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1. Putrefaction

   Putrefaction dysbiosis results from diet high in fat and animal flesh and low in insoluble fiber, i.e., typical of Western style diet. It is thought that, compared to normal patterns of intestinal flora, this diet produces an increased concentration of Bacteriodes sp, and a decreased concentration of bifidiobacteria in stools. The increased concentration of Bacteriodes sp is thought to be associated with increased urease, ultimately leading to a rising fecal pH. Bacteriodes sp is also thought to be associated with increased beta-glucoronidase, which functions to deconjugate bile acids, which are thought to be toxic to the colonic epithelium, causing diarrhea. Increased levels of beta-glucoronidase may also impact estrogen metabolism.

2. Fermentation

   A fermentation pattern of dysbiosis has been attributed to bacterial overgrowth. In mild cases, fermentation may be characterized principally by carbohydrate intolerance, manifested by abdominal distention, flatulence, diarrhea, constipation and feelings of malaise.  

3. Deficiency

   Antibiotic therapy or decrease in dietary fiber may result in relative deficiencies of normal fecal flora, including bifidiobacteria, lactobacillus, and Escherichia coli.

4. Sensitization

   A sensitization pattern of dysbiosis has been characterized as an abnormal immune response to the endotoxins and antigens associated with normal intestinal flora.

Laboratory analysis of both stool and urine have been investigated as markers of dysbiosis. Reference laboratories specializing in the evaluation of dysbiosis may offer comprehensive testing of various aspects of digestion, absorption, microbiology, and metabolic markers. For example, Genova Diagnostics (known as Great Smokies Diagnostic Laboratory until april 2003) offers a “Comprehensive Digestive Stool Analysis 2.0” that evaluates a stool sample for the following components:   

Digestion

• Triglycerides
• Chymotrypsin
• Iso-butyrate, iso-valerate, and n-valerate
• Meat and vegetable fibers

Absorption

• Long chain fatty acids
• Cholesterol
• Total fecal fat
• Total short chain fatty acids

Microbiology

• Levels of Lactobacilli, bifidobacteria, and E. coli and other “potential pathogens,” including Aeromonas, Bacillus cereus, Campylobacter, Citrobacter, Klebsiella, Proteus, Pseudomonas, Salmonella, Shigella, Staphylococcus aureus, and Vibrio
• Identification and quantitation of fecal yeast (including Candida albicans, C. tropicalis, Rhodotorula, and Geotrichum

Metabolic Markers

• N-butyrate (considered key energy source for colonic epithelial cells)
• Beta-glucoronidase 
• pH
• Short chain fatty acid distribution (adequate amount and proportions of the different short chain fatty acids reflect the basic status of intestinal metabolism) 

Immunology

• Fecal secretory IgA (as a measure of luminal immunologic function)
• Calprotectin

Results are reported both individually or combined into a “dysbiosis risk index,” which is based on gut microbiology, pH, and short chain fatty acids.

Note: Intestinal dysbiosis may also be considered a manifestation of idiopathic environmental intolerance (i.e., clinical ecology). Idiopathic environmental intolerance is discussed in the Diagnosis and Management of Idiopathic Environmental Intolerance (i.e., clinical ecology) policy.

• Triglycerides
• Chymotrypsin
• Iso-butyrate, iso-valerate and n-valerate
• Meat and vegetable fibers
• Long chain fatty acids
• Cholesterol
• Total short chain fatty acids
• Levels of Lactobacilli, bifidobacteria and E. coli and other "potential pathogens," including Aeromona, Bacillus cereus, Campylobacter, Citrobacter, Klebsiella, Proteus, Pseudomonas, Salmonella, Shigella, S. aureus, Vibrio.
• Identification and quantitation of fecal yeast (including C. albicans, C. tropicalis, Rhodoptorul and Geotrichum)
• N-butyrate
• Beta-glucoronidase
• pH
• Short chain fatty acid distribution (adequate amount and proportions of the different short chain fatty acids reflect the basic status of intestinal metabolism)
• Fecal secretory IgA
• Calprotectin

None

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

11/5/2003: Code Reference section updated, CPT code 82705, 89125 added, ICD-9 diagnosis code range 569.0-569.9, 579.0-579.9 listed separately

8/16/2005: Code Reference section updated, CPT code 82705 deleted, ICD-9 diagnosis code 564.1, 569.0.0, 569.1, 569.2, 569.3, 569.41, 569.42, 569.49, 569.5, 569.60, 569.61, 569.62, 569.69, 569.81, 569.82, 569.83, 569.84, 569.85, 569.86, 569.89, 569.9, 579.0, 579.1, 579.2, 579.3, 579.4, 579.8, 579.9 deleted

2/8/2006:  Code Reference table updated: code 82270 deleted

5/14/2007: Policy reviewed; description updated to include stool sample components. Added CPT 83631

8/18/2008: Policy reviewed, no changes

04/30/2010: Policy description and statement unchanged. Revised the description of CPT code 83986.

05/17/2011: Policy reviewed; no changes.

08/11/2011: Added the following CPT codes to the Non-Covered Codes table: 82239, 82240, 82492, 82656, 82705, 82726, 82784, 83993, 84490, 87075, 87106, 87335, and 88313.

03/02/2012: Policy reviewed; no changes.

04/17/2013: Policy reviewed; no changes.

Blue Cross Blue Shield Association policy # 2.04.26

All codes billed for this procedure are considered investigational and not eligible for coverage.

Non-Covered Codes

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