Capital Bluecross Helicobacter pylori Coverage

Coverage Criteria for H. pylori Testing

Covered

Covered when ANY of the following age- and indication-specific conditions are met

Adults (>=18) - noninvasive diagnosis: For individuals >=18 years, urea breath testing (UBT) or stool antigen testing is covered when any of the following are present: dyspepsia; active peptic ulcer disease (PUD); past PUD with recurrent symptoms; low‑grade gastric MALT lymphoma; history of resection of early gastric cancer; gastric intestinal metaplasia; initiating or receiving long‑term aspirin or NSAID therapy; unexplained iron deficiency anemia; idiopathic thrombocytopenic purpura (ITP); family history of gastric cancer; first‑generation immigrants from high‑prevalence areas.

Derived from policy bullets 1 a–k (chunks 3–4)

Adults (>=18) - invasive diagnosis: For individuals >=18 who are undergoing endoscopy or who have alarm symptoms, biopsy‑based histology plus either rapid urease test (RUT) or culture with susceptibility testing is covered to diagnose H. pylori infection.

Policy bullet 2 (chunk 4)

Children (<18) - noninvasive diagnosis: For individuals <18 years, urea breath testing or stool antigen testing is covered when any of the following are present: gastric or duodenal ulcers or erosions; family history of gastric cancer.

Policy bullet 3 a–b (chunk 4)

Children (<18) - invasive diagnosis: For individuals <18 years with refractory iron deficiency anemia, biopsy‑based histology plus either RUT or culture with susceptibility testing is covered.

Policy bullet 4 (chunk 4)

Eradication (test‑of‑cure): For all individuals with a prior positive H. pylori test, UBT or monoclonal stool antigen testing to confirm eradication is covered when performed at least four weeks after completion of therapy.>= 4 weeks

Policy bullet 5 (chunk 4); coding threshold (chunk 18)

Refractory infection - susceptibility testing: For individuals with refractory H. pylori infection, culture‑based or nucleic acid (molecular) susceptibility testing is covered to guide subsequent therapy.

Policy bullet 6 (chunk 4)

Not Medically Necessary / Exclusions

Not covered (does not meet coverage criteria) in the following situations

Asymptomatic individuals: UBT or stool antigen testing to diagnose H. pylori is not covered for asymptomatic individuals of any age.

Policy bullet 7a (chunk 5)

Adults with typical GERD symptoms only: For individuals >=18 years with typical gastroesophageal reflux disease symptoms (heartburn, regurgitation) and without a history of peptic ulcer disease, UBT or stool antigen testing to diagnose H. pylori is not covered.

Policy bullet 7b (chunk 5)

Serology: Serologic testing for H. pylori infection is not covered for individuals of any age.

Policy bullet 8 (chunk 5)

Pediatric invasive exclusions:

Indications for testing and treatment

Covered when ANY of the following indication groups are present (per cited guidelines):

Guideline indications to test and treat: Indications across guideline sources include: active or prior peptic ulcer disease; gastric MALT (marginal zone) lymphoma; uninvestigated dyspepsia (age thresholds applied separately); early gastric cancer resection; unexplained iron deficiency anemia; idiopathic thrombocytopenic purpura; patients taking or initiating long‑term NSAIDs or low‑dose aspirin; household contacts of infected individuals; populations at increased gastric cancer risk (including certain racial/ethnic groups and first‑generation immigrants from high‑incidence regions); and primary/secondary prevention of gastric adenocarcinoma and related premalignant conditions.

Summarized from ACG/ CAG and consensus statements (chunks 21,22,25,37)

Age and alarm features

Pathway decisions based on age and alarm features:

Younger patients without alarm features: For patients at or below guideline age thresholds (AGA: <=55 years; ACG/ CAG: <60 years) who do not have alarm features, noninvasive testing (UBT or stool antigen) with a test‑and‑treat approach is appropriate; treat if positive.age thresholds differ by guideline (<=55 vs <60)

Chunks 19,22,25

Older patients or presence of alarm features: Patients older than guideline age thresholds or those with alarm features (eg, vomiting, GI bleeding, unexplained weight loss, unexplained iron deficiency) should undergo upper endoscopy with biopsy; biopsies can be used for histology and, when indicated, RUT or culture with susceptibility testing.

Chunks 19,22,31

Pre-test washout and test-of-cure

Confirmation of eradication and pre-test preparation

Medication washout prior to testing: Hold proton pump inhibitors for at least 2 weeks and withhold antibiotics and bismuth for at least 4 weeks before testing to reduce false‑negative results.PPI >=2 weeks; antibiotics/bismuth >=4 weeks

NICE, Maastricht, and ESPGHAN/NASPGHAN recommendations (chunks 26,33,31)

Preferred test‑of‑cure: UBT is the preferred method to confirm eradication; monoclonal stool antigen testing is an acceptable alternative. Retesting is generally recommended for patients with peptic ulcer disease and other specific indications and should be performed at least four weeks after completion of therapy.>= 4 weeks

Maastricht and NICE guidance (chunks 33,26)

Therapy selection and susceptibility testing

Treatment recommendations and when to use susceptibility testing:

First‑line therapy (treatment‑naive): Guidelines recommend optimized bismuth quadruple therapy (BQT) as a first‑line option for treatment‑naive patients; rifabutin triple therapy or PCAB‑amoxicillin dual therapy are suggested alternatives depending on availability and context.

ACG treatment recommendations (chunks 23)

Susceptibility testing after treatment failures: After at least two failed eradication attempts with confirmed adherence, consider susceptibility testing (culture or molecular) to guide subsequent regimens; molecular testing can be performed on archival formalin‑fixed paraffin‑embedded (FFPE) gastric biopsy tissue.>=2 failed therapies

AGA guidance on refractory infection (chunk 20) and consensus recommending availability of testing (chunk 37)

Clarithromycin susceptibility consideration: Perform clarithromycin susceptibility testing when clarithromycin‑based therapy is being considered as first‑line only in populations/regions where documented clarithromycin resistance is low (<15%).

Indications — Consensus recommendations

Covered testing and indications when recommended by consensus

Consensus indications (Houston/others): Expert consensus recommends testing and treating for H. pylori in: all patients with active infection; current or past gastric or duodenal ulcers; uninvestigated dyspepsia; patients with MALT lymphoma; individuals with family history of gastric cancer; first‑generation immigrants from high‑prevalence areas; idiopathic thrombocytopenia; household contacts of infected patients; and individuals with family history of peptic ulcer disease. Consensus also supports universal availability of validated culture, susceptibility, and molecular testing.

Consensus statements and grades (chunks 37,38,39)

Testing methods and pre-test instructions

Appropriate diagnostic tests and timing

Tests for active infection and timing: Use tests that detect active infection (UBT, monoclonal stool antigen [HpSAg], or histology when endoscopy indicated) for initial diagnosis and for post‑treatment confirmation. Do not use serology to detect active infection. Stop bismuth and antibiotics at least 4 weeks before testing for active infection; a 2‑week PPI washout is also recommended.antibiotics/bismuth >=4 weeks; PPI >=2 weeks

Consensus recommendations statements 20,22,23,27 (chunk 38)

Serologic testing for H. pylori is explicitly excluded and DOES NOT MEET COVERAGE CRITERIA for individuals of all ages. This exclusion is absolute across the policy and applies regardless of presenting symptoms or setting; serology should not be used to diagnose active H. pylori infection.

The ESPGHAN/NASPGHAN guidance recommends against use of noninvasive testing for H. pylori as part of the initial investigation or management of iron deficiency anemia (IDA) in children. If IDA workup ultimately includes endoscopy after failed iron therapy, testing for H. pylori may be considered at that time and treated if found.

Serologic testing is not recommended for detection of active H. pylori infection. Consensus guidance states serology should not be utilized for detecting active infection, and the policy lists serologic testing as not meeting coverage criteria for all ages.

Multiple scenarios are specified as Not Medically Necessary / Does Not Meet Coverage Criteria. These include serologic testing for individuals of all ages; testing to diagnose H. pylori in asymptomatic individuals; testing in adults with typical GERD symptoms without a history of peptic ulcer disease; testing after recent antibiotic, PPI, or bismuth use; concurrent multiple test modalities for diagnosis; and nucleic acid testing except where explicitly covered by other criteria.

For pediatric patients ESPGHAN/NASPGHAN specifically advise that diagnostic testing (invasive or noninvasive) for H. pylori is not indicated for children with functional abdominal pain (a disorder of gut–brain interaction). The policy aligns with this guidance and limits pediatric testing indications to scenarios such as gastric or duodenal ulcers/erosions, family history of gastric cancer, and refractory iron deficiency anemia where endoscopic biopsy-based testing may be appropriate.

Routine testing for H. pylori solely for reflux symptoms is discouraged unless the patient is at high risk for H. pylori–related disease. Consensus recommendations emphasize use of tests that detect active infection (UBT, stool antigen, or histology when endoscopy is indicated) and explicitly advise against serology for this purpose.

Procedure and Billing Codes

Procedure and culture/susceptibility CPT codesCPT

83009	Helicobacter pylori, blood test analysis for urease activity, non-radioactive isotope (eg, C-13).
83013	Helicobacter pylori; breath test analysis for urease activity, non-radioactive isotope (eg, C-13).
83014	Helicobacter pylori; drug administration.
86318	Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step-method (eg, reagent strip).
86677	Antibody; Helicobacter pylori.
87070	Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates.
87077	Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate.
87149	Culture, typing; identification by nucleic acid (DNA or RNA) probe, direct probe technique, per culture or isolate, each organism probed.
87150	Culture, typing; identification by nucleic acid (DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed.
87153	Culture, typing; identification by nucleic acid sequencing method, each isolate (eg, sequencing of the 16S rRNA gene).

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Stool antigen, smear, molecular detection, and NGS resistance panelCPT | HCPCS | mixed

87205	Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types.
87338	Infectious agent antigen detection by immunoassay technique; Helicobacter pylori, stool.
87339	Infectious agent antigen detection by immunoassay technique; Helicobacter pylori.
87513	Infectious agent detection by nucleic acid (DNA or RNA); Helicobacter pylori (H. pylori), clarithromycin resistance, amplified probe technique.
0008U	Helicobacter pylori detection and antibiotic resistance, DNA, 16S and 23S rRNA, gyrA, pbp1, rdxA and rpoB, next generation sequencing, predictive for resistance to clarithromycin, fluoroquinolones, metronidazole, amoxicillin, tetracycline, and rifabutin (AmHPR proprietary test).

Post‑treatment interval for eradication testing

Post-treatment interval>= 4 weeks after completion of therapy before performing eradication testing (UBT or stool antigen)

Covered test types for eradication confirmationUrea breath test (UBT) or stool antigen testing to measure success of eradication

Documentation requirementDocument prior positive test/treatment and timing to confirm testing is performed at least four weeks post-treatment

Provider Actions, Documentation, and Billing Guidance

Documentation Required

Coverage depends on indication and benefits

Coverage for H. pylori testing depends on the member's specific benefit plan and the clinical indication. Verify eligibility and benefits before ordering tests; Medicare/Medicaid rules in the Applicable State and Federal Regulations section may supersede this policy for those members.

Coverage is limited to specified indications (see Indications and/or Limitations of Coverage).
Concurrent use of multiple diagnostic modalities to diagnose H. pylori (e.g., UBT + stool antigen + biopsy) is not covered unless specified.
Serologic testing for H. pylori is not covered.

Documentation Required

Required clinical documentation

Providers must document key clinical information to support medical necessity when submitting claims for H. pylori testing.

Patient age.
Presenting indication (e.g., dyspepsia, active or past peptic ulcer disease, MALT lymphoma, prior gastric cancer resection, gastric intestinal metaplasia, unexplained iron deficiency anemia, ITP, first-generation immigrant from high-prevalence area).

Background and Epidemiology

H. pylori is a gram-negative, spiral bacterium that colonizes the stomach and is associated with peptic ulcer disease, chronic gastritis, gastric adenocarcinoma, and MALT lymphoma. Testing is performed to diagnose active infection for purposes of treatment and to confirm eradication after therapy; choice of test depends on age, clinical presentation, recent medication use, and indication for endoscopy.

Definitions and Test Descriptions

Urea breath test (UBT)

DefinitionUrea breath test (UBT): noninvasive test in which the patient ingests 13C or 14C labeled urea and breath is analyzed for labeled CO2 produced by H. pylori urease activity

Use casesUsed to detect active H. pylori infection for initial diagnosis and recommended as the preferred test for confirmation of eradication

Test characteristicsNoninvasive; takes approximately 15–20 minutes; detects active infection by measuring labeled CO2 in breath after ingestion of labeled urea

Stool antigen test (SAT)

DefinitionStool antigen test (SAT): immunoassay that detects H. pylori antigen in stool specimens

PerformanceReported sensitivity and specificity >90% for detection of active H. pylori infection; monoclonal assays have higher sensitivity and specificity and are FDA cleared for all ages

Policy Revision History

2015-03-19policy_effective

Policy initial presentation/effective date published as AHS - G2044 Helicobacter pylori Testing.

2025-08-01policy_revisionLatest

Policy revision date (last review) updated on 2025-08-01 per document header.