CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB035

Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease

Defines reimbursement criteria for fecal and serologic laboratory tests used to diagnose or monitor IBD for Blue Cross Blue Shield of Oklahoma members; applies to providers submitting claims under BCBSOK plans (product-specific requirements may vary).

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyLaboratory Testing for the Diagnosis of Inflammatory Bowel Disease

Policy CodePolicy CPCPLAB035

Change TypeMerged + Added clarifications and codes

Effective DateJan 3, 2026

Next Review DateN/A

Key ActionIf fecal calprotectin and fecal lactoferrin are ordered at the same time, only fecal calprotectin will be approved for reimbursement.

SourceLink

POLICY UPDATE CHANGES

Combined prior fecal calprotectin policy into this policy and added explicit reimbursable indications for fecal calprotectin or fecal lactoferrin: differential diagnosis between IBS and IBD, and monitoring individuals with IBD.

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

Added code 0598U effective 2025-10-01.

Clarified that multianalyte serum biomarker panels (with or without algorithms) to distinguish IBD vs non-IBD or to diagnose/monitor IBD (examples: ibs-smart™, IBSchek®, Prometheus®) are not reimbursable.

Fecal calprotectin/fecal lactoferrinMay be reimbursable for differential diagnosis or monitoring

All other usesFecal calprotectin/fecal lactoferrin not reimbursable

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyLaboratory Testing for the Diagnosis of Inflammatory Bowel Disease

Policy CodePolicy CPCPLAB035

Change TypeMerged + Added clarifications and codes

Effective DateJan 3, 2026

Next Review DateN/A

Key ActionIf fecal calprotectin and fecal lactoferrin are ordered at the same time, only fecal calprotectin will be approved for reimbursement.

SourceLink

On This Page

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.

Reimbursable and Non‑Reimbursable Tests

Reimbursable indications for fecal calprotectin or fecal lactoferrin

Fecal calprotectin or fecal lactoferrin testing may be reimbursable for any of the following situations. If ordered outside these situations, testing is not reimbursable.

ANY of the following

Differential diagnosis between non-inflammatory gastrointestinal disease (e.g., irritable bowel syndrome) and inflammatory gastrointestinal disease (e.g., inflammatory bowel disease).
Monitoring individuals with IBD (e.g., assess response to therapy or detect relapse).

Non-reimbursable tests/uses

The following serum or panel tests are not reimbursable for workup or monitoring of IBD.

ALL of the following

Serologic markers including, but not limited to: ANCA, ASCA, pANCA, anti-OmpC, anti-I2, anti-cBir1, ACCA IgA, ALCA IgG, AMCA IgG, PKM2.
Multianalyte serum biomarker panels (with or without algorithmic analysis) designed to distinguish between IBD and non-IBD or to diagnose/monitor IBD (examples: ibs-smart™, IBSchek®, Prometheus®).
These multianalyte serum biomarker panels are not reimbursable.
Fecal calprotectin or fecal lactoferrin for any situation not listed in reimbursable indications above.

Procedure Codes and Billing Codes

Added reimbursement codemixed

0598U

Listed in policy update history as added code effective 2025-10-01 (specific descriptor not provided in document).

Billing, Documentation, and Denial Risk Guidance

Billing Rule

Concurrent fecal biomarker orders

If fecal calprotectin and fecal lactoferrin are ordered simultaneously, only fecal calprotectin will be approved for reimbursement.

Operational billing implication: concurrent billing for both tests may result in denial or only fecal calprotectin reimbursed.

Documentation Required

Submit supporting documentation upon request

Claims for these tests are subject to review; upon request providers should submit additional documentation to support medical necessity and coding.

Key Terms

Definitions

Fecal calprotectinA stool biomarker of intestinal inflammation; stated as the preferred biomarker for differentiating inflammatory vs non-inflammatory GI disease and for monitoring IBD.

Multianalyte serum biomarker panelsCommercial panels (with or without algorithmic analysis) designed to distinguish IBD from non-IBD or to diagnose/monitor IBD; examples include ibs-smart™, IBSchek®, Prometheus®; these are not reimbursable.

Scope and Clinical Context

This policy defines reimbursement criteria for fecal and serologic laboratory tests used to diagnose or monitor inflammatory bowel disease (IBD) for Blue Cross Blue Shield of Oklahoma members. It applies to providers submitting claims under BCBSOK plans; product-specific requirements and plan documents or provider contracts may override this policy, so providers should verify coverage for the product under which the member is entitled to services. The Plan has implemented lab management reimbursement criteria and not all requirements apply to each product. The Procedure Codes section states the code list is not all-encompassing and inclusion of a code does not guarantee coverage. (See Policy Number CPCPLAB035, approval date 09/26/2025; plan effective date 01/03/2026.)

Fecal biomarker testing is addressed specifically: fecal calprotectin or fecal lactoferrin testing may be reimbursable when ordered for (1) the differential diagnosis between non-inflammatory gastrointestinal disease (for example, irritable bowel syndrome) and inflammatory gastrointestinal disease (for example, IBD), or (2) to monitor individuals with IBD (for example, to assess response to therapy or detect relapse). For all other situations, fecal calprotectin and fecal lactoferrin testing are not reimbursable.

Per the policy, fecal calprotectin is the preferred biomarker. Operationally, if both fecal calprotectin and fecal lactoferrin are ordered at the same time, only fecal calprotectin will be approved for reimbursement. The policy also clarifies that multianalyte serum biomarker panels (with or without algorithmic analysis) designed to distinguish IBD from non-IBD or to diagnose/monitor IBD (examples: ibs-smart™, IBSchek®, Prometheus®) are not reimbursable.

Providers are responsible for submitting accurate documentation and coding claims using valid HIPAA-approved code sets. Claims are subject to code edit protocols and review; providers are urged to submit additional documentation upon request to support medical necessity. The policy update history documents that the former separate fecal calprotectin policy (CPCPLAB026) was merged into this policy and that code additions (including 0598U) and the preferred biomarker note were added during the 09/26/2025 update.

Policy Changes and Material Updates

2025-09-26policy_approval / consolidationLatest

Policy CPCPLAB035 approved (09/26/2025) and combined prior CPCPLAB026 (Fecal Calprotectin Testing in Adults) into CPCPLAB035, creating new items #1 and #2 that define reimbursable indications for fecal calprotectin or fecal lactoferrin (differential diagnosis between IBS and IBD; monitoring individuals with IBD).

2025-09-26added_note/billing_preference

Added Note that fecal calprotectin is the preferred biomarker and that if fecal calprotectin and fecal lactoferrin are ordered at the same time only fecal calprotectin will be approved (operational billing implication).