CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Fecal Calprotectin Testing Policy

Policy governing coverage determination for fecal calprotectin testing for diagnosis and management of intestinal conditions including inflammatory bowel disease (IBD) for BlueCHiP for Medicare and Commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyFecal Calprotectin Testing Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2015

Next Review Date

Key ActionRefer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for member-specific coverage determinations.

SourceLink

POLICY UPDATE CHANGES

There are no material clinical or coverage changes in this policy.

1Not covered CPT code listed

2Product lines with explicit noncoverage

Coverage Determination

Coverage determination

Fecal calprotectin testing coverage status for specified product lines:

ALL of the following

BlueCHiP for Medicare determination: For BlueCHiP for Medicare: Fecal calprotectin is considered not covered in the diagnosis and management of intestinal conditions, including the diagnosis and management of inflammatory bowel disease, as the evidence is insufficient to determine the effects of the technology on health outcomes.

Commercial Products determination: For Commercial Products: Fecal calprotectin testing is considered not medically necessary in the diagnosis and management of intestinal conditions, including the diagnosis and management of inflammatory bowel disease, as the evidence is insufficient to determine the effects of the technology on health outcomes.

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Coverage stance: not_covered_cosmetic. Scope: policy governs coverage determination for fecal calprotectin testing for the diagnosis and management of intestinal conditions, including the diagnosis and management of inflammatory bowel disease (IBD). For BlueCHiP for Medicare, fecal calprotectin is considered not covered for these indications; for Commercial Products it is considered not medically necessary.

Evidence conclusion: Evidence is insufficient to determine effects of fecal calprotectin testing on health outcomes for diagnosis or management of IBD.

Medical-Necessity / Not Medically Necessary

Not Medically Necessary

Fecal calprotectin testing coverage status for specified product lines:

ALL of the following

BlueCHiP for Medicare determination: For BlueCHiP for Medicare: Fecal calprotectin is considered not covered in the diagnosis and management of intestinal conditions, including the diagnosis and management of inflammatory bowel disease, as the evidence is insufficient to determine the effects of the technology on health outcomes.
Commercial Products determination: For Commercial Products: Fecal calprotectin testing is considered not medically necessary in the diagnosis and management of intestinal conditions, including the diagnosis and management of inflammatory bowel disease, as the evidence is insufficient to determine the effects of the technology on health outcomes.

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Relevant Codes

Not covered / not medically necessary CPT codeCPTNot Covered

83993

Calprotectin, fecal

Provider Actions & Billing Impact

Documentation Required

Refer to member-specific benefits

Benefits may vary between groups and contracts; providers must refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for member-specific coverage determinations.

Check the member's Benefit Booklet / Evidence of Coverage or Subscriber Agreement for applicable coverage and benefit limitations.

Denial Risk

Claims for fecal calprotectin testing risk denial

Claims for CPT 83993 for BlueCHiP for Medicare and Commercial Products are considered not covered / not medically necessary and may be denied.

Affected code: 83993

Background & Evidence Summary

Fecal calprotectin is a calcium- and zinc-binding protein released from neutrophils that can be measured in stool and has been proposed as a noninvasive marker of intestinal inflammation for diagnosing IBD, assessing response to treatment, and predicting relapse. It is relatively stable in stool at room temperature (up to about 1 week), which facilitates home collection and laboratory testing.

Limitations noted in the evidence include limited and inconsistent data on diagnostic accuracy and optimal cutoff values, variability in study findings for predicting treatment response and relapse, and that most studies were conducted in specialty settings rather than broader populations, raising concerns about spectrum effects and generalizability.

Policy evidence summary: The policy concludes that the evidence is insufficient to determine the effects of fecal calprotectin testing on health outcomes for either diagnosis of suspected IBD or for treatment assessment, disease activity assessment, or relapse prediction in patients with diagnosed IBD.

Fecal calprotectinA calcium- and zinc-binding protein released from neutrophils that can be measured in stool as a marker of intestinal inflammation.

Revision History

2015-10-01Effective Date

Policy effective date as published: 10/01/2015.

2018-12-18Last ReviewLatest

Policy last updated/reviewed on 12/18/2018.