Gastrointestinal (GI) Function/Health Panel

POLICY NUMBER

L.2.04.407

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.

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:

• Pathogen screening: bacteria, fungi, yeast, and various parasites.

• Digestion related screens: enzyme levels and immunochemical markers for intolerance to common offending foods.

• Intestinal function markers: evaluate irritation and inflammation and indicate overall status of gut immunity and integrity, i.e. occult blood, etc. 

POLICY

A Gastrointestinal (GI) Function/Health Panel is considered not medically necessary for all indications, including but not limited to the following:

• Inflammatory bowel disease

• Loose stool or diarrhea after travel or camping

• Chronic loose stool or constipation

• Sudden changes in bowel habits

• Insomnia

• Hyperactivity

• Fat, grain and food intolerance

• Bloating, maldigestion and heartburn

• School- and pool-acquired GI problems

• Excess gas and flatulence

• Chronic abdominal discomfort or pain

• Chronic skin conditions

• Chronic fatigue and fibromyalgia

• Excessive eating or anorexia

• Malaise and fatigue.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

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.

POLICY HISTORY

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.

05/24/2018: Links updated in Sources section.

12/15/2021: Code Reference section updated to add new CPT code 82653 and to revise code description for CPT code 82656, effective 01/01/2022.

11/07/2022: Policy reviewed. Policy statement unchanged. Sources updated.

10/18/2023: Policy reviewed; no changes.

12/04/2024: Policy reviewed; no changes.

SOURCE(S)

1. American College of Physicians PIER (Physicians' Information and Education Resource)

2. Blue Cross Blue Shield Association policy # 2.04.26

3. UpToDate® (uptodate.com)

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

Investigational Codes

CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.