Anthem Blue Cross Connecticut LAB.00016 Fecal Analysis in the Diagnosis of Intestinal Disorders Form

This document addresses the use of fecal analysis for the diagnosis of intestinal disorders. Fecal analysis may be suggested for people with gastrointestinal symptoms such as indigestion, constipation, diarrhea, gas, bloating or abdominal pain; symptoms that may overlap with a variety of gastrointestinal disorders such as intestinal dysbiosis, irritable bowel, malabsorption or small intestinal overgrowth of bacteria.

Note: For additional information regarding related documents, please see:

• LAB.00037 Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)

Position Statement

Investigational and Not Medically Necessary:

Fecal analysis panels are considered investigational and not medically necessary as a diagnostic test for the evaluation of intestinal dysbiosis, irritable bowel syndrome, malabsorption or small intestinal overgrowth of bacteria.

Fecal analysis of the following components is considered investigational and not medically necessary as a diagnostic test for the evaluation of intestinal dysbiosis, irritable bowel syndrome, malabsorption or small intestinal overgrowth of bacteria:

1. Beta-glucuronidase;
2. Cholesterol;
3. Chymotrypsin;
4. Fecal secretory IgA;
5. Iso-butyrate, N-butyrate;
6. Iso-valerate and N-valerate;
7. Levels of Lactobacilli, bifidobacteria and E. coli and other “potential pathogens,” including Aeromona, Bacillus cereus, Campylobacter, Citrobacter, Klebsiella, Proteus, Pseudomonas, Salmonella, Shigella, S. aureus, Vibrio Identification and quantitation of fecal yeast (including C. albicans, C. tropicalis, Rhodotorula and Geotrichum);
8. Long chain fatty acids;
9. Meat and vegetable fibers;
10. pH;
11. Short chain fatty acid distribution (adequate amount and proportions of the different short chain fatty acids reflect the basic status of intestinal metabolism);
12. Total short chain fatty acids;
13. Triglycerides.