ModifiedBlue Cross Blue Shield - TexasPolicy CPCPLAB025

Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing

Defines Blue Cross Blue Shield of Texas reimbursement stance and lab management criteria for fecal analysis used in diagnosing intestinal dysbiosis and for donor screening prior to fecal microbiota transplant; applies to providers submitting claims to BCBSTX and varies by product/plan.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyFecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing

Policy CodePolicy CPCPLAB025

Change TypeCodes added and removed; literature/references updated

Effective DateSep 26, 2025

Next Review Date

Key ActionPrior to FMT donation, specified bacterial culture and NAAT testing of donor fecal samples may be reimbursable for listed organisms.

SourceLink

POLICY UPDATE CHANGES

Edited clarifications that fecal microbiota transplantation testing is on the sample coming from the donor and edited several reimbursement items for clarity; added and removed specific CPT/other codes.

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

New policy created effective 09/13/2024.

4CPT/other codes added

10Codes removed

26Procedure codes listed

Not reimbursable categories

8Reimbursable NAAT organisms

Coverage Criteria and Policy Updates

Coverage criteria and exclusions

Reimbursement stance for fecal testing in the contexts of FMT donor screening and diagnostic evaluation of intestinal dysbiosis.

ALL of the following

Culture-based FMT donor screening reimbursable organisms
- Extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae
- Vancomycin-resistant Enterococci (VRE)
- Carbapenem-resistant Enterobacteriaceae (CRE)
- Methicillin-resistant Staphylococcus aureus (MRSA)
- Campylobacter
- Shigella
- Salmonella
NAAT-based FMT donor screening reimbursable organisms
- Clostridium difficile
- Campylobacter
- Salmonella
- Shigella
- Shiga toxin-producing Escherichia coli
- Norovirus
- Rotavirus

ALL of the following

ANY of the following
- Extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae
- Vancomycin-resistant Enterococci (VRE)
- Carbapenem-resistant Enterobacteriaceae (CRE)
- Methicillin-resistant Staphylococcus aureus (MRSA)
- Any other microorganisms not listed as reimbursable

ALL of the following

ANY of the following
- Triglycerides
- Chymotrypsin
- Iso-butyrate, iso-valerate, and n-valerate
- Meat and vegetable fibers
- Long chain fatty acids
- Cholesterol

Policy update summary

Summary of policy update history and reimbursement note

ALL of the following

09/13/2024 — New policy created (effective 09/13/2024).
02/05/2025 — Document updated with literature review; clarified that FMT testing applies to donor samples; edited item #4.h for clarity; codes added: 87076, 87077, 87081, 87106; codes removed: 82239, 82725, 82784, 83520, 83630, 87177, 87209, 87328, 87329, 87336.
09/26/2025 — Document updated with literature review; reimbursement information unchanged; references revised.

Procedure and Update Code Lists

Example procedure codesCPT | HCPCS

82542
82705
82710
82715
83986
84311
87045
87046
87075
87076

1–10 of 20

1/2

codes added/removed in policy updatemixed

87076	Code added per policy update
87077	Code added per policy update
87081	Code added per policy update
87106	Code added per policy update
82239	Code removed per policy update
82725	Code removed per policy update
82784	Code removed per policy update
83520	Code removed per policy update
83630	Code removed per policy update
87177	Code removed per policy update

1–10 of 14

1/2

Code list completeness note

Code list scopeThe procedure code list is not all-encompassing; inclusion of a code does not guarantee it is a covered service or eligible for reimbursement.

Examples providedCodes shown are examples for reference only (see procedure codes list).

Provider responsibilityProviders must code claims according to standard coding guidelines; coverage depends on benefit, contract, and claim review.

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior authorization and reimbursable testing summary

Prior to donation for a fecal microbiota transplant (FMT), analysis of the donor fecal sample by bacterial culture and by nucleic acid amplification testing (NAAT) for the specific organisms listed may be reimbursable; NAAT for ESBL-producing Enterobacteriaceae, VRE, CRE, MRSA, and any other organisms not listed is not reimbursable.

Reimbursable by bacterial culture: ESBL-producing Enterobacteriaceae; VRE; CRE; MRSA; Campylobacter; Shigella; Salmonella.
Reimbursable by NAAT: Clostridium difficile; Campylobacter; Salmonella; Shigella; Shiga toxin-producing E. coli; Norovirus; Rotavirus; COVID-19 (SARS‑CoV‑2).
NAAT not reimbursable for ESBL-producing Enterobacteriaceae, VRE, CRE, MRSA, or any other microorganisms not listed.

Documentation Required

Definitions and Test Coverage Details

Reimbursable donor stool testing

Culture-reimbursable organisms (examples)ESBL-producing Enterobacteriaceae; Vancomycin-resistant Enterococci (VRE); Carbapenem-resistant Enterobacteriaceae (CRE); Methicillin-resistant Staphylococcus aureus (MRSA); Campylobacter; Shigella; Salmonella.

NAAT-reimbursable organisms (examples)Clostridium difficile; Campylobacter; Salmonella; Shigella; Shiga toxin-producing Escherichia coli; Norovirus; Rotavirus; COVID-19 (SARS-CoV-2).

ContextThese tests are identified as prior-to-donation analyses of donor fecal samples for FMT screening and may be reimbursable per policy criteria.

Not reimbursable diagnostic fecal analysis

Non-reimbursable fecal diagnostic components (categories)Triglycerides; Chymotrypsin; Iso-butyrate/iso-valerate/n-valerate; Meat and vegetable fibers; Long chain fatty acids; Cholesterol; Total short chain fatty acids; Quantification of Lactobacilli, bifidobacteria, E. coli and other 'potential pathogens'; Identification and quantitation of fecal yeast; N-butyrate; Beta-glucuronidase; pH; Short chain fatty acid distribution; Fecal secretory IgA.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyFecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing

Policy CodePolicy CPCPLAB025

Change TypeCodes added and removed; literature/references updated

Effective DateSep 26, 2025

Next Review Date

Key ActionPrior to FMT donation, specified bacterial culture and NAAT testing of donor fecal samples may be reimbursable for listed organisms.

SourceLink

On This Page

COVID-19 (SARS-CoV-2)

Total short chain fatty acids

Quantification of Lactobacilli, bifidobacteria, and E. coli and other 'potential pathogens' (including Aeromonas, Bacillus cereus, Campylobacter, Citrobacter, Klebsiella, Proteus, Pseudomonas, Salmonella, Shigella, S. aureus, Vibrio)

Identification and quantitation of fecal yeast (including C. albicans, C. tropicalis, Rhodotorula and Geotrichum)

Short chain fatty acid distribution

Documentation and claim review

Providers must submit accurate documentation and code claims using valid, industry-standard code sets; claims are subject to code edit protocols and claim review, and providers may be asked to submit additional documentation upon request.

Submit claims using HIPAA-approved code sets and follow standard coding guidelines (CPT, HCPCS, ICD-10-CM/PCS, NDC, DRG, CMS/NCCI guidance).
Claims are subject to benefit, contract, medical policy, coding software logic, and code edit review; provide additional documentation when requested.

Note

Prior authorization / reimbursement note

The 09/26/2025/document updates revised literature and references but did not change reimbursement positions; the policy clarifies that FMT testing refers to analysis of the sample from the donor and lists code additions/removals.

Reimbursement information unchanged in the update; document updated with literature review and references revised.
Clarification: FMT testing is on the sample coming from the donor.
Codes added: 87076, 87077, 87081, 87106; codes removed: 82239, 82725, 82784, 83520, 83630, 87177, 87209, 87328, 87329, 87336.

Use caseThese components are not reimbursable when ordered as diagnostic tests for evaluation of intestinal dysbiosis, IBS, malabsorption, or small intestinal bacterial overgrowth.

Explicit exclusionNAAT for ESBL-producing Enterobacteriaceae, VRE, CRE, MRSA, and any other microorganisms not listed as reimbursable are not reimbursable for donor screening by NAAT.

FMT safety and donor screening

FDA safety concernsFDA communications have warned of risk of serious adverse reactions from transmission of multi‑drug resistant organisms via FMT.

Donor screening guidanceFDA issued safety information recommending additional protections for screening donors for COVID‑19 exposure and testing for SARS‑CoV‑2.

References supporting guidanceFDA safety communications and safety alerts cited in policy references provide the basis for donor screening considerations.