CommercialCoverageMedium impact
Fecal Bacteriotherapy (CPB 0844, reviewed 2026-03-25)
Aetna·Gastroenterology, Infectious Disease, Critical Care +1 more·Medical Policy
Effective date
Mar 25, 2026
We identified it
Aug 15, 2026
Summary
Aetna updated its Fecal Bacteriotherapy policy (CPB 0844) to clarify coverage for recurrent Clostridium difficile infection (CDI). The policy now covers fecal microbiota transplantation (FMT) for recurrent CDI after failed antibiotic therapy, and specifically approves Rebyota (fecal microbiota, live-jslm) as a one-time preventive dose for recurrent CDI meeting strict criteria. All other indications remain experimental and non-covered.
Action Required
By March 25, 2026: Billing team must update system configuration to enforce Rebyota (J1440) coverage requirements: (1) Member must be ≥18 years old; (2) Recurrent CDI confirmed by positive stool test within 30 days; (3) At least one recurrence after primary episode with standard-of-care antibiotic completion, OR ≥2 severe CDI hospitalizations in past year; (4) Single 150 mL rectal dose only, administered 24-72 hours after final antibiotic dose. Build denial logic to reject all other indications (listed as experimental). Update prior authorization workflows to require documented evidence of recurrent CDI and failed antibiotic therapy. Train coding staff to identify and deny claims for non-covered indications (Crohn's disease, ulcerative colitis, irritable bowel syndrome, etc.). Without proper edits, claims for experimental indications will be paid incorrectly or require post-payment recovery.