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Intestinal dysbiosis may be defined as a state of disordered microbial ecology that is believed to cause disease. Laboratory analysis of fecal samples is proposed as a method of identifying individuals with intestinal dysbiosis. There is insufficient evidence that fecal analysis to identify intestinal dysbiosis improves net health outcome in patients with gastrointestinal tract symptoms. Moreover, there is insufficient evidence that fecal analysis aids in the diagnosis or management of patients with irritable bowel syndrome (IBS), malabsorption, or small intestine bacterial overgrowth.
The gastrointestinal tract is colonized by a large number and variety of microorganisms including bacteria, fungi, and archaea. The concept of intestinal dysbiosis rests on the assumption that abnormal patterns of intestinal flora, such as overgrowth of some commonly found microorganisms, have an impact on human health. Symptoms and conditions attributed to intestinal dysbiosis include chronic disorders such as irritable bowel syndrome, inflammatory or autoimmune disorders, food allergy, atopic eczema, unexplained fatigue, arthritis and ankylosing spondylitis, malnutrition, or neuropsychiatric symptoms including autism, and breast and colon cancer. Leo Galland, MD, a researcher who has focused his studies on dysbiosis, has proposed four (4) patterns of dysbiosis:
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 offers a “Comprehensive Digestive Stool Analysis 2.0” that evaluates a stool sample for the following components:
The comprehensive stool analysis package has an optional parasitology component.
Fecal calprotectin as a stand-alone test is addressed separately in the Fecal Calprotectin Testing medical policy.
A related topic, fecal microbiota transplantation (FMT), the infusion of intestinal microorganisms to restore normal intestinal flora is addressed in the Fecal Microbiota Transplantation medical policy. FMT has been rigorously studied for the treatment of patients with recurrent Clostridium difficile infection (CDI). Use of the procedure to treat any other condition remains controversial and no specific stool testing, other than the identification of CDI, is currently recommended.
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.
POLICYFecal analysis of the following components is considered investigational as a diagnostic test for the evaluation of intestinal dysbiosis, irritable bowel syndrome, malabsorption, or small intestinal overgrowth of bacteria:
POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY5/2002: Approved by Medical Policy Advisory Committee (MPAC) ), Code Reference section completed, CPT code 82270, 82491, 82710, 82715, 82725, 83986, 84311, 86403, 87045, 87046, 87102, 87177, 89160 added, ICD-9 diagnosis code 564.1, 569.0-569.9, 579.0-579.9 added
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.
03/13/2014: Policy reviewed; no changes.
03/18/2015: Policy description updated to add information regarding laboratory analysis of fecal samples. Policy statement unchanged.
07/20/2015: Code Reference section updated for ICD-10.
Blue Cross Blue Shield Association policy # 2.04.26
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.