DESCRIPTION Intestinal 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. Leo Galland, MD, a researcher who has focused his studies on dysbiosis, has proposed four (4) patterns of dysbiosis:
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.
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.
Antibiotic therapy or decrease in dietary fiber may result in relative deficiencies of normal fecal flora, including bifidiobacteria, lactobacillus, and Escherichia coli.
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:
- Iso-butyrate, iso-valerate, and n-valerate
- Meat and vegetable fibers
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
N-butyrate (considered key energy source for colonic epithelial cells)
Short chain fatty acid distribution (adequate amount and proportions of the different short chain fatty acids reflect the basic status of intestinal metabolism)
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.
POLICY Fecal 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:
- Iso-butyrate, iso-valerate and n-valerate
- Meat and vegetable fibers
- Long chain fatty acids
- 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)
- 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
POLICY GUIDELINES 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.
POLICY HISTORY 5/2002: 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.
Blue Cross Blue Shield Association policy # 2.04.26
CODE REFERENCE This may not be a comprehensive list of procedure codes applicable to this policy.
Bile acids; total (Added 08-11-2011)
Bile acids; cholylglycine (Added 08-11-2011)
Chromatography, quantitative, column (eg, gas liquid or HPLC); single analyte not elsewhere specified, single stationary and mobile phase
Chromatography, quantitative, column (eg, gas liquid or HPLC); multiple analytes, single stationary and mobile phase (Added 08-11-2011)
Elastase, pancreatic (EL-1), fecal, qualitative or semi-quantitative (Added 08-11-2011)
Fat or lipids, feces; qualitative (Added 08-11-2011)
Fat or lipids, feces; quantitative
Fat differential, feces, quantitative
Fatty acids, nonesterified
Very long chain fatty acids (Added 08-11-2011)
Gammaglobulin (immunoglobulin); IgA, IgD, IgG, IgM, each (Added 08-11-2011)
Lactoferrin, fecal; quantitative (added 5-14-2007)
pH; body fluid, not otherwise specified (Description revised 01-01-2010)
Calprotectin, fecal (Added 08-11-2011)
Spectrophotometry, analyte not elsewhere specified
Trypsin; feces, quantitative, 24-hour collection (Added 08-11-2011)
Particle agglutination; screen, each antibody
Culture, bacterial; feces, with isolation and preliminary examination (eg, KIA, LIA), Salmonella and Shigella species
Culture, bacterial; stool, additional pathogens, isolation and preliminary examination (eg, Campylobacter, Yersinia, Vibrio, E. coli 0157), each plate
Culture, bacterial; any source, except blood, anaerobic with isolation and presumptive identification of isolates (Added 08-11-2011)
Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; other source (except blood)
Culture, fungi, definitive identification, each organism; yeast (Added 08-11-2011)
Ova and parasites, direct smears, concentration and identification
Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple-step method; Escherichia coli 0157 (Added 08-11-2011)
Special stains; Group II, all other (eg, iron, trichrome), except immunocytochemistry and immunoperoxidase stains, including interpretation and report, each (Added 08-11-2011)
Fat stain, feces, urine, or respiratory secretions (added 11-5-2003)
Meat fibers, feces