Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Fecal microbiota transplantation (FMT) may be considered medically necessary for treatment of individuals with recurrent Clostridium difficile infection when BOTH of the following are met:
- There have been at least three (3) episodes of recurrent infection; and
- There have been at least two (2) episodes that are refractory to appropriate antibiotic regimens, including at least one (1) regimen of pulsed vancomycin.
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.
Procedure Codes
