CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPLABO17

Celiac Disease Testing

Defines Blue Cross Blue Shield of New Mexico reimbursement criteria for serologic, genetic, and biopsy testing used to diagnose and monitor celiac disease for covered members and applicable providers.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyCeliac Disease Testing

Policy CodePolicy CPCPLABO17

Change TypeMaterial updates (added non-reimbursable assay, removed codes, clarified monitoring intervals)

Effective DateSep 26, 2025

Next Review DateN/A

Key ActionSubmit accurate documentation with claims and be prepared to provide additional documentation upon request; avoid billing non-reimbursable tests such as HLA-DQ-gluten tetramer assays.

SourceLink

POLICY UPDATE CHANGES

Serologic testing using an HLA-DQ-gluten tetramer-based assay, including flow cytometry-based HLA-DQ-gluten tetramer assays, is not reimbursable.

Codes 81376, 81377, 81382, 81383 were removed from the policy code list.

Intervals for reimbursable serologic monitoring after celiac disease diagnosis were specified for IgA-sufficient and IgA-deficient individuals.

13+reimbursement guidance items

8example procedure codes

3monitoring tiers

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Reimbursement Criteria and Exclusions

Reimbursement criteria and exclusions

Coverage determinations for specific test types and clinical scenarios.

For individuals with signs or symptoms of celiac disease, serologic testing with IgA anti-tissue transglutaminase (TTG) plus total IgA for diagnosis may be reimbursable.

For individuals at risk for celiac disease, when IgA anti-TTG is negative or weakly positive, testing for IgA endomysial antibodies may be reimbursable.

For individuals with clinical suspicion of celiac disease who are IgA deficient, testing for IgG endomysial antibodies, IgG deamidated gliadin peptide (DGP), or IgG TTG may be reimbursable.

For confirmation of celiac disease in individuals at high risk, regardless of serology results, pathological examination of a small intestine biopsy may be reimbursable.

Not reimbursable

Rapid antigen point-of-care testing for anti-TTG is not reimbursable.
Panel testing, multiplex testing, or multi-analyte testing for more than two analytes for diagnosis or evaluation of celiac disease is not reimbursable.
Testing for asymptomatic individuals not at increased risk for developing celiac disease is not reimbursable.
Testing for anti-reticulin antibodies is not reimbursable for the diagnosis of celiac disease.
Testing of stool or saliva samples for the evaluation of celiac disease is not reimbursable.
Serologic testing using an HLA-DQ-gluten tetramer-based assay, including flow cytometry-based HLA-DQ-gluten tetramer assays, is not reimbursable.

Procedure Codes and Monitoring Frequency

Example procedure codes mentionedCPT

82784
83516
86231
86255
86256
86258
86364
88305

Monitoring frequency tiers

First follow-up3–6 months after diagnosis

Short-term monitoringEvery 6 months until normalization of antibody levels

Long-term monitoringEvery 12–24 months thereafter

Documentation, Claims, and Denial Risk

Documentation Required

Documentation and claim review

Providers must submit accurate documentation and may be asked to provide additional records to support medical necessity, coding, and billing for celiac disease testing. Claims are reviewed against plan benefit terms, provider contract language, medical policies, clinical payment and coding policies, and automated code-edit logic. Upon request, providers should furnish supporting documentation to expedite claim review and determination.

Submit claims using valid HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, etc.).
Claims are subject to code edit protocols and may be denied or adjusted if documentation or coding is incomplete or inconsistent.

Denial Risk

Denial risk for non-reimbursable tests

Tests and panels identified as not reimbursable in this policy carry a risk of claim denial when billed. Examples include rapid point-of-care anti-TTG, panel/multiplex/multi-analyte tests (more than two analytes), anti-reticulin antibody testing, stool or saliva testing for celiac disease evaluation, and HLA‑DQ‑gluten tetramer‑based serologic assays (including flow cytometry‑based assays).

Clinical Definitions and IgA Status

Signs and symptoms of celiac disease

Common gastrointestinal and systemic signsUnexplained chronic or intermittent diarrhea; unexplained weight loss; chronic or intermittent abdominal pain or bloating; recurrent nausea or vomiting

Hematologic and nutritional findingsUnexplained iron deficiency anemia; unexplained vitamin B12 or folate deficiency; unexplained liver transaminase elevations

Associated autoimmune and dermatologic conditionsDermatitis herpetiformis; type 1 diabetes; autoimmune hepatitis; primary biliary cirrhosis

Reproductive and skeletal issuesUnexplained subfertility or miscarriage; unexplained osteoporosis, osteomalacia, or low bone density

Pediatric-specific signsFatty stools, failure to thrive, delayed puberty, stunted growth, short stature; amenorrhea