CurrentWellCarePolicy CG.CP.MP.04

Outpatient gastrointestinal pathogen and H. pylori testing

Defines medical necessity criteria for outpatient syndromic multiplex gastrointestinal pathogen panels (11-or-fewer targets and 12-or-more targets) and Helicobacter pylori noninvasive tests (urea breath, stool antigen, and antibody). Also provides CPT coding guidance for referenced tests.

Policy Summary

PayerWellCare

PolicyOutpatient gastrointestinal pathogen and H. pylori testing

Policy CodePolicy CG.CP.MP.04

Change TypeAdministrative / Coding revisions

Effective Date

Next Review Date

Key ActionDocument that the member presents with suspected infectious gastroenteritis (outpatient) and that test results will influence clinical management; include which qualifying clinical feature(s) are present.

POLICY UPDATE CHANGES

No material clinical or coverage changes were made; revisions reflect coding corrections and administrative formatting (including policy number correction to CG.CP.MP.04 and CPT table adjustments).

2Panel size categories covered

8H. pylori indications listed

1Frequency limit (per incident / 14 days)

Coverage Summary & Scope

This policy (CG.CP.MP.04, status: CURRENT) defines outpatient medical necessity criteria for syndromic multiplex gastrointestinal (GI) pathogen panels and noninvasive Helicobacter pylori testing. It distinguishes two multiplex panel-size categories — 11-or-fewer targets and 12-or-more targets — and addresses H. pylori noninvasive tests including urea breath, stool antigen, and antibody assays. Coverage is covered_with_criteria, requiring that specific clinical criteria and documentation be met before testing is considered medically necessary, consistent with guideline recommendations from ACG, IDSA, and ESPGHAN/NASPGHAN.

Medical Necessity Rules

Syndromic Multiplex Gastrointestinal Pathogen Panels with 11 or Fewer Targets - Medically Necessary

May be considered medically necessary when ALL of the following are met:

ALL of the following

- AND ONE of
  - Immunocompromised status (e.g., HIV/AIDS, immunosuppression therapy, primary immunodeficiency)
  - Recent travel to/contact with travelers from an infectious diarrheal disease-endemic area
  - Dysentery (presence of blood or mucus in stool)
  - Fever
  - Dehydration
  - Abdominal pain/tenderness
  - Bacteremia
  - Diarrhea persisting longer than 7 days
  - Symptoms of enteric fever (i.e., Typhoid/paratyphoid fever)
Results of the testing will influence the member's/enrollee's clinical management

ref

title

ref

Syndromic Multiplex Gastrointestinal Pathogen Panels with 11 or Fewer Targets - Frequency Limit

Operational frequency rule:

ALL of the following

Use is medically necessary once per incident of diarrheal disease, or no more than once per 14-day period

Syndromic Multiplex Gastrointestinal Pathogen Panels with 12 or More Targets - Medically Necessary

May be considered medically necessary when ALL of the following are met:

ALL of the following

- AND ONE of
  - Immunocompromised status (e.g., HIV/AIDS, immunosuppression therapy, primary immunodeficiency)
  - Recent travel to/contact with travelers from an infectious diarrheal disease-endemic area
  - Bacteremia
  - Symptoms of enteric fever (i.e., Typhoid/paratyphoid fever)

Syndromic Multiplex Gastrointestinal Path Panels with 12 or More Targets - Frequency Limit

Operational frequency rule:

ALL of the following

Use is medically necessary once per incident of diarrheal disease, or no more than once per 14-day period

Helicobacter pylori Urea Breath or Stool Antigen Tests - Medically Necessary

May be considered medically necessary when ANY of the following indication groups are met:

ANY of the following

A
- Member/enrollee displays at least ONE of: active peptic ulcer disease (PUD); low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma; history of endoscopic resection of early gastric cancer (EGC)
B
- Member/enrollee has a past history of PUD
- Previous cure of H. pylori infection has NOT been documented
C

Helicobacter pylori Urea Breath or Stool Antigen Tests - Not Supported

Current evidence does not support use for the following (examples):

ANY of the following

Evaluation of individuals with GERD
Lymphocytic gastritis
Hyperplastic gastric polyps
Hyperemesis gravidarum
Asymptomatic individuals with a family history of gastric cancer

Helicobacter pylori Antibody Tests - Not Supported

Policy position:

Current evidence does not support H. pylori antibody tests for all indications

CPT Coding Guidance

CPT codes referenced (informational coding table)CPT

83013	Helicobacter pylori; breath test analysis for urease activity, non-radioactive isotope (eg, C-13)
83014	Helicobacter pylori; drug administration
86677	Antibody; Helicobacter pylori
87338	Infectious agent antigen detection by immunoassay; Helicobacter pylori, stool
87339	Infectious agent antigen detection by immunoassay; Helicobacter pylori
87493	Infectious agent detection by nucleic acid; Clostridium difficile, toxin gene(s), amplified probe technique
87498	Infectious agent detection by nucleic acid; enterovirus, amplified probe technique
87500	Infectious agent detection by nucleic acid; vancomycin resistance (eg, enterococcus species van A, van B)
87505	Gastrointestinal pathogen, 3-5 targets, multiplex
87506	Gastrointestinal pathogen, 6-11 targets, multiplex

1–10 of 22

1/3

Provider Documentation & Billing Rules

Documentation Required

Clinical indication and expected management impact

Document that the member presents with suspected infectious gastroenteritis (outpatient) and that test results will influence clinical management; include which qualifying clinical feature(s) are present (see policy list: immunocompromised status, recent travel/contact with travelers from endemic areas, dysentery, fever, dehydration, abdominal pain/tenderness, bacteremia, diarrhea >7 days, or symptoms of enteric fever).

Billing Rule

Frequency limit for multiplex GI panels

Do not bill for syndromic multiplex gastrointestinal pathogen panels more than once per incident of diarrheal disease or more than once per 14-day period.

87505
87506
87507
87800
87801

Documentation Required

H. pylori testing prerequisites

For H. pylori testing, document the specific indication for testing (examples include: active peptic ulcer disease; low-grade gastric MALT lymphoma; history of endoscopic resection of early gastric cancer; past PUD without documented cure; uninvestigated dyspepsia in patients <60 years without alarm features; initiation of prophylactic low-dose aspirin; initiation of chronic NSAID therapy; unexplained iron deficiency anemia after appropriate evaluation; or adult idiopathic thrombocytopenic purpura).

83013
87338
87339

Background & Evidence

Multiplex molecular GI testing platforms can detect multiple viral, bacterial, and parasitic targets simultaneously and are increasingly used instead of single-target culture or microscopy methods. Given this capability, guideline guidance supports targeted use: testing should be performed when results are likely to influence clinical management (for example, in dysentery, moderate-to-severe disease, symptoms >7 days, or specific high-risk scenarios). Recommendations from the American College of Gastroenterology (ACG), Infectious Diseases Society of America (IDSA), and pediatric societies (ESPGHAN/NASPGHAN) inform when multiplex testing and H. pylori testing are appropriate.

Evidence

Key guideline referencesACG 2016; IDSA 2017; ACG 2017; ESPGHAN/NASPGHAN 2016

Uninvestigated dyspepsia: dyspepsia that has not already been evaluated via investigations such as upper GI endoscopy and/or is not already classified as functional/organic dyspepsia.

Dyspepsia alarm features: vomiting, bleeding or anemia, abdominal mass or unintended weight loss, and dysphagia.

Gastroenteritis: characterized by vomiting and/or diarrhea.

Revision History

2024-03-24revisionLatest

Revision dated 03/24: Corrected coding descriptions in CPT table; removed 0369U and corrected policy number from CG.CP.MP.104 to CG.CP.MP.04 (coding corrections and policy number change).

2024-02revision

Revision dated 02/24: Administrative formatting and coding table changes — added 'lab' to title; removed CPT and ICD-10 codes from the policy reference table; added CPT code table and moved the 'Coding Implications' section.

2024-02approval

Approval noted 02/24: Policy developed and reviewed by external specialist (administrative approval/review history; no change to clinical coverage criteria indicated).

2023-11revision

Revision noted 11/23: Policy developed and reviewed by external specialist (administrative review history; no change to clinical coverage criteria indicated).