorganized and clarified (examples: changed 'dyspeptic' to 'dyspepsia (see Note 1)'; clarified recurrent symptoms after past PUD; added test-of-cure and susceptibility testing reimbursement statements).

New explicit Notes defining dyspepsia and alarm features of dyspepsia were added.

Added code 87513 to the procedure/code list.

≥6listed adult noninvasive/biopsy reimbursable indications

2test-of-cure modalities

4 weeksminimum interval for test-of-cure

Multiple

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Reimbursable Helicobacter pylori Testing Criteria

Coverage criteria

Reimbursable testing is defined by age, clinical indication, testing modality, and timing.

ALL of the following

Indications (ONE or more):
- Dyspepsia (see Note 1)
- Active peptic ulcer disease
- Past peptic ulcer disease with recurrent symptoms
- History of resection of early gastric cancer
- Low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma
- Gastric intestinal metaplasia
- Unexplained iron deficiency anemia
- Initiating chronic or on long-term aspirin or NSAID therapy
- Idiopathic immune thrombocytopenic purpura
- First-generation immigrants from high-prevalence areas
- Family history of gastric cancer

Adults (>=18 years) undergoing endoscopy OR with alarm symptoms: biopsy-based endoscopic histology PLUS either rapid urease test OR culture with susceptibility testing may be reimbursable.

ALL of the following

ANY of the following
- Family history of gastric cancer
- Gastric or duodenal ulcers or erosions

Children (<18 years) with refractory iron deficiency anemia: biopsy-based endoscopic histology PLUS either rapid urease test OR culture with susceptibility testing may be reimbursable.

Post‑treatment test-of-cure for all ages: urea breath test OR stool antigen test to document eradication may be reimbursable WHEN performed at least four weeks after completion of therapy.

Refractory H. pylori infection: susceptibility testing (culture OR nucleic-acid–based) may be reimbursable.

Not reimbursable (these situations are exclusions):

Urea breath test or stool antigen to diagnose H. pylori in adults with typical GERD symptoms (eg, heartburn, regurgitation) without a history of peptic ulcer disease
Testing in asymptomatic individuals of any age
Serologic testing for H. pylori at any age
Biopsy-based testing in children for specified indications such as functional abdominal pain or as part of initial investigation in children with iron deficiency anemia
Testing within recent use of antibiotics, proton pump inhibitors, or bismuth (tests to diagnose infection not reimbursable)
Concurrent duplicate testing using any combination of urea breath, stool antigen, and biopsy-based tests to diagnose infection

Procedure and Test Coding

Listed procedure codes (not all-encompassing)mixed

83009
83013
83014
86318
86677
87070
87077
87081
87149
87150

1–10 of 12

1/2

Test-of-cure timing — inv-03

Test-of-cure timingUrea breath test or stool antigen test performed at least four weeks post-treatment to measure eradication of H. pylori.

Post-treatment modalitiesAllowed test-of-cure modalities: urea breath test or stool antigen testing.

Refractory infection noteFor refractory H. pylori infection, susceptibility testing (culture or nucleic-acid–based) may be reimbursable.

Documentation and Payer Discretion

Documentation Required

Submit accurate documentation and use appropriate codes; BCBSNM may request additional documentation and exercise discretion

Providers must submit accurate documentation of services performed and use valid, industry-standard codes when billing. BCBSNM may request additional documentation and applies reasonable discretion in interpreting and applying this policy; if plan documents or provider contracts conflict with this policy, the plan document or contract governs.

Submit claims using valid code combinations from HIPAA-approved code sets (CPT, HCPCS, ICD-10, etc.).
Code claims appropriately per industry coding guidelines (Uniform Billing, AMA CPT resources, CMS NCCI, CCI edits).
Be prepared to provide additional documentation upon request for claim review or appeals.

Key Definitions

Dyspepsia definition — inv-05

DefinitionDyspepsia: bothersome upper abdominal symptoms often meal-related, including postprandial fullness (bloating after meals), early satiety, or epigastric pain or burning; pain is not required for diagnosis.

Typical symptom timingSymptoms are often related to meals; postprandial fullness and satiety are predominant when dyspepsia is chronic.

Pain frequencyEpigastric pain is a less common feature in chronic dyspepsia compared with postprandial fullness or early satiety.

Alarm features of dyspepsia — inv-06

Alarm featuresVomiting, gastrointestinal bleeding, unexplained iron deficiency, or weight loss.

ImplicationPresence of alarm features may alter diagnostic approach and reimbursement eligibility (see coverage criteria for individuals with alarm symptoms).