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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:
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
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.
12/31/2015: Investigative definition updated in the policy guidelines section. Revised code description for CPT code 82542 with an effective date of 01/01/2016.
06/07/2016: Policy number L.2.04.407 added.
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.
CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.