Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Policy Application
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.
Fecal microbiota transplantation (FMT) may be considered medically necessary for treatment of individuals with recurrent Clostridium difficile infection when the following is met:
- There have been at least two (2) recurrences that are refractory to standard antibiotic treatment.
FMT not meeting the criteria in this policy is considered experimental/investigational and, therefore, not covered because their safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.
A single dose of Rebyota may be considered medically necessary for the prevention of the recurrence of CDI in individuals when ALL of the following criteria is met:
- Individual is 18 years of age or older; and
- Single dose is given rectally one (1) to three (3) days following a course of appropriate antibiotics (examples; metronidazole, vancomycin, fidaxomicin) used to treat recurrent CDI; and
- Must be administrated by a health care professional; and
- Individual has recurrent CDI as evidenced by one of the following:
- At least two (2) episodes of CDI recurrence after a primary episode; or
- At least two (2) episodes of severe CDI resulting in hospitalization within the last year.
Treatment with Rebyota not meeting the criteria as indicated in this policy, is considered experimental/investigational and, therefore, not covered because their safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.
Procedure Codes