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Fecal Microbiota Transplantation

Section: Surgery
Effective Date: July 01, 2018
Revised Date: May 14, 2018
Last Reviewed: September 26, 2019

Description

Fecal microbiota transplantation (FMT) involves the infusion of intestinal microorganisms via transfer of stool from a healthy person into a diseased patient, with the intent of restoring normal intestinal flora. Fecal transplant is proposed for the treatment of treatment-refractory Clostridium difficile infection (CDI), as well as for other conditions including inflammatory bowel disease (IBD). 

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.

Criteria

Coverage is subject to the specific terms of the member’s benefit plan.

FMT may be considered medically necessary for treatment of individuals with recurrent CDI when BOTH of the following are met:

  • There have been at least three (3) episodes of recurrent infection; and
  • Episodes are refractory to appropriate antibiotic regimens, including at least one (1) regimen of pulsed vancomycin.

All other uses for FMT are 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

44705   G0455

Diagnosis Codes

Covered diagnosis Codes for procedures 44705 and G0455

A04.71 A04.72

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