0369U
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical record must include a detailed clinical history and exposure history.
- Medical record must include a documented differential diagnosis justifying the targets ordered and how results will affect management.
- Documentation of patient signs/symptoms and clinical correlation with NAAT results to justify treatment decisions (e.g., antibiotic therapy).
- When viability or pathogenicity is uncertain, documentation of consideration for confirmatory testing (e.g., culture, additional assays) or rationale for not performing such testing.
Key Coverage Criteria
- Acute diarrhea with moderate-to-severe symptoms (e.g., fever, bloody or mucoid stools, dysentery, severe dehydration, severe abdominal pain).
- Community-acquired diarrhea that persists for more than seven days.
- Travel-associated diarrhea of uncertain etiology.
- Individuals with signs and symptoms of gastroenteritis or infectious colitis (specified as the clinical indication for CPT 87507).
- Immunocompromised individuals (e.g., HIV, receiving chemotherapy or systemic steroids) presenting with acute diarrhea.
- Use of GI panels (CPT 87505, 87506, 87507) to detect bacterial, viral, or parasitic nucleic acid in stool from patients with signs/symptoms suggesting paralytic ileus with persistent abdominal pain ≤24 hours plus either fever or nausea/vomiting.
1 Active Policy
MED207.155 — Gastrointestinal Panels
Related Codes
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