H Pylori Testing

For individuals 18 years of age and older, urea breath testing or stool antigen testing to diagnose an H. pylori infection is considered MEDICALLY NECESSARY in any of the following situations:

1. For individuals with dyspeptic symptoms
2. For individuals with active peptic ulcer disease (PUD)
3. For individuals with past PUD without H. Pylori history
4. For individuals with low-grade gastric mucosa-associated lymphoid tissue (MALT) lymphoma
5. For individuals with a history of endoscopic resection of early gastric cancer (EGC)
6. For individuals with gastric intestinal metaplasia (GIM)
7. For individuals with uninvestigated dyspepsia who are under the age of 60 years and without alarm features
8. For individuals initiating chronic treatment with a non-steroidal anti-inflammatory drug (NSAID)

1. For individuals with unexplained iron deficiency anemia

1. For the evaluation of individuals with chronic immune thrombocytopenic purpura (ITP) and suspected H. pylori infection
2. For individuals with a family history of gastric cancer
3. For individuals who are first-generation immigrants from a high prevalence area

For individuals less than 18 years of age, a biopsy-based endoscopic histology test and either a rapid urease test or a culture with susceptibility testing to diagnose an H. pylori infection is considered MEDICALLY NECESSARY in any of the following situations:

1. For individuals with gastric or duodenal ulcers
2. For individuals with refractory iron deficiency anemia (when other causes have been ruled out)

Infection with H. pylori is common, with conservative estimates at 50% of the world’s population affected. Prevalence in the United States is significant, estimated to be 30 – 40% in the general population (Siao & Somsouk, 2014). H. pylori is associated with many conditions, such as peptic ulcer disease, chronic gastritis, and gastric mucosa associated lymphoid tissue (MALT) lymphoma. Other conditions such as dyspepsia have been attributed to H. pylori as well (Lamont, 2023). Common symptoms of these conditions include gastritis, dyspepsia, heartburn, and stomach pain (Jensen, 2023; Longstreth, 2022).

Identification of H. pylori infection is accomplished with one or more of the several tests available. The choice of test is guided by the reason for the test, cost and availability of the test, the patient’s age and clinical presentation, prevalence in a population, and the patient’s use of certain medications. Testing for H. pylori infection is done for two main reasons; to detect an active infection that will be treated and to confirm eradication of the infection post-treatment. Invasive and non-invasive approaches have been used. Endoscopy and collection of biopsy specimens for evaluation of H. pylori infection and early gastric cancer detection typically is done in older individuals and those with “alarm” symptoms, including bleeding, unexplained anemia, unexplained weight loss, progressing dysphagia, recurrent vomiting, a family history of gastrointestinal cancer, or a personal history of esophagogastric malignancy. Tissue samples can be tested for H. pylori via methods such as a rapid urease test, culture, or staining. Molecular methods include PCR and next-generation sequencing, and serological methods include ELISA, immunoassays, and dried blood spots. Other non-invasive methods include urea breath test and stool antigen test. Testing for eradication of infection may be performed with the same tests used for diagnosis (Lamont, 2023).