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February 19, 2015

Fecal Microbiota Transfer

Effective for dates of service on or after January 1, 2015, fecal bacteriotherapy or fecal microbiota transplant (FMT) may be considered medically necessary as a treatment for recurrent or relapsing Clostridium difficile infection (CDI) as indicated by a positive C. difficile toxin stool test and defined as one of the following:

  • At least 3 episodes of mild to moderate CDI and failure of a 6-8 week taper with vancomycin with or without an alternative antibiotic (e.g., rifaximin, nitazoxanide), or
  • At least two episodes of severe CDI resulting in hospitalization and associated significant morbidity, or
  • Moderate CDI not responding to standard therapy (vancomycin) for at least a week, or
  • Severe fulminant C. difficile colitis with no response to standard therapy after 48 hours.

CGS considers FMT investigational for any other indication (e.g., Crohn's disease or inflammatory bowel disease, irritable bowel syndrome, and intestinal dysbiosis).

Claims for FMT must include:

  • The appropriate ICD-9 code. At this time, ICD-9 code 008.45 (intestinal infections due to clostridium difficile) is the only diagnosis code that will be considered for coverage; all other indications for these procedures will be denied as investigational.
  • HCPCS code G0455 (Preparation with instillation of fecal microbiota by any method, including assessment of donor specimen)

Reference:

  • Definition of "reasonable and medically necessary": Social Security Act, section 1862(a)(1)(A)

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