Confirm authorization and benefits before ordering

Services must meet authorization and medical necessity guidelines and applicability depends on the member's benefit coverage and applicable state/federal regulations at the time of the request. Providers are responsible for submission of accurate documentation and appropriate coding; failure to follow coding/billing guidelines may result in denial or recoupment of payment.

• Confirm member benefit coverage and any plan-specific prior authorization requirements before requesting services.
• Apply applicable state and federal regulations (see policy 'Applicable State and Federal Regulations').

Prior-authorize EGD with multiple duodenal biopsies; justify selective HLA testing

Prior authorization requests should reflect that esophagogastroduodenoscopy (EGD) with multiple duodenal biopsies is the recommended means to confirm celiac disease when indicated; selective HLA (DQ2/DQ8) testing may be requested with justification (e.g., serology-histology discrepancy or prior gluten-free diet).

• When requesting authorization for endoscopy, document planned multiple duodenal biopsies (see biopsy adequacy guidance).
• If requesting HLA testing, include rationale (discrepant results or evaluation after gluten-free diet).

Obtain duodenal biopsy to confirm adult diagnosis

For most adults, duodenal biopsy (EGD with multiple duodenal biopsies) is required to confirm diagnosis and should be performed when indicated.

• Obtain multiple biopsies during EGD (see biopsy specimen adequacy block for recommended sampling).

Reference CPT/HCPCS codes — verify payer rules

Procedure codes listed in the policy are provided for reference only; providers must follow payer-specific prior authorization rules and confirm whether authorization is required for these CPT/HCPCS codes.

• Referenced codes include: 82784, 83516, 86231, 86255, 86256, 86258, 86364, 88305.

No other provider actions specified here

No additional specific provider action is specified in this section beyond the listed authorization, documentation, and testing requirements; follow the policy's stated steps for diagnostic evaluation and documentation.

• Adhere to the policy's diagnostic and monitoring pathways when managing suspected or confirmed celiac disease.

Documented gluten challenge before repeat serology when needed

If a patient began a gluten-free diet before diagnostic testing, document and, when appropriate, perform a gluten reintroduction (e.g., about 3 slices of wheat bread daily for 1–3 months) prior to repeat serology unless HLA testing excludes celiac disease.

• Document the gluten challenge regimen and duration in the record.
• If HLA DQ2/DQ8 testing is negative, a gluten challenge may be unnecessary.

Retest after ≥3 months on gluten before endoscopy in asymptomatic patients

In asymptomatic patients with a positive serology, retest serology after at least 3 months consuming a gluten-containing diet before referring for endoscopy to confirm persistence of seropositivity.

• Ensure documented gluten consumption for the retest period and include results when requesting endoscopy authorization.

Use TTG-IgA as initial test; biopsy for confirmation when indicated

Start diagnostic evaluation with tissue transglutaminase IgA (TTG-IgA) serology as first-line testing; intestinal biopsy is commonly used to confirm diagnosis when indicated.

• Measure total IgA concurrently with TTG-IgA to detect IgA deficiency and guide further testing.

Submit accurate documentation and follow coding guidelines

Providers must submit accurate clinical and procedural documentation and follow industry-standard coding guidelines; applicability of policy criteria depends on the individual's benefit coverage at the time of request.

• Include clinical indication, relevant symptoms, and prior test results with authorization or claims submissions.

Document EGD, biopsy sites/number, and numeric TTG-IgA assay/result

Document EGD and the sites/number of multiple duodenal biopsies obtained (including bulb and distal duodenum) and record the serology assay type and the exact numeric TTG-IgA result with its relation to the laboratory's upper limit of normal (ULN).

• Specify number and location of biopsies (e.g., at least 4 distal duodenum + ≥1 duodenal bulb when applicable).
• Record assay manufacturer/type and numeric TTG-IgA value and ULN relation (e.g., ≥10× ULN if applicable).

Document total IgA and details for no‑biopsy pediatric pathway

Record concurrent total IgA level with TTG-IgA testing to identify IgA deficiency; when using a no-biopsy pathway in children, document the TGA-IgA value (including that it meets the ≥10× ULN threshold) and confirmatory EMA-IgA result on a second sample.

• If total IgA is low, document use of IgG-based tests (IgG-EMA, IgG-DGP, or IgG-TTG).
• For pediatric no-biopsy diagnosis, include assay details demonstrating the 10× ULN measurement capability and second-sample EMA-IgA.

Follow TTG-IgA first, then biopsy for histologic confirmation when indicated

Follow the standard diagnostic sequence: perform TTG-IgA (with total IgA) as first-line serology and proceed to intestinal biopsy for histologic confirmation in most patients when indicated.

• Use the same assay for follow-up serology until normalization where applicable.

Risk of denial or recoupment for noncompliant coding/documentation

Claims may be denied or recouped if coding/billing guidelines or current reimbursement policies are not followed; services must meet authorization and medical necessity guidelines and the member's benefit coverage at the time of request.

• Include required clinical documentation with claims to avoid denials or recoupment.

Do not use point‑of‑care rapid TTG, multi‑analyte panels, stool/saliva, or anti‑reticulin tests

Rapid antigen point-of-care anti-TTG tests, panel/multiplex testing for more than two analytes, stool or saliva tests, and anti-reticulin testing are stated as NOT MEETING CRITERIA and may be denied if submitted for diagnosis or evaluation.

• Do not rely on or submit claims for these tests for diagnostic evaluation unless specifically justified by policy exception.

Ensure biopsy specimen adequacy (1–2 bulb + ≥4 distal duodenum)

Obtain the recommended multiple duodenal biopsies (at least 1–2 from the duodenal bulb and at least 4 from the distal duodenum); failure to obtain recommended sampling may prevent confirmation of diagnosis and affect coverage/authorization.

• Document the exact number and anatomical sites of biopsy specimens in the procedure and pathology reports.

Avoid serologic testing off a gluten-containing diet — risk of non-diagnostic results

Do not perform serologic testing after the patient has reduced or avoided gluten intake; testing off a gluten-containing diet reduces sensitivity and may yield non-diagnostic results that could lead to denial of further testing without appropriate documented challenge or HLA justification.

• If testing was performed off-gluten, document this and follow guidance for gluten challenge or HLA testing before repeating serology or pursuing biopsy.

Do not start gluten‑free diet before testing — document diet during testing

Advise patients to remain on a gluten-containing diet during diagnostic testing; starting a gluten-free diet before specialist-confirmed diagnosis invalidates serology and biopsy sensitivity and risks inappropriate conclusions or denial.

• Explicitly instruct patients not to start a gluten-free diet until diagnostic evaluation is complete unless directed by the specialist.

Follow government coverage rules when they supersede this policy

When this policy conflicts with applicable government policies (e.g., Medicare NCDs/LCDs or state Medicaid rules), adjudication will follow the government policy; include relevant government coverage references in requests when applicable.

• Check for and document any relevant NCD/LCD or state Medicaid requirement when submitting authorization requests for Medicare or Medicaid members.