G0455, Preparation with instillation of fecal microbiota by any method, including
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
1.31
Facility
$61.46
Non-Facility
$146.30
Documentation Required
- Imaging and laboratory/biomarker data used in studies: brain CT or MRI, amyloid PET (e.g., florbetapir), cerebrospinal fluid (CSF) biomarkers (Aβ1-42, total tau, phospho-tau), and APOE ε4 genotyping when reported in trials.
- For some interventional procedures/trials, pre-procedure evaluations included medical/neurological and psychological examinations, depression rating scales (e.g., Montgomery–Asberg Depression Rating Scale), and lumbar puncture with CSF analysis.
- Documentation of prior/concurrent standard therapies (e.g., use of cholinesterase inhibitors and/or memantine) is often recorded in trials and may be relevant when considering investigational add-on therapies.
- None specified in this policy document. (The CPB lists investigational/experimental treatments and codes not covered; it does not define separate documentation requirements for coverage of the listed items.)
Key Coverage Criteria
- None specified. This Clinical Policy Bulletin addresses experimental treatments for Alzheimer's disease and lists treatments considered experimental and investigational (i.e., not established as effective) for this indication.
- No explicit covered indications are stated in this document. The document discusses potential therapeutic use in the following conditions:
- Alzheimer's disease (AD)
- mild cognitive impairment (MCI)
- amnestic MCI
- pre-clinical AD
5 Active Policies
AETNA-CPB-0788, Alzheimer's Disease: Experimental, Investigational, or Unproven Treatments
BCBSIL-SUR703.049, Fecal Microbiota Transplantation (FMT)
BCBSMT-SUR703.049, Fecal Microbiota Transplantation (FMT)
BCBSNM-SUR703.049, Fecal Microbiota Transplantation (FMT)
BCBSOK-SUR703.049, Fecal Microbiota Transplantation (FMT)
Related Codes
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