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02-40000-24

Original Effective Date: 09/15/14

Reviewed: 07/27/17

Revised: 10/01/17

Subject: Fecal Microbiota Transplantation

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Fecal microbiota transplantation (FMT) involves the infusion of intestinal microorganisms via transfer of stool from a healthy person into a diseased person, 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). The stool can be infused as a liquid suspension into an individual’s upper gastrointestinal tract though a nasogastric tube or gastroscopy, or into the colon through a colonoscope or rectal catheter.

The goal of FMT is to replace damaged and/or disordered native microbiota with a stable community of donor microorganisms. The treatment is based on the premise that an imbalance in the community of microorganisms residing in the gastrointestinal tract (ie, dysbiosis) is associated with specific disease states, including susceptibility to infection.

The human microbiota, defined as the aggregate of microorganisms (bacteria, fungi, archaea) on and in the human body, is believed to consist of approximately 10 to 100 trillion cells, approximately 10 times the number of human cells. Most human microbes reside in the intestinal tract, and most of these are bacteria. In its healthy state, intestinal microbiota perform a variety of useful functions including aiding in the digestion of carbohydrates, mediating the synthesis of certain vitamins, repressing growth of pathogenic microbes, and stimulating the lymphoid tissue to produce antibodies to pathogens.

To date, the major potential clinical application of fecal microbiota transplantation is treatment of CDI. Infection of the colon with C difficile is a major cause of colitis and can cause life-threatening conditions, including colonic perforation and toxic megacolon. Clostridium difficile occurs naturally in intestinal flora.

Other potential uses of fecal microbiota transplant include treatment of conditions in which altered colonic flora may play a role. These include IBD, irritable bowel syndrome, idiopathic constipation and nongastrointestinal disease such as multiple sclerosis, obesity, autism, and chronic fatigue syndrome. However, for these conditions, the contribution of alterations in colonic flora to the disorder is uncertain or controversial.

POSITION STATEMENT:

Fecal microbiota transplantation meets the definition of medical necessity for treatment of individuals with recurrent Clostridium difficile infection when ALL of the following are met:

• There have been at least 3 episodes of recurrent infection; AND

• Episodes are refractory to appropriate antibiotic regimens, including at least 1 regimen of pulsed vancomycin.

Fecal microbiota transplantation for all other conditions is considered experimental or investigational, including, but not limited to, the following:

• Autism spectrum disorders

• Autoimmune disorders (e.g., multiple sclerosis)

• Chronic fatigue syndrome

• Crohn’s disease

• Diabetes

Fatty liver disease

First-line therapy for Clostridium difficile infection

• Idiopathic constipation

Idiopathic thrombocytopenic purpura

• Irritable bowel disease (IBS); irritable bowel syndrome (IBS)

• Metabolic syndrome

• Neurological disorders (e.g., Parkinson’s disease)

• Obesity

• Ulcerative colitis

There is insufficient published clinical evidence to support the safety and effectiveness of FMT in conditions other than recurrent Clostridium difficile infection.

BILLING/CODING INFORMATION:

CPT Coding:

44705

Preparation of fecal microbiota for instillation, including assessment of donor specimen

HCPCS Coding:

G0455

Preparation with instillation of fecal microbiota by any method, including assessment of donor specimen

ICD-10 Diagnosis Codes That Support Medical Necessity:

A04.71

Enterocolitis due to Clostridium difficile, recurrent

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products: The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Noncovered Services (L33777), located at fcso.com.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

None applicable.

OTHER:

Index terms:

Donor feces infusion

Intestinal microbiota transplantation

Fecal bacteriotherapy

REFERENCES:

  1. American College of Gastroenterology (ACG). Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. February 2013). Accessed at http://gi.org on 07/22/14.
  2. Aroniadis OC, Brandt LJ. Intestinal microbiota and the efficacy of fecal microbiota transplantation in gastrointestinal disease. Gastroenterol Hepatol (N Y). 2014 Apr;10(4):230-7.
  3. Blue Cross Blue Shield Association Medical Policy Reference Manual. 2.01.92, Fecal Microbiota Transplantation. (November 2016).
  4. Cammarota G, et al. European consensus conference on faecal microbiota transplantation in clinical practice. Gut. 2017 Apr;66(4):569-580.
  5. Choi HH, Cho YS.Fecal Microbiota Transplantation: Current Applications, Effectiveness, and Future Perspectives. Clin Endosc. 2016 May;49(3):257-65.
  6. ClinicalTrials.gov. NCT01972334, Stool Transplant in Pediatric Patients With Recurring C Difficile Infection. Last updated March 2014.
  7. ClinicalTrials.gov. NCT01226992, Oral Vancomycin Followed by Fecal Transplant Versus Tapering Oral Vancomycin. Last updated January 2013.
  8. ClinicalTrials.gov. NCT01545908, Fecal Biotherapy for the Induction of Remission in Active Ulcerative Colitis.Last updated April 2014.
  9. ClinicalTrials.gov. NCT01793831, Standardized Fecal Microbiota Transplantation for Crohn Diseases. Last updated December 2013.
  10. ClinicalTrials.gov. NCT01398969, Multi-Centre Trial of Fresh vs. Frozen-and-Thawed HB T(Fecal Transplant)for Recurrent CDI. Last updated February 2014.
  11. ECRI Institute Emerging Technology Report: Fecal Microbiota Transplantation for Treating Recurrent Clostridium difficile Infection (06/20/13).
  12. ECRI Institute Health Technology Forecast: Fecal microbiota transplantation concept developed into synthetic stool alternative for C. difficile infection (01/18/13).
  13. ECRI Institute Health Technology Forecast: Study suggests fecal transplant is more effective than vancomycin for recurrent Clostridium difficile infection (01/25/13).
  14. First Coast Service Options, Inc. (FCSO). Florida Medicare Part B Local Coverage Determination L29288, Noncovered Services (02/02/09). Retired 09/30/15.
  15. First Coast Service Options, Inc. (FCSO). Florida Medicare Part B Local Coverage Determination L33777, Noncovered Services. (05/01/17).
  16. Gallo A, Passaro G, Gasbarrini A, Landolfi R, Montalto M. Modulation of microbiota as treatment for intestinal inflammatory disorders: An uptodate. World J Gastroenterol. 2016 Aug 28;22(32):7186-202.
  17. Gough E, Shaikh H, Manges AR. Systematic review of intestinal microbiota transplantation (fecal bacteriotherapy) for recurrent Clostridium difficile infection. Clin Infect Dis 2011; 53(10):994-1002.
  18. Guo B, Harstall C, Louie T et al. Systematic review: faecal transplantation for the treatment of Clostridium difficile-associated disease. Aliment Pharmacol Ther 2012; 35(8):865-75.
  19. Mattila E, Uusitalo-Seppala R, Wuorela M, et al. Fecal transplantation, through colonoscopy, is effective therapy for recurrent Clostridium difficile infection. Gastroenterology 2012;142:490-496.
  20. McCarville JL, Caminero A, Verdu EF.Novel perspectives on therapeutic modulation of the gut microbiota. Therap Adv Gastroenterol. 2016 Jul;9(4):580-93.
  21. National Institute for Health and Care Excellence. Interventional Procedure Guidance (IPG) 485: Faecal microbiota transplant for recurrent Clostridium difficile infection. March 2014. Accessed at https://www.nice.org.uk/.
  22. National Institute for Health and Care Excellence. Research Recommendation IPG485/1. June 2015. Accessed at https://www.nice.org.uk/.
  23. Petrof EO, Gloor GB, Vanner SJ et al. Stool substitute transplant therapy for the eradication of Clostridium difficile infection: 'RePOOPulating' the gut. Microbiome 2013; 1(1):3.
  24. Postigo R, Kim JH. Colonoscopic verus nasogastric fecal transplantation for the treatment of Clostridium difficile infection: a review of pooled analysis. Infection. 2012;40:643-648.
  25. Ray A, Smith R, Breaux J. Fecal Microbiota Transplantation for Clostridium difficile Infection: The Ochsner Experience. Ochsner J. 2014 Winter;14(4):538-44.
  26. Rossen NG, MacDonald JK, de Vries EM, D'Haens GR, de Vos WM, Zoetendal EG, Ponsioen CY. Fecal microbiota transplantation as novel therapy in gastroenterology: A systematic review. World J Gastroenterol. 2015 May 7;21(17):5359-71.
  27. Schenck LP, Beck PL, MacDonald JA. Gastrointestinal dysbiosis and the use of fecal microbial transplantation in Clostridium difficile infection. World J Gastrointest Pathophysiol. 2015 Nov 15;6(4):169-80.
  28. Shi Y, Dong Y, Huang W, Zhu D, Mao H, Su P. Fecal Microbiota Transplantation for Ulcerative Colitis: A Systematic Review and Meta-Analysis. PLoS One. 2016 Jun 13;11(6):e0157259.
  29. Sung H, Kim SW, Hong M, Suk KT. Microbiota-based treatments in alcoholic liver disease. World J Gastroenterol. 2016 Aug 7;22(29):6673-82.
  30. United States Food and Drug Administration (FDA). Guidance for Industry: Enforcement policy regarding investigational new drug requirements for use of fecal microbiota for transplantation to treat Clostridium difficile infection not responsive to standard therapies. (July 2013). Accessed at http://www.fda.gov on 07/22/14.
  31. Van Nord E, Vrieze A, Nieuwdorp M, et al. Duodenal infusion of donor feces for recurrent Clostridium difficile. N Engl J Med 2013;368:407-415.
  32. Wang AY, Popov J, Pai N. Fecal microbial transplant for the treatment of pediatric inflammatory bowel disease. World J Gastroenterol. 2016 Dec 21;22(47):10304-10315.
  33. Wang ZK, Yang YS, Chen Y, Yuan J, Sun G, Peng LH. Intestinal microbiota pathogenesis and fecal microbiota transplantation for inflammatory bowel disease. World J Gastroenterol. 2014 Oct 28;20(40):14805-20.
  34. Wei Y, Gong J, Zhu W, Guo D, Gu L, Li N, Li J. Fecal microbiota transplantation restores dysbiosis in patients with methicillin resistant Staphylococcus aureus enterocolitis. BMC Infect Dis. 2015 Jul 11;15:265.
  35. Wei Y, Zhu W, Gong J, Guo D, Gu L, Li N, Li J. Fecal Microbiota Transplantation Improves the Quality of Life in Patients with Inflammatory Bowel Disease. Gastroenterol Res Pract. 2015;2015:517597.
  36. Zanella Terrier MC, Simonet ML, Bichard P, Frossard JL. Recurrent Clostridium difficile infections: The importance of the intestinal microbiota. World J Gastroenterol. 2014 Jun 21;20(23):7416-7423.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 07/27/17.

GUIDELINE UPDATE INFORMATION:

09/15/14

New Medical Coverage Guideline.

09/15/15

Scheduled review. Maintained position statement and updated references.

11/01/15

Revision: ICD-9 Codes deleted.

08/15/16

Scheduled review. Maintained Position Statement section. Updated references.

08/15/17

Scheduled review. Maintained Position Statement section. Updated reference. Reformatted guideline.

10/01/17

Quarterly CPT/HCPCS coding update: deleted A04.7; added A04.71.

Date Printed: October 23, 2017: 02:13 AM