About this policy
Jurisdiction: J15 MAC Part B. States: Kentucky, Ohio. Type: Active LCD
Coverage indications
This is a non-coverage policy for the Prometheus IBD sgi Diagnostic® test. The intended use of this test is to aid healthcare providers in differentiating inflammatory bowel disease (IBD) vs non-IBD, and Crohn’s disease (CD) vs Ulcerative Colitis (UC) in a comprehensive blood test. The test includes 9 serological markers: ASCA IgA, ASCA IgG, anti-OmpC IgA, anti-CBir1 IgG, anti-A4 Fla2 IgG, anti-FlaX IgG, IBD-specific pANCA auto-antibody, IBD-specific pANCA IFA (perinuclear pattern), IBD-specific pANCA IFA DNAse Sensitivity; 4 genetic immune response markers (SNPs): ATG16L1, STAT3, NKX2-3, and ECM1; and 5 inflammatory biomarkers: ICAM-1, VCAM-1, VEGF, CRP and SSA. A proprietary Smart Diagnostic Algorithm interprets patterns among the multiple assay values to produce an IBD score. The test results are reported as “consistent with IBD” (consistent with UC; consistent with CD, or inconclusive for UC vs CD) or “not consistent with IBD”. In addition to the algorithmic test interpretation, the results of the 17 biomarkers are also individually reported.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.
| Code | Code system | Status in this policy |
|---|---|---|
| 81479 | CPT | Covered |