J1440 — Fecal microbiota, live - jslm, 1 ml
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
- Medical record documentation of the diagnosis of recurrent CDI including clinical findings and microbiologic evidence (positive stool test for C. difficile toxin).
- Documentation of diarrhea consistent with the policy definition (3 or more loose bowel movements within a 24-hour period for 2 consecutive days).
- Record of patient age (≥ 18 years).
- Documentation of prior CDI episodes / recurrences (evidence patient has had one or more recurrence(s) following initial CDI episode).
Key Coverage Criteria
- Prevention of recurrence of Clostridioides difficile infection (rCDI) in patients who meet all specified criteria (see below).
- Covered diagnosis code referenced: A04.71 - Enterocolitis due to Clostridium difficile, recurrent.
- 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)
4 Active Policies
AETNA-CPB-0788 — Alzheimer's Disease: Experimental Treatments
UHC-POL-rebyota — Rebyota (Fecal Microbiota, Live-Jslm)
UMR-POL-UMR-rebyota — Rebyota (Fecal Microbiota, Live-Jslm)
SUREST-POL-SUREST-rebyota — Rebyota (Fecal Microbiota, Live-Jslm)
Related Codes
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