Highmark Commercial Medical Policy - Pennsylvania |
Medical Policy: | L-32-017 |
Topic: | Laboratory Studies for Diagnosing and Managing Inflammatory Bowel Disease |
Section: | Laboratory |
Effective Date: | January 9, 2017 |
Issue Date: | January 9, 2017 |
Last Reviewed: | September 2016 |
The term IBD refers to a chronic and relapsing inflammatory disorder of the gastrointestinal tract (GIT) accompanied by abdominal pain, rectal bleeding and malabsorption. It comprises two major entities, ulcerative colitis (UC) and Crohn’s disease (CD). Serologic panels of multiple antibodies are proposed to aid in differential diagnosis of Crohn’s disease versus ulcerative colitis in stratifying patients according to disease phenotype and risk of complications. |
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
Serological markers/laboratory tests (e.g. Fecal calprotectin) for the diagnosis or management of inflammatory bowel disease are considered experimental/investigational. There is a lack of scientific evidence that the use of these tests is likely to alter the diagnostic workup, the final diagnosis made, or the treatment provided for patients with suspected IBD.
Examples of serological markers/laboratory tests include:
Refer to Medical Policy Bulletin L-113 Investigational and Experimental Molecular/Genomic Testing. |
Place of Service: Inpatient/Outpatient |
Experimental/Investigational (E/I) services are not covered regardless of place of service.
Laboratory Studies for Diagnosing and Managing Inflammatory Bowel Disease is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
The policy position applies to all commercial lines of business |
Denial Statements |
Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
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