CurrentHumanaPolicy LAB2023010

Laboratory - Helicobacter Pylori Testing

Humana Medicare Advantage payment policy governing reimbursement for H. pylori laboratory tests (urea breath test, stool antigen, serology, nucleic-acid susceptibility) and related billing rules for Humana Medicare Advantage members.

Policy Summary

PayerHumana

PolicyLaboratory - Helicobacter Pylori Testing

Policy CodePolicy LAB2023010

Change TypeNo material change

Effective DateApr 1, 2023

Next Review Date

Key ActionReimburse urea breath or stool antigen testing (no more than once every four weeks) only for listed clinical indications; nucleic acid–based susceptibility testing is reimbursable for refractory infection.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1/4wmax frequency

83013/83014/87338primary reimbursable tests

87513/0008Urefractory testing

83009/86318/86677/87339not reimbursable

88305biopsy conflict

Coverage Criteria for H. pylori Testing

Reimbursable noninvasive testing criteria

Urea breath testing (CPT 83013, 83014) or stool antigen testing (CPT 87338) are reimbursable (no more than one test every four weeks) when used for any of the listed clinical indications.

Urea breath testing (CPT 83013, CPT 83014) or stool antigen testing (CPT 87338) is reimbursable when used for an indicated clinical situation.

Maximum frequency: no more than one urea breath or stool antigen test every 4 weeks.

List of clinical indications

Testing reimbursable for any of the following:

Active peptic ulcer disease (PUD)

Dyspeptic symptoms including abdominal pain, nausea or vomiting

Policy Summary

PayerHumana

PolicyLaboratory - Helicobacter Pylori Testing

Policy CodePolicy LAB2023010

Change TypeNo material change

Effective DateApr 1, 2023

Next Review Date

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Not reimbursable

The following are not reimbursable under this policy:

Serologic testing for H. pylori (CPT 83009, CPT 86677, CPT 87339) is not reimbursable.

Single-step serologic testing for H. pylori (CPT 86318) is not reimbursable for individuals diagnosed with H. pylori infection.

Urea breath testing (CPT 83013, CPT 83014), stool antigen testing (CPT 87338), or nucleic acid–based susceptibility testing (CPT 87513, CPT 0008U) are not reimbursable for situations not listed as reimbursable above.

Stool antigen testing (CPT 87338) performed simultaneously with the urea breath test (CPT 83013) is not reimbursable.

Urea breath testing or stool antigen testing performed simultaneously with biopsy-based testing (CPT 88305) is not reimbursable.

Relevant Codes and Billing Limits

Relevant CPT / Proprietary codesCPT

83013	Helicobacter pylori; breath test analysis for urease activity, non-radioactive isotope (e.g. C-13)
83014	Helicobacter pylori; drug administration
87338	Infectious agent antigen detection by immunoassay technique; Helicobacter pylori, stool
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, formalin-fixed paraffin-embedded or fresh tissue or fecal
83009	Helicobacter pylori, blood test analysis for urease activity, non-radioactive isotope
86318	Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step-method (eg, reagent strip)
86677	Antibody; Helicobacter pylori
87339	Infectious agent antigen detection by immunoassay technique; Helicobacter pylori
88305	Level IV - Surgical pathology, gross and microscopic examination

Testing frequency limit (inv-06: testing_frequency_limit)

Frequency limitNo more than one urea breath test (CPT 83013, 83014) or stool antigen test (CPT 87338) every 4 weeks.

Applies to testsUrea breath testing (CPT 83013, 83014) and stool antigen testing (CPT 87338).

ScopeLimit applies to reimbursable uses listed in the policy (see clinical indications).

Concurrent testing prohibitionStool antigen testing (CPT 87338) is not reimbursable when performed simultaneously with urea breath testing (CPT 83013).

Nonreimbursable situationsFor situations not addressed as reimbursable, these tests are not covered despite frequency limit.

Provider Actions and Authorization Requirements

Prior Authorization

Medicare Advantage claims subject to plan medical necessity and authorization rules

Medicare Advantage claims remain subject to plan requirements, including medical necessity, reasonableness, and any applicable referral or authorization rules; reimbursable H. pylori tests are limited to the specified indications and frequency, and certain tests are not reimbursable under this policy.

Claims are subject to other plan requirements for processing and payment, including medical necessity and reasonableness.
Reimbursable tests are limited to the clinical indications and frequency outlined (e.g., no more than one urea breath or stool antigen test every four weeks).
Certain tests (for example, serologic testing and tests performed simultaneously with biopsy or with each other in specified combinations) are not reimbursable.

Definitions of Test Types

Urea breath testing (inv-08)

DefinitionNoninvasive breath test for H. pylori urease activity (CPT 83013, CPT 83014).

CPT codes83013: H. pylori; breath test analysis for urease activity, non-radioactive isotope; 83014: H. pylori; drug administration.

Reimbursement stanceReimbursable when used for listed clinical indications and subject to the one-test-per-4-weeks frequency limit.

Not reimbursableNot reimbursable when used in situations not listed as covered by the policy.

Stool antigen testing (inv-09)

DefinitionNoninvasive stool immunoassay for H. pylori antigen (CPT 87338).

CPT code87338: Infectious agent antigen detection by immunoassay technique; Helicobacter pylori, stool.

Reimbursement stanceReimbursable when used for listed clinical indications and subject to the one-test-per-4-weeks frequency limit.

Concurrent testing prohibitionNot reimbursable when performed simultaneously with the urea breath test (CPT 83013).

Nucleic acid–based susceptibility testing (inv-10)

DefinitionMolecular (nucleic acid–based) tests to detect H. pylori and antibiotic resistance.

CPT/proprietary codes87513: H. pylori clarithromycin resistance, amplified probe technique; 0008U*: H. pylori detection and antibiotic resistance by NGS panel.

Indication for reimbursementReimbursable for individuals with refractory H. pylori infection.

Specimen types noted0008U describes testing on formalin-fixed paraffin-embedded or fresh tissue or fecal specimens.

Serologic testing (inv-11)

DefinitionBlood-based antibody/serology tests for H. pylori.

CPT codes listed as not reimbursable83009 (H. pylori blood test analysis), 86318 (single-step immunoassay for infectious agent antibody), 86677 (Antibody; H. pylori), 87339 (infectious agent antigen detection; H. pylori).

Reimbursement stanceSerologic testing for H. pylori infection is not reimbursable under this policy; single-step serologic testing (CPT 86318) is explicitly not reimbursable for individuals diagnosed with H. pylori.

Relation to other testsNoninvasive tests reimbursable only in specified indications; serology is excluded from reimbursable noninvasive options.