This policy version was replaced on March 28, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).
Helicobacter pylori (H. pylori) infection is a common bacterial infection and has been identified as a causative agent for peptic ulcer, gastritis, dyspepsia, and stomach cancer. Usually acquired in childhood, the exact means of this acquisition are unclear. Risk factors for H. pylori infection include socioeconomic status, increasing number of siblings, and having an infected parent. The infection may also be spread through contaminated water supplies.
Indications for testing for H. pylori include active peptic ulcer disease or past history of such disease if H. pylori infection has not been documented, early gastric cancer, and low-grade gastric mucosa lymphoid tissue (MALT) lymphoma. Testing for H. pylori may be done via upper endoscopy, urea breath test, or stool antigen assay. Concerns over the accuracy of serology testing precludes its use in the recommendations in professional guidelines.
All patients with an active infection with H. pylori should be offered treatment. H. pylori infections are typically treated with combinations of antibiotics along with a proton pump inhibitors (PPIs) for a period of 10 to 14 days as a first-line treatment. Following treatment, it is recommended that testing for eradication be performed.
Serology testing for H. pylori infection is considered EXPERIMENTAL/INVESTIGATIVE due to the lack of clinical evidence demonstrating an impact on improved health outcomes.
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Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.
Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.
Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites.
Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.
Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.
These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Acknowledgements:
CPT® codes copyright American Medical Association® 2022. All rights reserved.
CDT codes copyright American Dental Association® 2022. All rights reserved.