Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Gastroesophageal reflux disease (GERD)

Treatment: Blood test code 86677 antibody testing for helicobacter pylori	

The insurer denied coverage for blood test code 86677 antibody testing for helicobacter pylori. The denial is upheld.The patient was a male diagnosed with gastroesophageal reflux disease.  The documentation submitted includes a chart note for the patient which stated his gastroesophageal reflux disease has worsened.  The patient complained of regurgitation and chest tightness.  The documentation indicated on physical examination there were no significant abnormalities.  It was recommended the patient undergo laboratory studies to include H. pylori and begin utilizing Protonix.  The patient did undergo H. pylori testing revealing a negative result.

When there is an appropriate indication for Helicobacter pylori (Hp) testing there is evidence supported by gastroenterology societies that treating the infection results in better outcomes such as reduction in gastric cancer risk.  One indication for testing would be in patients with uninvestigated dyspepsia who are under the age of 60 years and without alarm features in which non-endoscopic testing for H. pylori infection is a consideration.  Those who test positive should be offered eradication therapy (conditional recommendation, quality of evidence: high for efficacy, low for the age threshold).  However, patients with typical symptoms of gastroesophageal reflux disease (GERD) who do not have a history of peptic ulcer disease (PUD) need not be tested for H. pylori infection.

The gastroenterology societies have guidelines supporting the use of blood antibody testing even though there are better and more accurate tests such as tissue biopsy, breath testing, and stool antigen.  Blood serology only represents exposure to Hp and cannot be used to confirm active infection or eradication.
This patient is not a good candidate for blood test code 86677 antibody testing for Helicobacter pylori, based on the indication for testing being reflux disease. This is not an indication for Hp testing.  There was no dyspepsia as another indication in less than 60-years-old that Hp testing is reasonable and suggested in guidelines.

Blood test code 86677 antibody testing for Helicobacter pylori is not the best available treatment for this patient at this time.   
The gastroenterology societies have guidelines supporting the use of blood antibody testing even though there are better and more accurate tests such as tissue biopsy, breath test, and stool antigen.  Blood serology only represents exposure to Hp and cannot be used to confirm active infection or eradication.
The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.
The gastroenterology societies have guidelines supporting the use of blood antibody testing even though there are better and more accurate tests such as tissue biopsy, breath test, and stool antigen.  Blood serology only represents exposure to Hp and cannot be used to confirm active infection or eradication.
Review Outcome:  Upheld  

The carrier's denial of coverage for blood test code 86677 antibody testing for helicobacter pylori should be upheld.