HumanaCommercial Clinical Policy

Fecal Microbiota Transplantation Form

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Fecal Microbiota Transplantation

Notes: Requests for treatment of recurrent CDI may require review by a medical director. FMT for other uses is considered experimental/investigational and is not covered.

Indications

(959482) Has the patient experienced a minimum of 3 episodes of C. difficile infection, including antibiotic therapy for the initial episode and 2 recurrences? 
(959483) Is the associated diarrhea refractory to antibiotic therapy, such as fidaxomicin, metronidazole, or vancomycin? 
(959484) Is the C. difficile infection confirmed by a positive stool test? 

Contraindications

(959485) Is FMT being requested for the primary treatment of CDI? 
(959486) Is FMT being requested for conditions other than recurrent CDI, such as acute GVHD following stem cell transplant, autism spectrum disorders, autoimmune disorders, chronic intestinal pseudo-obstruction, constipation, Crohn’s disease, diabetes mellitus, D-lactic acidosis, fatty liver disease, hepatic encephalopathy, insulin resistance, IBS, metabolic syndrome, neurological disorders, obesity, pouchitis, or ulcerative colitis? 
Effective Date

09/01/2023

Last Reviewed

NA

Original Document

  Reference



Fecal Microbiota Transplantation

Medical Coverage Policy

Effective Date: 09/01/2023
Revision Date: 09/01/2023
Review Date: 07/27/2023

Policy Number: HUM-0519-013

Change Summary: Updated Description

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

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