Effective January 1, 2014, Harvard Pilgrim will begin covering medically necessary fecal bacteriotherapy for members of our HMO, POS, or PPO products who have been diagnosed with severe, recurrent Clostridium difficile, provided a prior authorization is obtained.
With prior authorization, coverage will include assessment of a healthy donor specimen, preparation of fecal microbiota for instillation, and instillation of fecal microbiota solution derived from donor’s fecal matter. Please be sure to use code G0455 when requesting authorization.
Instillation of fecal bacteriotherapy via colonoscope is authorized when healthy donor stool is available for transplant, and there is medical record documentation confirming the member has had:
- Three or more episodes of Clostridium difficile, confirmed by positive stool tests; and
- Recurrent and/or persistent Clostridium difficile after at least two courses of antibiotic therapy (for example, metronidazole or vacomycin for the first episode, pulsed vancomycin for the second).
To obtain prior authorization, providers must submit the required written information and meet the criteria as specified in the Fecal Bacteriotherapy Medical Review Criteria.