Blue Cross Blue Shield OK H. pylori Coverage Update

Coverage Criteria for H. pylori Testing

Adult diagnostic indications

For individuals 18 years of age and older, urea breath testing OR stool antigen testing to diagnose an H. pylori infection may be reimbursable when ANY of the following are present:

Adult diagnostic indications: a. Dyspeptic symptoms; b. Active peptic ulcer disease; c. Past peptic ulcer disease without documented H. pylori history; d. Low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma; e. History of endoscopic resection of early gastric cancer; f. Gastric intestinal metaplasia; g. Uninvestigated dyspepsia in individuals <60 years without alarm features; h. Initiating chronic nonsteroidal anti-inflammatory drug (NSAID) therapy; i. Unexplained iron deficiency anemia; j. Evaluation of chronic immune thrombocytopenic purpura with suspected H. pylori infection; k. Family history of gastric cancer; l. First-generation immigrants from high-prevalence areas.

Adult diagnostic indications list

Adult test-of-eradication

For individuals 18 years of age and older, urea breath testing or stool antigen testing to confirm eradication may be reimbursable when ANY of the following apply (testing should be at least 4 weeks post-treatment):

Adult test-of-eradication indications: a. H. pylori–associated ulcer; b. Persistent dyspepsia despite appropriate antibiotic treatment for H. pylori; c. Gastric MALT lymphoma; d. After resection of early gastric cancer.>=4 weeks post-treatment

Test-of-eradication scenarios; follow-up measurement at least 4 weeks post-treatment

Endoscopic/biopsy-based testing (adults)

For adults undergoing endoscopy or with alarm symptoms, biopsy-based testing may be reimbursable when ALL of the following apply:

Endoscopic/biopsy indication: Undergoing endoscopic examination or presence of alarm symptoms

When met, a biopsy-based endoscopic histology test plus either a rapid urease test or a culture with susceptibility testing to diagnose H. pylori may be reimbursable.

Biopsy-based endoscopic testing

Covered when ALL of the following are met

Biopsy-based testing for adults: Individual is 18 years of age or older AND is undergoing endoscopic examination OR has alarm symptomsage >= 18

When met, a biopsy-based endoscopic histology test plus either a rapid urease test or a culture with susceptibility testing to diagnose H. pylori infection may be reimbursable.

Pediatric noninvasive indications

For individuals less than 18 years of age, noninvasive testing (urea breath test OR stool antigen) to diagnose an H. pylori infection may be reimbursable when ANY of the following are present:

Pediatric noninvasive indications: a. Chronic immune thrombocytopenic purpura with suspected H. pylori infection; b. To measure success of eradication of H. pylori infection (follow-up measurement at least 4 weeks post-treatment).>=4 weeks post-treatment for eradication testing

Pediatric noninvasive indications

Pediatric endoscopic/biopsy indications

For individuals less than 18 years of age, biopsy-based endoscopic histology with rapid urease test or culture may be reimbursable when ANY of the following are present:

Pediatric endoscopic indications: a. Gastric or duodenal ulcers; b. Refractory iron deficiency anemia when other causes have been ruled out.

Pediatric biopsy-based indications

The policy specifies explicit noninvasive and laboratory testing exclusions. Serologic testing for H. pylori is not reimbursable for individuals of any age, and nucleic acid testing is not reimbursable. Concurrent testing using multiple modalities (for example, performing urea breath test, stool antigen testing, and biopsy-based testing together) is also not reimbursable. Testing performed within the window of recent use of antibiotics, proton pump inhibitors, or bismuth is excluded from reimbursement. Additionally, urea breath or stool antigen testing to diagnose H. pylori is not reimbursable for asymptomatic individuals of all ages.

For pediatric members (<18 years), the policy identifies specific endoscopic/biopsy scenarios that are not eligible for reimbursement. Biopsy-based endoscopic testing is not reimbursable for children with functional abdominal pain, when used as part of the initial investigation of iron deficiency anemia, or when performed to investigate causes of short stature. Reimbursable pediatric biopsy-based indications are limited to situations such as gastric or duodenal ulcers and refractory iron deficiency anemia after other causes have been ruled out.

The policy treats testing in asymptomatic individuals and serologic testing as non-covered. Specifically, urea breath test or stool antigen testing to diagnose H. pylori is not reimbursable for asymptomatic individuals of all ages, and serologic testing is not reimbursable. These exclusions are framed as reimbursement policy determinations and align with the policy’s characterization of such testing as not eligible for coverage.

No explicit additional exclusions are listed in the extracted section of the policy update history beyond those already described in the reimbursement information.

The policy update history and extracted sections do not present separate explicit 'not medically necessary' statements beyond the stated reimbursement exclusions (for example, asymptomatic testing and serologic testing), which are characterized elsewhere in the policy as not reimbursable.

Procedure and Billing Codes

Listed procedure codesmixed

83009
83013
83014
86318
86677
87070
87077
87081
87149
87150

1–10 of 19

1/2

Covered CPT Codes (policy update)CPTCovered

87513

Infectious agent detection by nucleic acid; Helicobacter pylori, amplified probe technique (new code added in policy update)

Provider Billing, Documentation, and Operational Guidance

Note

Code applicability and plan-product review

BCBSOK has implemented lab management reimbursement criteria. Not all requirements apply to every product; providers must review the member’s specific plan documents (Certificates of Benefits, summary plan descriptions, provider contracts, etc.) to confirm coverage, benefit limits, and any plan-specific rules. When plan documents and this clinical payment and coding policy conflict, the plan document (or provider contract where applicable) governs.

Providers are responsible for verifying plan-product applicability before ordering or billing laboratory testing.
Plan documents govern coverage determinations when they conflict with this policy.

Billing Rule

CPT coding update — use CPT 87513 effective 01/01/2025

A new CPT code (87513) for stool antigen testing was added effective 01/01/2025. Use CPT 87513 for stool antigen testing services performed on or after 2025-01-01 and confirm any operational billing steps with your billing system and clearinghouse.

Background

Helicobacter pylori diagnostic approaches include both noninvasive and invasive options. Noninvasive methods described in the policy are the urea breath test and stool antigen testing, which are used for initial diagnosis and for documenting eradication when performed at least 4 weeks post-treatment. Invasive or biopsy-based approaches involve endoscopic gastric biopsy specimens evaluated by histology supplemented with a rapid urease test or culture (with susceptibility testing); the policy notes biopsy-based testing may be reimbursable for adults undergoing endoscopy or who present with alarm symptoms. The clinical context in the policy differentiates adult and pediatric indications and emphasizes appropriate timing (post-treatment interval) and select clinical scenarios (eg, peptic ulcer disease, gastric MALT lymphoma, refractory iron deficiency anemia) where testing is considered.

Definitions and Key Terms

Test-of-eradication (inv-24)

DefinitionTesting performed to document eradication of H. pylori after therapy; urea breath test or stool antigen testing performed at least 4 weeks following completion of treatment.

Allowed methodsUrea breath test; Stool antigen testing (validated assays)

Minimum timing>= 4 weeks post-treatment

Biopsy-based testing (inv-25)

DefinitionEndoscopic biopsy–based approach using gastric tissue evaluated by histology in combination with either a rapid urease test or culture with susceptibility testing to diagnose H. pylori infection.

ComponentsEndoscopic gastric biopsy specimens; histologic examination; adjunct rapid urease test or culture (with susceptibility testing)

Revision History / Policy Updates

2024-11-19policy_updateLatest

Added new CPT code 87513 to the policy's code set (effective 01/01/2025).

2024-04-29literature_review

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

2023-06-15policy_revision

Reimbursement information revised for clarity and biopsy-based endoscopic testing guidance added for adults (endoscopic examination or alarm symptoms) including histology plus rapid urease test or culture with susceptibility testing.

OpenPayer

Helicobacter pylori Testing