CurrentHealth NetPolicy CP.MP.153

H. Pylori Serology Testing (PDF)

Defines the medical necessity policy for H. pylori serology testing for health plans affiliated with Centene Corporation, including background, guideline references, and coding implications. States the plan position on use of serology for diagnosis or test-of-cure.

Policy Summary

PayerHealth Net

PolicyH. Pylori Serology Testing (PDF)

Policy CodePolicy CP.MP.153

Change TypeRevised (references/background updates)

Effective Date

Next Review Date

Key ActionProviders should not order H. pylori serology (CPT 86677) for diagnosing active infection or assessing eradication; use urea breath test or stool antigen testing instead.

SourceLink

POLICY UPDATE CHANGES

Date of Last Revision updated to 09/24 with annual review and references updated.

Policy statement: H. pylori serology testing determined to be not medically necessary for diagnosis or evaluating treatment effectiveness.

1Primary CPT code listed

0Covered indications for serology

2Preferred noninvasive tests noted (UBT, stool)

Coverage Summary

scope_summary: Defines the medical necessity policy for H. pylori serology testing for health plans affiliated with Centene Corporation, including background, guideline references, and coding implications. States the plan position on use of serology for diagnosis or test-of-cure.

Medical Necessity Determination

It is the policy of health plans affiliated with Centene Corporation that:

ALL of the following

H. pylori serology testing is not medically necessary for diagnosing infection
H. pylori serology testing is not medically necessary for evaluating treatment effectiveness (test-of-cure)

Not Medically Necessary / Not Covered

The policy states that H. pylori serology testing is not medically necessary for diagnosing infection and is not medically necessary for evaluating treatment effectiveness (test-of-cure).

Serology for H. pylori (CPT 86677) is therefore considered not covered / not medically necessary when used to diagnose active infection or to confirm eradication. This determination is a standing policy; recent revisions reflect annual review and updates to references and dates without material change to the clinical policy.

Provider Actions

Documentation Required

Do not use serology for diagnosis or test-of-cure

Do not order H. pylori serology (CPT 86677) to diagnose active infection or to confirm eradication. Serologic antibody testing detects IgG to H. pylori but cannot distinguish active from past infection and therefore cannot be used as a test-of-cure.

86677
Serology cannot distinguish active from past infection

Documentation Required

Use preferred noninvasive tests

Use noninvasive tests that detect active infection — specifically urea breath testing or stool antigen testing — for diagnosis of active H. pylori infection and for test-of-cure. This policy does not enumerate specific CPT or laboratory codes for these preferred tests.

Specific CPT/Lab codes for urea breath test and stool antigen testing are not enumerated in this policy

Background and Evidence

Serologic antibody testing detects IgG to H. pylori but cannot distinguish active infection from past infection and cannot be used to confirm cure. Urea breath tests and stool antigen tests detect active infection and can be used as test-of-cure; UBT has high sensitivity (88%–95%) and specificity (95%–100%).

Major professional societies (American Society for Clinical Pathology, American Gastroenterological Association, American College of Gastroenterology) no longer recommend serology-based testing for diagnosing infection or evaluating treatment effectiveness and advise using UBT or stool antigen testing instead.

Definitions

Evidence

Revision History

12/17revised

Policy developed. Removed from background the statement 'Serology testing is useful in screening and epidemiological studies.' and indications for testing in individuals without alarm symptoms.

04/18revised

Removed from background the statement 'Serology testing is useful in screening and epidemiological studies.' and indications for testing in individuals without alarm symptoms.

11/18revised

References reviewed and updated.

11/19revised

References reviewed and updated. Replaced 'member' with 'member/enrollee' in all instances.

10/20revised

References reviewed and updated. Replaced 'member' with 'member/enrollee' in all instances.

10/21revised

Annual review. References reviewed and updated. Reviewed by specialist. Changed 'Last Review Date' in header to 'Date of Last Revision' and changed 'Date' in Revision log to 'Revision Date.'

09/22revised

Annual review completed. Background updated and minor rewording with no clinical significance. References reviewed and updated.

09/23revised

Annual review. References reviewed and updated. Reviewed by external specialist.

09/24revisedLatest