86318
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Record of the chosen diagnostic test and FDA clearance status: e.g., stool antigen test (HpSA) cleared for initial diagnosis, therapeutic monitoring and eradication confirmation in adults and children; urea breath test cleared for initial diagnosis and eradication confirmation in adults.
- If urea breath test is used, documentation that the test was performed while fasting.
- For post-treatment confirmation of eradication, documentation of a negative stool antigen test or negative urea breath test result is required.
- For patients requiring endoscopic evaluation (age >55 or alarm symptoms), documentation should include endoscopy report and biopsy-based test results (rapid urease test, histology, culture) when applicable.
Key Coverage Criteria
- Confirmation of the presence of the H. pylori bacterium can be determined non-invasively using an FDA-cleared urea breath test or a stool antigen test or invasively on endoscopic biopsy followed by rapid urease testing (CLOtest™, PyloriTek™, Hpfast™), histology with special stains, or culture.
- Adults with idiopathic thrombocytopenic purpura
- Antibiotic therapy is indicated for all H. pylori -infected ulcer patients.
- The stool antigen test (HpSA, Meridian Bioscience, Cincinnati, OH) and the urea breath tests (UBT (Meretek Diagnostics, Lafayette, CO), PYtest (Halyard Health, Alpharetta, GA)) determine the presence of active H. pylori infection.
- The HpSA stool antigen test is cleared by the U.S. Food and Drug Administration (FDA) for use in the initial diagnosis, therapeutic monitoring and eradication confirmation in adults and children.
- Urea breath tests are cleared by the FDA for the initial diagnosis, and eradication confirmation in adults.
1 Active Policy
AETNA-CPB-0177 — Helicobacter Pylori Infection Testing
Related Codes
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