Anthem Blue Cross Connecticut GENE.00055 Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity Form

This document addresses risk stratification of inflammatory bowel disease (IBD) severity using gene expression profiling from peripheral blood biomarkers, including the use of PredictSURE IBD^™ (PredictImmune, LTD., Cambridge, United Kingdom). This document does not address initial irritable bowel syndrome (IBS), IBD diagnosis, ongoing IBD disease management nor the use of inflammatory markers, fecal samples or tissue biopsies for risk stratification of IBD disease severity.

Note: Please see the following related documents for additional information:

• CG-MED-59 Upper Gastrointestinal Endoscopy in Adults
• CG-MED-70 Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule
• CG-SURG-01 Colonoscopy
• LAB.00016 Fecal Analysis in the Diagnosis of Intestinal Disorders
• LAB.00037 Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)

Position Statement

Investigational and Not Medically Necessary:

Gene expression profiling for risk stratification of inflammatory bowel disease (IBD) severity, including use of PredictSURE IBD, is considered investigational and not medically necessary for all indications.