Helicobacter pylori Testing
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Defines Molina Healthcare's coverage criteria and limitations for diagnostic and eradication testing for Helicobacter pylori infection for covered individuals, including recommended test modalities and age-specific indications.
No material clinical or coverage changes in this revision.
Coverage Criteria for H. pylori Testing
Coverage criteria — Coverage determinations for H. pylori diagnostic and eradication testing
Covered when the following criteria are met (age- and situation-specific):
ANY of the following
- Adults (>=18) - noninvasive diagnosis covered: Urea breath test (UBT) or stool antigen testing to diagnose H. pylori infection meets coverage criteria for individuals 18 years and older in any of the following: 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 (GIM); initiating or on long-term aspirin/NSAID therapy; unexplained iron deficiency anemia; idiopathic thrombocytopenic purpura (ITP); family history of gastric cancer; first-generation immigrants from high-prevalence areas.
- Adults - invasive testing covered: For individuals 18 years and older undergoing endoscopic examination or who have alarm symptoms, a biopsy-based endoscopic histology test plus either a rapid urease test (RUT) or culture with susceptibility testing meets coverage criteria to diagnose H. pylori.
- Children (<18) - noninvasive diagnosis covered: For individuals under 18 years of age, UBT or stool antigen testing meets coverage criteria for diagnosis when there are gastric or duodenal ulcers/erosions or a family history of gastric cancer.
- Children (<18) - invasive testing with limited indications: For children under 18 with refractory iron deficiency anemia, a biopsy-based endoscopic histology test plus RUT or culture with susceptibility testing meets coverage criteria; biopsy-based testing does not meet coverage for children with functional abdominal pain, as part of initial evaluation of iron deficiency anemia, or for investigation of short stature.
- Post-treatment (eradication) testing: For all individuals who tested positive, UBT or stool antigen testing to confirm eradication meets coverage criteria when performed at least four weeks after completion of therapy.
- Refractory infection - susceptibility testing: For individuals with refractory H. pylori infection, susceptibility testing (culture or nucleic acid–based) meets coverage criteria.
ALL of the following
- Not covered - serology: Serologic (antibody) testing for H. pylori does not meet coverage criteria for individuals of any age.
- Not covered - asymptomatic or GERD-only adults: UBT or stool antigen testing to diagnose H. pylori does not meet coverage criteria for asymptomatic individuals of any age, or for adults with typical GERD symptoms who do not have a history of peptic ulcer disease.
- Not covered - recent interfering medications: UBT, stool antigen, or biopsy-based testing to diagnose H. pylori does not meet coverage criteria if there has been recent use of antibiotics, proton pump inhibitors (PPIs), or bismuth.
- Not covered - concurrent multiple tests: Concurrent diagnostic testing using any combination of UBT, stool antigen, and/or biopsy-based testing to diagnose H. pylori does not meet coverage criteria.
- Not covered - nucleic acid testing generally: Nucleic acid testing for H. pylori does not meet coverage criteria except as specified (for example, susceptibility testing in refractory cases).
Coverage criteria and clinical guidance — Documented guideline-supported coverage stance and clinical criteria referenced in the policy.
Guideline-supported clinical guidance referenced in this policy (high-level recommendations):
Procedure Codes, Timing, and Coding Notes
| 83009 | Helicobacter pylori, blood test analysis for urease activity, non-radioactive isotope (e.g., C-13). |
| 83013 | Helicobacter pylori; breath test analysis for urease activity, non-radioactive isotope (e.g., C-13). |
| 86318 | Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step-method. |
| 86677 | Antibody; Helicobacter pylori. |
| 0008U | Proprietary or specific molecular/next-generation sequencing test code referenced in policy. |
Provider Actions, Coverage Decisions, and Denial Risks
Coverage decision — verify benefit and apply clinical criteria
Apply the policy coverage criteria only after verifying the member's individual benefit coverage. For adults (>=18) noninvasive testing (UBT or stool antigen) meets coverage criteria for dyspepsia, active PUD, past PUD with recurrent symptoms, low‑grade gastric MALT lymphoma, history of resection of early gastric cancer, gastric intestinal metaplasia, initiating/ongoing chronic aspirin/NSAID therapy, unexplained iron deficiency anemia, ITP, family history of gastric cancer, or first‑generation immigrants from high prevalence areas. Biopsy-based testing meets coverage when adults are undergoing endoscopy or have alarm symptoms. For individuals <18, UBT or stool antigen testing meets criteria for those with gastric or duodenal ulcers/erosions or a family history of gastric cancer; biopsy-based testing with susceptibility testing meets coverage for children with refractory iron deficiency anemia. Eradication testing with UBT or stool antigen is covered if performed at least four weeks after completion of therapy. Susceptibility testing meets coverage for refractory infection.
- Verify member benefit coverage before ordering tests (application dependent on individual benefit).
- Adults (>=18): UBT or stool antigen covered for listed clinical indications (dyspepsia; active/past PUD; MALT lymphoma; EGC resection; GIM; aspirin/NSAID use; unexplained iron deficiency anemia; ITP; family history of gastric cancer; first‑generation immigrants from high‑prevalence areas).
- Adults undergoing endoscopy or with alarm symptoms: biopsy-based histology plus RUT or culture with susceptibility testing covered.
- Children (<18): UBT or stool antigen covered for gastric/duodenal ulcers or erosions and family history of gastric cancer; biopsy-based testing with susceptibility testing covered for refractory iron deficiency anemia.
- Eradication testing (UBT or stool antigen) covered when performed >=4 weeks post-treatment.
- Susceptibility testing (culture or nucleic acid based) covered for refractory H. pylori infection.
Denial conditions and coverage risks
Do not order UBT or stool antigen testing for asymptomatic individuals or for adults with only typical GERD symptoms and no history of PUD; serologic testing for H. pylori is not covered for any age. Testing (UBT, stool antigen, or biopsy-based) is not covered if there has been recent use of antibiotics, PPIs, or bismuth. Concurrent diagnostic testing using any combination of UBT, stool antigen, and/or biopsy-based testing is not covered. Nucleic acid testing is not covered except as specified (e.g., susceptibility testing for refractory cases).
- Not covered: UBT or stool antigen for asymptomatic individuals of any age.
- Not covered: UBT or stool antigen for adults with only typical GERD symptoms without history of PUD.
- Not covered: serologic (antibody) testing for any age.
- Not covered: testing performed while the patient has recent antibiotics, PPIs, or bismuth.
- Not covered: concurrent use of UBT, stool antigen, and/or biopsy-based tests for diagnosis.
- Not covered generally: nucleic acid testing except as specified (e.g., for susceptibility in refractory infection).
Applicable CPT/HCPCS and microbiology procedure codes
Use the policy‑listed CPT/HCPCS and microbiology procedure codes when billing for H. pylori testing, cultures, and susceptibility or sequencing procedures.
- 83009 — Helicobacter pylori, blood test analysis for urease activity, non‑radioactive isotope (e.g., C‑13).
- 83013 — Helicobacter pylori; breath test analysis for urease activity, non‑radioactive isotope (e.g., C‑13).
- 83014 — Helicobacter pylori; (e.g., C‑13) drug administration.
- 86318 — Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step‑method.
- 86677 — Antibody; Helicobacter pylori.
- 87070, 87077, 87081, 87149 — Culture and identification/sequencing and related microbiology codes for isolates and typing.
- Codes for susceptibility studies and sequencing (e.g., methods for MIC, gradient strips, 16S rRNA sequencing) are included in the policy's code list.
Definitions and Abbreviations
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