Find policies, billing codes, payers, states, and providers
Helicobacter pylori Testing
Customize your policy alerts
Sign up for all Oscar Health policy alerts
Know when Oscar Health releases new policies or updates existing guidance.
Monitor payer policy activity
Defines coverage, limitations, and testing methods for diagnosing and confirming eradication of H. pylori infection for members, including adults and children, and lists situations where testing meets or does not meet criteria.
No material clinical or coverage changes in this revision.
Coverage Criteria for H. pylori Testing
Adult diagnostic indications (noninvasive)
Covered when ANY of the following (adults ≥18) — noninvasive testing (UBT or stool antigen) meets criteria:
See Note 1 for dyspepsia definition.
Adult invasive testing (endoscopy/alarm)
Covered when ALL of the following (adults with endoscopy or alarm symptoms) — invasive biopsy-based testing meets criteria:
Alarm features include vomiting, GI bleeding, unexplained iron deficiency, or weight loss (see Note 2).
Pediatric diagnostic indications (noninvasive)
Covered when ANY of the following (children <18) — noninvasive testing meets criteria:
Pediatric invasive testing (refractory IDA)
Covered when ALL of the following (children with refractory iron deficiency anemia) — invasive biopsy-based testing meets criteria:
Eradication testing
Covered when ALL of the following — eradication testing
UBT is preferred for test-of-cure; monoclonal stool antigen is an alternative.
Susceptibility testing for refractory infection
Covered when ANY of the following — susceptibility testing
Can be performed on archival biopsy specimens to guide subsequent therapy selection after treatment failures.
Not medically necessary / Not covered conditions
Not covered in these explicit situations:
Rapid office serology tests should be avoided.
ESPGHAN/NASPGHAN recommendations.
Indications for testing (guideline-aligned indications)
Indications to test for and treat H. pylori per major gastroenterology guidelines
Age and alarm-feature thresholds differ across guidelines.
Diagnostic methods and washout (preferred tests and pre-test considerations)
Preferred diagnostic methods and pre-test considerations
UBT preferred for confirmation of eradication; monoclonal stool antigen is an alternative.
Treatment recommendations (treatment and post-treatment testing guidance)
Treatment and post-treatment testing guidance
Document prior therapies and adherence when considering susceptibility‑guided therapy.
Pediatric criteria (pediatric-specific criteria and guidance)
Pediatric-specific criteria and guidance
Consider treatment of incidental H. pylori found at endoscopy after risk–benefit discussion with family.
Covered when guideline-based indications and test selection are met (guideline-aligned recommendations)
Covered when guideline-based indications and test selection are met (consensus statements and guideline citations):
Maastricht V guidance.
Concurrent testing with multiple modalities to diagnose H. pylori infection is not supported. Concurrent testing with any combination of the urea breath test, stool antigen testing, and/or biopsy-based testing to diagnose an H. pylori infection DOES NOT MEET CRITERIA. Providers should select a single appropriate diagnostic test for active infection based on clinical context and guideline recommendations rather than ordering overlapping tests.
Antibody-based serologic testing is not appropriate for diagnosing active H. pylori infection. For individuals of all ages, serologic testing for H. pylori infection DOES NOT MEET CRITERIA, and consensus guidance recommends against using serology to detect active infection.
Routine testing of asymptomatic individuals is not supported. Urea breath testing or stool antigen testing to diagnose H. pylori infection DOES NOT MEET CRITERIA for asymptomatic individuals of all ages. Pediatric guidance also recommends against screening asymptomatic children and against routine noninvasive testing for many indications such as initial evaluation of functional abdominal pain.
Serological antibody tests and rapid office serology are not recommended for detection of active infection or for confirming eradication. Guidelines advise using tests that evaluate active infection (e.g., UBT, stool antigen, or histology when endoscopy is indicated), and recommend against single serological tests to confirm eradication.
Noninvasive testing (UBT or stool antigen) to diagnose H. pylori infection is not appropriate for asymptomatic individuals and should only be used when guideline-based indications are met. Specifically, UBT or stool antigen testing to diagnose H. pylori infection DOES NOT MEET CRITERIA for asymptomatic individuals of all ages. For post-treatment confirmation of eradication, UBT or stool antigen testing MEETS CRITERIA when performed at least four weeks post-treatment.
Recent use of certain medications invalidates testing. For individuals with recent use of antibiotics, proton pump inhibitors (PPIs), or bismuth, the urea breath test, stool antigen, or biopsy-based testing to diagnose an H. pylori infection DOES NOT MEET CRITERIA. Guidelines recommend stopping PPIs for at least 2 weeks and antibiotics/bismuth for at least 4 weeks before testing for active infection.
Office-based serological tests should be avoided for routine diagnosis. NICE and pediatric guidance indicate that office-based rapid serology is not recommended for routine diagnosis and that serology should only be used if a locally validated laboratory-based test is available; otherwise, prefer UBT or stool antigen for active infection testing.
Do not use serology to confirm eradication. Use of single serological tests to confirm eradication and use of rapid office serology for detection of active infection are not recommended. Confirm eradication with tests that detect active infection (UBT or monoclonal stool antigen) performed at least 4 weeks after completion of therapy.
Coding and Procedure Codes
| No CPT/ICD codes listed | This document excerpt contains guideline and clinical evidence discussion but does not list specific billing codes. |
| 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. |
| 87070 | Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and... |
| 87077 | Presumptive identification of isolates Culture, bacterial; aerobic isolate, additional methods required for definitive identification... |
| 87081 | Culture, presumptive, pathogenic organisms, screening only. |
| 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). |
Provider Actions, Authorization, and Billing Guidance
Verify member benefits and authorization requirements
Coverage and authorization decisions depend on the member’s specific benefit plan and applicable medical necessity rules; providers must verify authorization requirements with the member’s benefits before ordering tests or submitting claims.
Order susceptibility testing for refractory infections
Susceptibility testing (culture or nucleic-acid based) for refractory H. pylori infection meets criteria and may be used to guide therapy selection; providers should request susceptibility testing when managing refractory infection.
Use applicable CPT/HCPCS codes for authorization and claims
Use the listed CPT/HCPCS procedure codes when requesting prior authorization or submitting claims for H. pylori testing, culture, susceptibility, and pathology services.
No standalone prior authorization program specified in these excerpts
No specific prior authorization program or authorization-only requirement is stated in the provided document chunks; however, coverage is still subject to member benefits and medical necessity.
Obtain culture or molecular susceptibility testing for refractory cases
For refractory infection, order culture-based or nucleic-acid-based susceptibility testing (including testing from archival biopsy specimens) to identify antibiotic resistance and guide salvage therapy selection.
- Molecular resistance testing can be performed on archival formalin-fixed paraffin-embedded gastric biopsy tissue.
- Susceptibility testing is recommended after two failed therapies with confirmed adherence.
Use guideline-preferred first-line regimens before salvage therapies
Follow guideline-preferred sequencing: offer guideline-preferred first-line regimens (e.g., optimized bismuth quadruple therapy) for treatment-naive patients before alternative or salvage therapies unless susceptibility data indicate otherwise.
- ACG 2024 recommends optimized BQT as a first-line option for treatment-naive adults.
- If treatment-experienced, optimized BQT or other guideline-recommended salvage regimens are suggested based on prior therapies.
Perform susceptibility-guided therapy when local resistance is not low
Consider susceptibility-guided therapy (including clarithromycin susceptibility testing) before using clarithromycin-based first-line regimens in areas without well-documented low clarithromycin resistance; omit testing only when local resistance is <15%.
- Maastricht V recommends clarithromycin susceptibility testing when considering standard clarithromycin-based first-line therapy except where local clarithromycin resistance is <15%.
No step therapy rules specified in these excerpts
There are no step therapy requirements specified in the provided document chunks; therapy selection should follow guideline recommendations and susceptibility results where applicable.
Provide accurate documentation and note benefit-dependency
Submit accurate clinical documentation with authorization or claims and note that application of criteria depends on the individual member’s benefit coverage at the time of request.
- Providers are responsible for submission of accurate documentation of services performed.
- Application of criteria is dependent upon an individual’s benefit coverage at time of request.
Document treatment history and adherence
Document prior H. pylori therapies, patient adherence, and prior macrolide (clarithromycin) exposure when considering susceptibility-guided therapy or clarithromycin-based regimens.
- AGA recommends susceptibility testing after two failed therapies with confirmed adherence.
- Clarify prior macrolide exposure before choosing clarithromycin-containing regimens.
Document test choice and medication washout/hold
Document the type of diagnostic test used for active infection (UBT, stool antigen, or histology when endoscopy indicated) and record medication holds: stop PPIs ≥2 weeks and antibiotics/bismuth ≥4 weeks before testing when applicable.
- UBT and stool antigen are recommended tests for active infection and for test-of-cure.
- Stop PPIs 2 weeks and antibiotics/bismuth 4 weeks before testing for active infection or test-of-cure.
Publication history recorded; no extra documentation specified here
Publication history and governance approval are recorded (06/16/2026); no additional or separate provider documentation requirements are specified in these document chunks.
Risk of claim denial or recoupment for incorrect coding
Claims may be denied or recouped if coding/billing guidelines or current reimbursement policies are not followed; ensure appropriate coding per industry standards.
- Follow coding systems including CPT, HCPCS, ICD-10, NDCs, and CMS coding guidance to avoid denials or recoupment.
Avoid testing during invalid medication conditions (washout required)
Testing performed without appropriate medication washout (PPIs less than 2 weeks off, or antibiotics/bismuth less than 4 weeks off) can yield inaccurate results and may be considered not meeting criteria.
- NICE and Maastricht recommend a 2-week PPI washout and a 4-week antibiotic/bismuth washout prior to testing.
- Testing after recent use of antibiotics, PPIs, or bismuth does not meet criteria per the policy.
Follow government policy when conflicts exist to avoid denial
If this policy conflicts with any applicable government policy (e.g., LCDs or NCDs), the government policy takes precedence and following the payer policy instead may lead to denial.
No other provider actions specified in these excerpts
No additional miscellaneous provider actions are specified in the provided document chunks.
Background
H. pylori is a gram-negative, spiral bacterium associated with chronic gastritis, peptic ulcer disease, gastric adenocarcinoma and MALT lymphoma. Testing is used to detect active infection to guide eradication therapy and to confirm successful treatment; choice of test depends on age, clinical presentation, and recent medication use. Guidelines consistently recommend using tests of active infection (13C-urea breath test or stool antigen) for initial diagnosis and for post-treatment confirmation, reserving biopsy-based testing for patients undergoing endoscopy or with alarm features.
Definitions and Test Descriptions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.