CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPLAB035

Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease

This policy defines BCBSOK reimbursement criteria for laboratory tests used in the workup and monitoring of inflammatory bowel disease (IBD), including which serologic and algorithm-based tests are not reimbursable; it applies to providers submitting claims to Blue Cross Blue Shield of Oklahoma and may vary by product/plan.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyLaboratory Testing for the Diagnosis of Inflammatory Bowel Disease

Policy CodePolicy CPCPLAB035

Change TypeNo material changes

Effective DateNov 1, 2023

Next Review DateN/A

Key ActionSubmit accurate documentation and claims using HIPAA‑approved code sets and provide additional documentation upon request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥11not reimbursable tests listed

2explicit reimbursement rules

12procedure codes listed

20+references

Coverage Criteria for IBD Laboratory Testing

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Not reimbursable tests and testing approaches

Tests and test categories that are not reimbursable for the workup or monitoring of IBD:

ALL of the following

Not reimbursable serologic markers
- Anti-neutrophil cytoplasmic antibody (ANCA)
- AntiSaccharomyces cerevisiae antibody (ASCA)
- Perinuclear anti-neutrophilic cytoplasmic antibody (pANCA)
- Antibody to Escherichia coli outer membrane porin C (anti-OmpC)
- Antibody to Pseudomonas fluorescens -associated sequence I2 (anti-I2)
- Anti-CBir1 flagellin antibody (anti-cBir1)
- Antichitobioside antibodies (ACCA IgA)
- Antilaminaribioside antibodies (ALCA IgG)
- Antimannobioside antibodies (AMCA IgG)
- Ppyruvate kinase M2 (PKM2)
Diagnostic algorithm-based testing that combines serologic, genetic, and inflammation markers (e.g., Prometheus® testing) is not reimbursable for diagnosis or monitoring of IBD.

Coverage and reimbursement note

Policy update history notes and that reimbursement language was revised; specific coverage criteria appear elsewhere in the full policy.

Policy Update History: 7/5/2023 — document updated with literature review; reimbursement information revised for clarity; references revised. 11/1/2022 — New policy.

Provider Documentation and Billing Actions

Documentation Required

Documentation and claim submission requirements

Providers are responsible for submission of accurate documentation of services performed. Providers are expected to submit claims for services rendered using valid code combinations from HIPAA‑approved code sets. Claims should be coded appropriately according to industry standard coding guidelines including, but not limited to: Uniform Billing (UB) Editor, American Medical Association (AMA) Current Procedural Terminology (CPT®), CPT® Assistant, Healthcare Common Procedure Coding System (HCPCS), ICD‑10 CM and PCS, National Drug Codes (NDC), Diagnosis Related Group (DRG) guidelines, Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI) Policy Manual, CCI table edits and other CMS guidelines. Claims are subject to the code edit protocols for services/procedures billed and to claim review including, but not limited to, plan benefit terms, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, the provider is urged to submit any additional documentation.

Submit claims using HIPAA‑approved code sets
Provide accurate supporting documentation upon request
Claims subject to plan documents, provider contract, and policy review

Note

Reimbursement update note

Reimbursement information in this policy was revised for clarity. Providers should refer to the Reimbursement section of the policy for current payment guidance and any applicable updates.

Document updated 7/5/2023: reimbursement information revised for clarity
Providers must follow the reimbursement section and payer communications for payment rules and rates

Definitions and Evidence Base

Reimbursement criteria (compact definition)

TermLab management reimbursement criteria

DefinitionBCBSOK-established requirements that govern reimbursement for laboratory tests used in the workup and monitoring of inflammatory bowel disease (IBD).

ScopeApplies to providers submitting claims to Blue Cross Blue Shield of Oklahoma; not all requirements apply to every product—providers must review plan documents for coverage determination.

Provider responsibilitySubmit services consistent with plan documents and provide additional documentation upon request; claims processed using HIPAA-approved code sets.

References / Evidence base

Primary guideline sourcesECCO Position Paper on Ulcerative Colitis Histopathology; Third European Evidence-based Consensus on Diagnosis and Management of Ulcerative Colitis (Magro et al.).

Clinical guidelinesACG Clinical Guideline: Ulcerative Colitis in Adults (Rubin et al.).

Diagnostic evidenceStudies on serologic markers and diagnostic precision including anti-Saccharomyces cerevisiae and pANCA (Reese et al., Peeters et al.).

NICE and UpToDate resourcesNICE Crohn's disease and ulcerative colitis pathways; UpToDate reviews on IBD definitions, epidemiology, and clinical manifestations.

Policy useThese references form the evidence base cited by BCBSOK to inform reimbursement decisions for IBD-related laboratory testing.