Medical Policy

 

Subject: Fecal Analysis in the Diagnosis of Intestinal Disorders
Document #: LAB.00016 Publish Date:    08/29/2018
Status: Reviewed Last Review Date:    07/26/2018

Description/Scope

This document addresses the use of fecal analysis for the diagnosis of intestinal disorders.  Fecal analysis may be suggested for people with gastrointestinal symptoms such as indigestion, constipation, diarrhea, gas, bloating or abdominal pain; symptoms that may overlap with a variety of gastrointestinal disorders such as intestinal dysbiosis, irritable bowel, malabsorption or small intestinal overgrowth of bacteria.

Position Statement

Investigational and Not Medically Necessary:

Fecal analysis of the following components is considered investigational and not medically necessary as a diagnostic test for the evaluation of intestinal dysbiosis, irritable bowel syndrome, malabsorption or small intestinal overgrowth of bacteria:

Rationale

While the literature includes much discussion regarding the relationship between intestinal microflora and various disorders, intestinal dysbiosis as a specific disorder is poorly defined.  A literature search revealed no published studies establishing diagnostic criteria for this disorder.  The gastrointestinal symptoms attributed to intestinal dysbiosis (for example, bloating, flatulence, diarrhea or constipation) overlap in part with irritable bowel syndrome and small intestinal bacterial overgrowth syndrome.  The diagnosis of irritable bowel syndrome is typically made clinically, based on a set of criteria referred to as the Rome criteria.  Small intestine bacterial overgrowth may result from altered motility (including blind loops), decreased intestinal acidity, exposure to antibiotics, or surgical resection of the small bowel.  Symptoms include malabsorption, diarrhea, fatigue and lethargy.  Although the diagnosis of bacterial overgrowth may be made clinically and the condition treated empirically with antibiotics, the laboratory diagnosis may consist of cultural analysis of a jejunal fluid sample or hydrogen breath testing.  Hydrogen breath tests, commonly used to evaluate lactose intolerance, have been adapted for use in diagnosing both small intestinal bacteria overgrowth and irritable bowel disease.  No studies in the published literature have been identified describing stool analysis for bacterial flora or metabolic products as a diagnostic technique for irritable bowel syndrome or small intestine bacterial overgrowth.

Measurement of fecal fat (that is, qualitative, quantitative and fat differential) is an established diagnostic technique for malabsorption.  A literature search did not identify any published studies regarding the diagnostic performance of fecal analysis of digestion, absorption, microbiology, metabolic markers or immunology as a diagnostic tool for suspected malabsorption syndrome, small intestine bacterial overgrowth or intestinal dysbiosis.  Chronic intestinal candidiasis has been linked with various gastrointestinal complaints as well as systemic complaints, such as chronic fatigue syndrome.  However, chronic intestinal candidiasis is an ill-defined condition without established diagnostic parameters.

There have not been any studies published to date linking fecal testing for dysbiosis with any specific treatment or other clinical utility. 

Background/Overview

The symptoms and conditions that have been attributed to dysbiosis include chronic intestinal disorders including irritable bowel disease, inflammatory or autoimmune disorders, food allergy, atopic eczema, unexplained fatigue, arthritis and ankylosing spondylitis, malnutrition, breast and colon cancer or neuropsychiatric symptoms, including autism.

Laboratory analysis of both stool and urine has been investigated as potential markers of dysbiosis.  Reference laboratories specializing in the evaluation of dysbiosis may offer comprehensive testing of various aspects of digestion, absorption, microbiology and metabolic markers.  For example, Genova Diagnostics offers the Comprehensive Digestive Stool Analysis (CDSA)TM (Asheville, NC) that evaluates a stool sample for the following components:

Digestion/Absorption

Gut Metabolic Markers

Gut Microbiology Markers

Another example of a fecal analysis test is SmartGutTM (uBiome, San Francisco, CA). This test identifies certain pathogenic microorganisms, potentially harmful microorganisms, and potentially beneficial microorganisms. With these results, a Microbial Diversity Score is measured to indicate an association with intestinal dysbiosis.

Definitions

Autoimmune: Disease that results when the immune system mistakenly attacks the body's own tissues.

Intestinal flora: Microorganisms (for example, bacteria) that inhabit the intestinal tract and are essential for its normal functioning.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When Services are Investigational and Not Medically Necessary:
When the code(s) describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

CPT

 

89240

Unlisted miscellaneous pathology test [when specified as fecal analysis for intestinal dysbiosis or other intestinal symptoms and disorders]

 

 

ICD-10 Diagnosis

 

 

All diagnoses, including but not limited to the following:

K58.0-K58.9

Irritable bowel syndrome

K63.9

Disease of intestine, unspecified (no specific diagnosis code for intestinal dysbiosis)

References

Peer Reviewed Publications:

  1. Pimentel M, Chow EJ, Lin HC. Eradication of small intestinal bacterial overgrowth reduces symptoms of irritable bowel syndrome. Am J Gastroenterol. 2000; 95(12):3503-3506.
  2. Vanner SJ, Depew WT, Paterson WG, et al. Predictive value of the Rome criteria for diagnosing the irritable bowel syndrome. Am J Gastroenterol. 1999; 94(10):2912-2917.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Gastroenterological Association (AGA). Medical position statement: irritable bowel syndrome. Gastroenterology. 2002; 123(6):2105-2107.
Index

Comprehensive Digestive Stool Analysis (CDSA)
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
GI Effects Comprehensive Profile
Intestinal Dysbiosis
SmartGut

Document History

Status

Date

Action

Reviewed

07/26/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Background/Overview and Index sections.

 

05/15/2018

The document header wording updated from “Current Effective Date” to “Publish Date.”

Reviewed

08/03/2017

MPTAC review. Updated Background/Overview section.

Reviewed

08/04/2016

MPTAC review. Updated Rationale and Background/Overview sections. Removed ICD-9 codes from Coding section.

Reviewed

08/06/2015

MPTAC review. Title revised. Updated Description and Rationale sections.

Reviewed

08/14/2014

MPTAC review.  Updated Description/Scope and Coding sections.

Reviewed

08/08/2013

MPTAC review. 

Reviewed

08/09/2012

MPTAC review.

Reviewed

08/18/2011

MPTAC review. 

Reviewed

08/19/2010

MPTAC review. 

Reviewed

08/27/2009

MPTAC review. 

Reviewed

08/28/2008

MPTAC review.

 

02/21/2008

The phrase "investigational/not medically necessary" was clarified to read "investigational and not medically necessary." This change was approved at the November 29, 2007 MPTAC meeting.

Reviewed

08/23/2007

MPTAC review.

Reviewed

09/14/2006

MPTAC review. 

 

11/17/2005

Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).

Revised

09/22/2005

MPTAC review.  Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization. 

Pre-Merger Organizations Last Review Date Document Number Title
Anthem, Inc. None   None
WellPoint Health Networks, Inc. 04/28/2005   Fecal Analysis in the Diagnosis of Intestinal Dysbiosis.