Fecal Microbiota Transplantation

Policy ID: S-241-011

Section: Surgery

Effective Date: July 01, 2018

Revised Date: June 05, 2023

Revision Effective Date: July 01, 2023

Last Reviewed: July 26, 2023

Applies To: Commercial and Medicaid Expansion

Description

Fecal microbiota transplantation (FMT) involves the infusion of intestinal microorganisms via transfer of stool from a healthy person into a diseased individual, with the intent of restoring normal intestinal flora. Fecal transplant is proposed for the treatment of treatment-refractory Clostridium difficile infection (CDI). Rebyota (fecal microbiota, live jslm) is a single-dose microbiota-based live biotherapeutic that may be indicated for the prevention of recurrent CDI.

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 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

0780T

44705

G0455

J1440

Diagnosis Codes

Covered diagnosis code for procedures 0780T, 44705, G0455 and J1440

A04.71

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-19-2020 Revision

Added procedure code 44799

Internal Medical Policy Committee 11-23-2021 Annual Review, no changes in criteria

Internal Medical Policy Committee 01-20-2022 Criteria updated

Updated with clarifying language

Internal Medical Policy Committee 11-29-2022 Coding update- Effective January 01, 2023

Removed Procedure code 44799
Added Procedure Code 0780T

Internal Medical Policy Committee 01-26-2023 Coding update - Effective March 06, 2023

Removed Diagnosis code A04.72

Internal Medical Policy Committee 5-23-2023 Revision with Coding - Effective July 03, 2023

Added criteria for Rebyota

Internal Medical Policy Committee 7-26-2023 Coding update - Effective July 01, 2023

Added new code J1440

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-241-010

Section: Surgery

Effective Date: July 01, 2018

Revised Date: May 23, 2023

Revision Effective Date: July 03, 2023

Last Reviewed: May 23, 2023

Archived Date: June 30, 2023