Currentpriority healthPolicy N/A

Fecal Microbiota Transplantation / Fecal Bacteriotherapy

Defines medical necessity, coverage stance, coding, and administrative application for fecal microbiota transplantation (FMT)/fecal bacteriotherapy primarily for Clostridioides difficile infection (CDI) and describes excluded indications and product guidance for Priority Health members.

Policy Summary

Payerpriority health

PolicyFecal Microbiota Transplantation / Fecal Bacteriotherapy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateDec 1, 2025

Next Review DateNov 20, 2025

Key ActionSubmit prior authorization with documentation of diagnosis, prior antibiotic therapy and response, and applicable procedure/drug codes when requesting FMT.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3episodes threshold

48 hrstime to consider FMT

J1440,44705procedure/drug codes

A04.71,A04.72ICD-10 codes

Coverage Criteria

Medically necessary indications

Policy Summary

Payerpriority health

PolicyFecal Microbiota Transplantation / Fecal Bacteriotherapy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateDec 1, 2025

Next Review DateNov 20, 2025

Key ActionSubmit prior authorization with documentation of diagnosis, prior antibiotic therapy and response, and applicable procedure/drug codes when requesting FMT.

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.

Covered indications: 1) Recurrent or relapsing C. difficile infection (CDI) defined as either: (a) at least 3 episodes of mild to moderate CDI and failure of a 6-8 week taper with vancomycin with or without an alternative antibiotic (e.g., rifaximin, nitazoxanide), OR (b) at least 2 episodes of severe CDI resulting in hospitalization and associated with significant morbidity; 2) Moderate CDI not responding to standard therapy (vancomycin) for at least a week; 3) Severe or fulminant C. difficile colitis with no response to standard therapy after 48 hours.see text

Preserves original OR/AND grouping from policy

Coding — Diagnosis and Procedure Codes

ICD-10 supporting diagnosesICD-10

A04.71	Enterocolitis due to Clostridium difficile, recurrent
A04.72	Enterocolitis due to Clostridium difficile, not specified as recurrent

CPT/HCPCS codesmixed

J1440	Fecal microbiota, live - jslm, 1 ml - See Priority Health Medical Benefit Drug List for current coverage
44705	Preparation of fecal microbiota for instillation, including assessment of donor specimen
G0455	Preparation with instillation of fecal microbiota by any method, including assessment of donor specimen
0780T	Instillation of fecal microbiota suspension via rectal enema into lower gastrointestinal tract (Not Covered for Medicaid)
44799	Unlisted procedure, small intestine (submit with explanatory notes if administration is via NG tube or enema)

Provider Actions and Administrative Requirements

Prior Authorization

Prior Authorization Required

Prior authorization requirement — providers must submit requests demonstrating medical necessity and include applicable procedure/drug information.

Include relevant CPT/HCPCS/NDC codes (see CPT/HCPCS Codes section) and clinical documentation supporting criteria for FMT
If administration is via colonoscopy, EGD, NG tube, or enema, include procedure notes and rationale
When drug product (e.g., Rebyota™) is used, reference the Priority Health Medical Benefit Drug List (MBDL) for coverage and prior authorization guidance

Documentation Required

Antibiotic Therapy Requirement

Antibiotic therapy requirement — members must have attempted and failed appropriate standard antibiotic therapy prior to FMT where applicable.

Document prior antibiotic regimens, durations, and clinical response (e.g., vancomycin tapered 6-8 weeks, rifaximin use)
For moderate CDI, document at least one week of standard therapy with lack of response prior to FMT
For severe/fulminant CDI, document standard therapy and 48-hour nonresponse when applicable

Documentation Required

Documentation Required for Medical Necessity

Medical necessity documentation — when prior authorization is required, submit documentation demonstrating medical necessity per the policy criteria.

Clinical history supporting diagnosis of recurrent, relapsing, moderate, or severe/fulminant CDI per policy criteria
Number and severity of prior CDI episodes, hospitalizations, and prior treatment attempts
Donor testing documentation when donor testing is performed (testing for donor selection is a covered benefit if the FMT recipient is a Priority Health member)
If using a nonstandard route or product, provide justification and supporting evidence

Denial Risk

Experimental/Investigational Exclusions

Experimental/Investigational exclusions — requests for FMT for indications not listed as medically necessary, oral administration, or standardized stool-derived products are not covered.

Do not submit authorization requests for FMT for indications outside the policy's medically necessary list (these will be denied as experimental/investigational)
Oral FMT/fecal bacteriotherapy (including capsules) is not covered — do not bill as covered service
Use of standardized stool-bank products or commercial stool preparations for FMT is considered experimental and investigational and is not covered
Testing for donor selection is covered when the recipient is a Priority Health member, but this does not imply coverage for excluded FMT indications or products

Background

Clostridioides difficile infection (CDI) is a toxin-producing, spore-forming bacterium that can cause diarrhea and colitis, frequently occurring after disruption of the intestinal microbiota (for example, following antibiotic exposure). Recurrent CDI (rCDI) — defined as recurrence of symptoms with a positive stool test within 8 weeks after successful treatment — is associated with substantial morbidity and may require therapies beyond standard antibiotics.

Fecal microbiota transplantation (FMT) restores gut microbial communities and is included in this policy as a medically necessary option for specified CDI scenarios: recurrent or relapsing CDI meeting the criteria in this document, moderate CDI not responding to standard therapy after at least a week, and severe or fulminant C. difficile colitis that fails to respond to standard therapy after 48 hours. Donor testing for recipient-directed FMT is a covered benefit for Priority Health members; however, use of standardized stool preparations from stool banks and oral administration are considered experimental/investigational and not covered.

Definitions

Recurrent CDI (rCDI) definition

DefinitionRecurrent CDI (rCDI) — recurrence of symptoms with a positive stool test that occurs within 8 weeks after successful treatment of the CDI episode.

Clinical relevancerCDI is difficult to eradicate and can lead to substantial morbidity and death (complications include hypotension, dehydration, toxic megacolon, colonic perforation, septicemia).

Typical causeOften follows antibiotic treatment that alters intestinal microbiota, allowing C. difficile overgrowth.

Stool bank definition

DefinitionStool bank — an establishment that collects, prepares, and stores FMT product for distribution to other establishments, health care providers, or other entities for use in patient therapy or clinical research.

Policy relevanceUse of standardized stool sample preparations from a stool bank (e.g., products from OpenBiome) is considered experimental/investigational and not covered by Priority Health.

Associated requirementDonor selection testing is a covered benefit if the FMT recipient is a Priority Health member (testing separate from stool bank product coverage).