Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing for Infectious Diarrhea – Commercial and Individual Exchange Medical Policyopen_in_new

UnitedHealthcare covers multiplex PCR GI pathogen panels up to 5 targets only when performed as part of an evaluation that includes blood cultures for patients with defined severity features (diarrhea >7 days; fever; bloody/mucoid stools; severe abdominal pain/tenderness; signs of sepsis; or suspected enteric fever with relevant travel/exposure) and up to 11 targets for persistent diarrhea in patients at risk for C. difficile or who are immunocompromised (including AIDS, transplant-related or other immunosuppression) after other stool studies have failed; panels >11 targets and multiplex testing for other indications are unproven/not medically necessary. Coverage requires documentation of the clinical criteria, travel/exposure history for enteric fever, record of blood cultures when required, proof of immunocompromised status and prior stool testing/results as applicable, and verification of member-specific benefits and applicable mandates.

"Multiplex PCR panel testing of gastrointestinal pathogens >11 targets (unproven and not medically necessary due to insufficient evidence of efficacy)"