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DESCRIPTIONIntestinal dysbiosis may be defined as a state of disordered microbial ecology that causes disease. Specifically, the concept of dysbiosis rests on the assumption that patterns of intestinal flora, specifically overgrowth of some microorganisms found commonly in intestinal flora, have an impact on human health. Symptoms and conditions attributed to dysbiosis include chronic intestinal disorders including irritable bowel disease, 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.
The GI Health Panel™ (Diagnos-Techs, Inc.) is utilized as a non-invasive screen of the gastrointestinal tract and its function. It includes 15-22 individual tests. Stool and saliva samples are submitted by the patient after home collection. The panel includes the following:
POLICYA Gastrointestinal (GI) Function/Health Panel is considered not medically necessary for all indications, including but not limited to the following:
Investigative 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.
05/01/2013: New policy added. Approved by Medical Policy Advisory Committee.
12/31/2014: Code Reference section updated to revise the description of the following CPT code: 82542.
07/20/2015: Code Reference section updated for ICD-10.
SOURCE(S)American College of Physicians PIER (Physicians' Information and Education Resource)
Blue Cross Blue Shield Association policy # 2.04.26
This may not be a comprehensive list of procedure codes applicable to this policy.