Fecal Microbiota Transplantation

Policy ID: S-241-008

Section: Surgery

Effective Date: July 01, 2018

Revised Date: December 02, 2022

Revision Effective Date: January 01, 2023

Last Reviewed: November 29, 2022

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).

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

0780T

44705

G0455

Diagnosis Codes

Covered diagnosis code for procedures 0780T, 44705 and G0455

A04.71

A04.72

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

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-241-007