Background

Diagnosis

Celiac disease (CD) is characterized by inflammation of the small intestine resulting from an immunologic intolerance to gluten (i.e., proteins derived from wheat, barley, and rye). The symptoms of the disease are markedly variable and can be broadly subdivided into intestinal and extraintestinal manifestations; the latter is thought to be related to nutrient malabsorption. For example, osteopenia and osteoporosis, which are commonly seen in adults with untreated CD, are related to the impaired absorption of vitamin D and binding of intraluminal calcium and magnesium to unabsorbed dietary fatty acids, forming insoluble soaps. The only treatment for CD is lifelong adherence to a gluten-free diet.

Many symptoms of CD (e.g., diarrhea, abdominal pain, weight loss) are nonspecific and are often overlooked. In addition, the disease may develop at any time in life, from infancy to very old age. In children, the disease typically presents following weaning between 6 and 24 months and is characterized by abnormal stools, poor appetite, and irritability. In adults, diarrhea is the main presenting symptom, but presenting symptoms may be entirely nonspecific, such as anemia or infertility. Typical or classical CD refers to the presence of malabsorption, while atypical CD consists primarily of extraintestinal manifestations.

CD is associated with the human leukocyte antigen (HLA). Approximately 90% to 95% of patients with CD carry the HLA-DQ2 allele, and the remaining 5% to 10% carry the HLA-DQ8 allele. However, not all people with one of these two alleles will develop CD. It is believed that approximately 25% to 40% of the general population of the U. S. carries either the HLA-DQ2 or HLA-DQ8 allele but only about 3% of people carrying the DQ2 or DQ8 alleles will develop gluten intolerance.^1,2,

Given the nonspecific nature of the symptoms, the definitive diagnosis has been based on the results of small intestinal biopsies showing a flattened intestinal mucosa in association with an inflammatory infiltrate. Diagnostic criteria were first established in 1969 by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition and consisted of a series of 3 intestinal biopsies: at diagnosis, after the institution of a gluten-free diet, and the third after a repeat gluten challenge. This cumbersome method of diagnosis was revised in 1990 by simplifying the diagnostic criteria to a positive biopsy at a presentation in conjunction with the consistent history and serologic results, followed by clinical response to a gluten-free diet.^3,

Testing

While a positive biopsy result is considered the criterion standard for diagnosis, the serologic evaluation of patients with possible CD, together with a consistent clinical history and a positive response to a gluten-free diet, can sometimes be adequate for diagnosis. Serologic studies are also useful in triaging the large numbers of patients with nonspecific symptoms for biopsy. In approximately 10% of cases in which clinical suspicion suggests CD, serologic testing, and intestinal biopsy are nondiagnostic, either because the results of serology and biopsy are discordant, or because both tests are negative, despite persistent symptoms suggestive of CD. In these cases, HLA testing may be useful for ruling out a diagnosis of CD.

National guidelines and position statements recommend serologic testing as the first step in diagnosing CD and recommend the immunoglobulin (Ig) A antibody to human recombinant tissue transglutaminase test.^4,5,6, Guidelines have indicated that the IgA antibody to anti-endomysium antibody test has similar sensitivity and specificity as the tissue transglutaminase IgA test, but national organizations have indicated that the anti-endomysium antibody test is more prone to interpretation error. For subjects with known selective IgA deficiency, testing with tissue transglutaminase IgG and/oranti-endomysium antibody IgG is recommended.

Regulatory Status

Clinical laboratories may develop and validate tests in-house and market them as a laboratory service; laboratory-developed tests must meet the general regulatory standards of the Clinical Laboratory Improvement Amendments. Several methods are used for HLA typing, including simple sequence-specific-primer, polymerase chain reaction, reverse dot blot hybridization and real-time polymerase chain reaction. Laboratories that offer laboratory-developed tests must be licensed by the Clinical Laboratory Improvement Amendments for high-complexity testing. To date, the U.S. Food and Drug Administration has chosen not to require any regulatory review of this test.

Related Policies

• Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon (Policy #017 in the Radiology Section)

For Medicare Advantage, please refer to the Medicare Coverage Section below for coverage guidance.)

1. HLA-DQ2 and HLA-DQ8 testing is considered medically necessary to rule out celiac disease in:

• members with discordant serologic and histologic (biopsy) findings; or
• members with persistent symptoms despite negative serology and histology.

Genetics Nomenclature Update
The Human Genome Variation Society nomenclature is used to report information on variants found in DNA and serves as an international standard in DNA diagnostics. It is being implemented for genetic testing medical policy updates starting in 2017 (see Table PG1). The Society’s nomenclature is recommended by the Human Variome Project, the Human Genome Organization, and by the Human Genome Variation Society itself.

The American College of Medical Genetics and Genomics and the Association for Molecular Pathology standards and guidelines for interpretation of sequence variants represent expert opinion from both organizations, in addition to the College of American Pathologists. These recommendations primarily apply to genetic tests used in clinical laboratories, including genotyping, single genes, panels, exomes, and genomes. Table PG2 shows the recommended standard terminology“pathogenic,” “likely pathogenic,” “uncertain significance,” “likely benign,” and “benign”to describe variants identified that cause Mendelian disorders.

Table PG1. Nomenclature to Report on Variants Found in DNA

Previous	Updated	Definition
Mutation	Disease-associated variant	Disease-associated change in the DNA sequence
	Variant	Change in the DNA sequence
	Familial variant	Disease-associated variant identified in a proband for use in subsequent targeted genetic testing in first-degree relatives

Table PG2. ACMG-AMP Standards and Guidelines for Variant Classification

Variant Classification	Definition
Pathogenic	Disease-causing change in the DNA sequence
Likely pathogenic	Likely disease-causing change in the DNA sequence
Variant of uncertain significance	Change in DNA sequence with uncertain effects on disease
Likely benign	Likely benign change in the DNA sequence
Benign	Benign change in the DNA sequence

ACMG: American College of Medical Genetics and Genomics; AMP: Association for Molecular Pathology.

Genetic Counseling
Experts recommend formal genetic counseling for patients who are at risk for inherited disorders and who wish to undergo genetic testing. Interpreting the results of genetic tests and understanding risk factors can be difficult for some patients; genetic counseling helps individuals understand the impact of genetic testing, including the possible effects the test results could have on the individual or their family members. It should be noted that genetic counseling may alter the utilization of genetic testing substantially and may reduce inappropriate testing; further, genetic counseling should be performed by an individual with experience and expertise in genetic medicine and genetic testing methods.

Medicare Coverage:
Per L35062, Human Leukocyte Antigen Testing for Celiac Disease is covered. For additional information, refer to Local Coverage Determination (LCD): Biomarkers Overview (L35062).

Available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/LcdSearch?_afrLoop=90769712476969#!%40%40%3F_afrLoop%3D90769712476969%26centerWidth%3D100%2525%26leftWidth%3D0%2525%26rightWidth%3D0%2525%26showFooter%3Dfalse%26showHeader%3Dfalse%26_adf.ctrl-state%3D63y7eftob_46.

[RATIONALE: This policy was created in 2015 and has been updated regularly with searches of the MEDLINE database. The most recent literature update was performed through September 9, 2019.

Evidence reviews assess whether a medical test is clinically useful. A useful test provides information to make a clinical management decision that improves the net health outcome. That is, the balance of benefits and harms is better when the test is used to manage the condition than when another test or no test is used to manage the condition.

The first step in assessing a medical test is to formulate the clinical context and purpose of the test. The test must be technically reliable, clinically valid, and clinically useful for that purpose. Evidence reviews assess the evidence on whether a test is clinically valid and clinically useful. Technical reliability is outside the scope of these reviews, and credible information on technical reliability is available from other sources.

Genetic Testing for Symptoms Suggestive of Celiac Disease

Clinical Context and Test Purpose

CD, also referred to as celiac sprue or gluten-sensitive enteropathy, is a relatively common disorder with variable clinical expression. Population-based screening surveys suggest a prevalence of 1 in 250 to 500 in most countries, including the U. S. However, this prevalence may vary widely depending on how the disease is defined, i.e., whether only clinically apparent cases are considered, as opposed to including all people with any serologic or histologic evidence of disease.

The purpose of genetic testing for the human leukocyte antigen (HLA) genes HLA-DQ2 and HLA-DQ8 of individuals with symptoms suggestive of CD are to rule out CD in:

• those with persistent symptoms despite negative serology and histology; or
• those with discordant serologic and histologic (biopsy) findings.

The following PICOs were used to select literature to inform this policy.

Patients

The relevant populations of interest are individuals with persistent symptoms despite negative serology and histology; and those with discordant serologic and histologic (biopsy) findings.

Interventions

The relevant intervention is genetic testing for the HLA genes HLA-DQ2 and HLA-DQ8. Commercial testing is available from numerous companies. Ordering and interpreting genetic testing may be complex and is best done by experienced specialists such as gastroenterologists. Most patients are likely to be tested in an outpatient setting. Referral for genetic counseling is important for the explanation of the genetic disease, heritability, genetic risk, test performance, and possible outcomes.

Comparators

The following practice is currently being used to diagnose CD: clinical management without genetic testing, which is administered in an outpatient setting.

Outcomes

The potential beneficial outcomes of primary interest would be the avoidance of all downstream consequences that occur with a lack of correct diagnoses such as the use of ineffective disease management options or the gain of benefits that occur with a correct diagnosis such as the use of appropriate and effective disease management options. Implementation of an empirical gluten-free diet in individuals with clinical ambiguity may not only be ineffective but may also lead to inconvenience without any benefit. An early confirmed diagnosis can avoid delayed treatment of appropriate treatment and lifestyle changes and subsequent avoidance of morbidity associated with the disease. False-positive or -negative test results can lead to the initiation of unnecessary treatment and adverse events from that treatment or undertreatment.

Genetic testing for HLA-DQ2 and HLA-DQ8 alleles may be performed at any point during a lifetime.

Technical Reliability

Assessment of technical reliability focuses on specific tests and operators and requires a review of unpublished and often proprietary information. Review of specific tests, operators, and unpublished data are outside the scope of this policy and alternative sources exist. This policy focuses on the clinical validity and clinical utility.

Clinically Valid

A test must detect the presence or absence of a condition, the risk of developing a condition in the future, or treatment response (beneficial or adverse).

Study Selection Criteria

For the evaluation of the clinical validity of this test, studies that meet the following eligibility criteria were considered:

• Reported on the accuracy of the marketed version of the technology (including any algorithms used to calculate scores)
• Included a suitable reference standard (describe the reference standard)
• Patient/sample clinical characteristics were described
• Patient/sample selection criteria were described.

A report conducted by Maglione et al (2016) for the Agency of Healthcare Research and Quality indicated that HLA testing could be used to rule out CD with close to 100% sensitivity.^7, The report cited the 2013 American College of Gastroenterology estimates^8, of negative predictive value (NPV) of the HLA-DQ2 and -DQ8 combination test at over 99%. In the Agency report, 2 studies were cited on the accuracy of HLA testing, a large 2013 prospective cohort found that HLA testing had a sensitivity of 100% and specificity of 18.2% and a 1999 cohort also reported a sensitivity of 100% and a specificity of 33.3%.

Prospective and Retrospective Studies

Several studies have established that HLA typing has high sensitivity and a high NPV for the diagnosis of CD. For example, Werkstetter et al (2017) reported on the results of a large, international prospective study to validate a biopsy free approach for diagnosis of CD in symptomatic children plus 10 times the upper limit of normal levels of immunoglobulin A against tissue transglutaminase (TGA-IgA) (aka serologic marker) and positive finding for HLA-DQ2 and -DQ8.⁹ The primary aim was to determine whether the nonbiopsy approach would identify children with CD with a positive predictive value (PPV) above 99% in clinical practice. Data on symptoms, total IgA, TGA, endomysium antibodies, and biopsy findings (reference standard) were collected from 803 consecutive pediatric patients (≤18 years) on a gluten-containing diet. When results were concordant, cases were classified as a proven CD. Those with TGA-IgA levels of three times or below the upper limit of normal low but without other features of CD were classified as no CD. Biopsy analyses were performed and reviewed in a blinded manner. Inconclusive cases were regarded as not having CD. Data were analyzed for 707 children (65.1% girls; median age, 6.2 years); 645 were diagnosed with CD, 46 were found not to have CD, and 16 had inconclusive results. Use of test results including TGA-IgA 10 times or more the upper limit of normal, a positive result from the test for endomysium antibodies, and any symptom identified children with CD (n=399) yielded a PPV of 99.75% (95% confidence interval [CI], 98.61% to 99.99%); the PPV was 100% (95% CI, 98.68% to 100%) when only malabsorption symptoms were used instead of any symptom (n=278).The inclusion of HLA analyses did not increase accuracy.

Pallav et al (2014) retrospectively assessed HLA testing in 256 patients with known or suspected CD.^9, Taking into account all available clinical and laboratory data, 44 patients were diagnosed with CD, and in 173 patients CD was ruled out. A final diagnosis could not be obtained in 39 (15%) of 256 patients. HLA-DQ2 or -DQ8 alleles were absent in 40% of non-CD patients and 2 CD patients. The NPV was 98%. A total of 154 patients were found to carry HLA-DQ2 or -DQ8 alleles. Forty-two of the 44 patients diagnosed with CD tested positive for one or both of the HLA alleles, with a test sensitivity of 95.5%. The diagnostic accuracy data are somewhat limited by the 15% of patients without a definitive diagnosis.

A prospective study by Hadithi et al (2007) included a total of 463 patients who were referred for evaluation of CD.^10,Sixteen (3.5%) of the 463 patients met European Society of Paediatric Gastroenterology, Hepatology and Nutrition diagnostic criteria for CD (i.e., characteristic histologic findings) (Marsh III) on small bowel biopsy and unequivocal symptom resolution after initiating a gluten-free diet. All 16 patients were positive for HLA-DQ2 and/or HLA-DQ8. In contrast, 192 (43%) of 227 patients who did not meet diagnostic criteria for CD were positive for one or both of these alleles. Testing positive for HLA-DQ2 or HLA-DQ8 had a PPV of 7.7% (95% CI, 4.5% to 12%) and a NPV of 100% (95% CI, 98.6% to 100%).

Section Summary: Clinically Valid

More than 99% of patients with CD have HLA-DQ2 and/or -DQ8 compared with about 25% to 40% of the general population. Thus, CD is highly unlikely in patients without these haplotypes. Testing positive for HLA-DQ2 or HLA-DQ8 had a PPV of 7.7% (95% CI, 4.5% to 12%) and a NPV of 100% (95% CI, 98.6% to 100%).

Clinically Useful

A test is clinically useful if the use of the results informs management decisions that improve the net health outcome of care. The net health outcome can be improved if patients receive correct therapy, or more effective therapy, or avoid unnecessary therapy, or avoid unnecessary testing.

Direct Evidence

Direct evidence of clinical utility is provided by studies that have compared health outcomes for patients managed with and without the test. Because these are intervention studies, the preferred evidence would be from randomized controlled trials.

Randomized controlled trials assessing the use of HLA testing were not identified.

Chain of Evidence

Indirect evidence on clinical utility rests on clinical validity. If the evidence is insufficient to demonstrate test performance, no inferences can be made about clinical utility.

HLA-DQ2 and HLA-DQ8 genotype testing in patients who are suspected of CD with discordant serologic and histologic results or in those who are symptomatic of CD but test negative for serologic and histologic tests has clinical utility based on a chain of evidence. Confirming exclusion of a diagnosis of CD in clinically ambiguous patients may lead to avoidance of improper or ineffective interventions, including the implementation of a gluten-free diet. For patients in whom CD is excluded as a diagnosis, this further allows the implementation of appropriate diagnostic strategies to ascertain true etiologies of their symptoms (i.e., microscopic colitis, Crohn disease).

Summary of Evidence

For individuals who are suspected of having CD and have negative or discordant serologic and biopsy findings, the evidence includes several retrospective and prospective cohort studies. The relevant outcomes are test validity, other test performance measures, and change in disease status. Several studies have reported that the sensitivity and NPV of HLA-DQ2 and HLA-DQ8 genotype testing for CD approached 100%, meaning that this test is highly accurate for ruling out CD. In contrast, a substantial number of patients who do not have CD carry the HLA-DQ2 and/or HLA-DQ8 alleles, resulting in suboptimal specificity, meaning that this test is less accurate for confirming the diagnosis. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

SUPPLEMENTAL INFORMATION

Practice Guidelines and Position Statements

American College of Gastroenterology

The guidelines from the American College of Gastroenterology (2013) addressing the diagnosis and management of celiac disease (CD) stated the following on human leukocyte antigen (HLA) gene testing:

"1. HLA-DQ2/DQ8 testing should not be used routinely in the initial diagnosis of CD [celiac disease] (Strong recommendation, moderate level of evidence).

2. HLA-DQ2/DQ8 genotyping testing should be used to effectively rule out the disease in selected clinical situations (Strong recommendation, moderate level of evidence).

3. Examples of such clinical situations include but are not limited to:

• Equivocal small-bowel histological finding (Marsh I-II) in seronegative patients
• Evaluation of patients on a gluten-free diet in whom no testing for CD was done before gluten-free diet
• Patients with discrepant celiac-specific serology and histology
• Patients with suspicion of refractory CD where the original diagnosis of celiac remains in question."^8,

The 2009 guidance, which was updated in 2015, from the National Institute for Health and Care Excellence on CD included the following statement on HLA typing:

“Do not use human leukocyte antigen (HLA) DQ2 (DQ2.2 and DQ2.5)/DQ8 testing in the initial diagnosis of coeliac disease in non-specialist settings.

Only consider using HLA DQ2 (DQ2.2 and DQ2.5)/DQ8 testing in the diagnosis of coeliac disease in specialist settings (for example, in children who are not having a biopsy, or in people who already have limited gluten ingestion and choose not to have a gluten challenge).”^11,

The American Gastroenterological Association Institute (2006) issued a position statement on the diagnosis and management of CD. Regarding serologic testing, the Institute concluded that, in the primary care setting, the transglutaminase immunoglobulin (Ig) A antibody test is the most efficient single serologic test for diagnosing CD.^5, The guidelines indicated that the antiendomysial antibodies IgA test is more time-consuming and operator dependent than the tissue transglutaminase (tTG). If IgA deficiency is strongly suspected, testing with IgG antiendomysium antibody (EMA) and/or tTG IgG antibody test is recommended. If serologic test results are negative and CD is still strongly suspected, providers can test for the presence of the disease-associated HLA alleles and, if present, perform a small intestinal mucosal biopsy. Alternatively, if signs and symptoms suggest that small intestinal biopsy is appropriate, patients can proceed to biopsy without testing for HLA alleles.

National Institutes of Health

National Institutes of Health (2004) issued a consensus statement based on a meeting and an independent literature review.^4, The National Institutes of Health considered serologic testing as the first step in pursuing a diagnosis of CD and stated that the best tests are the tTG IgA and EMA IgA tests, which the Institutes considered to be of equivalent accuracy. In patients with suggestive symptoms and negative tTG IgA or EMA tests, it was recommended that consideration be given to IgA deficiency and, if identified, that a tTG IgG or EMA IgG be performed. When the diagnosis of CD is uncertain because of indeterminate results, testing for certain genetic markers (HLA haplotypes) was recommended to stratify individuals into high- or low-risk for CD. Greater than 97% of individuals with CD have the DQ2 and/or DQ8 marker, compared with about 40% of the general population. Therefore, an individual negative for DQ2 or DQ8 would be extremely unlikely to have CD (high negative predictive value). Biopsy of the proximal small bowel was indicated in those with a positive CD antibody test, except those with biopsy-proven dermatitis herpetiformis. No specific approach was suggested when there was a positive serology and normal biopsy findings. Options included additional biopsies, repeat serology testing and a trial of a gluten-free diet. Testing was indicated in patients with gastrointestinal tract symptoms and other signs and symptoms suggestive of CD.

U.S. Preventive Services Task Force Recommendations

The US Preventative Service Task Form (2017) released guidelines on screening adults and children for CD.^12, These guidelines reviewed the use of tTG IgA testing followed by an intestinal biopsy to screen asymptomatic patients. Genotype testing was not discussed. The overall conclusion of this policy was that the current balance of evidence was insufficient to assess benefits and harms resulting from screening for CD.

Ongoing and Unpublished Clinical Trials

A search of ClinicalTrials.gov in September 2019 did not identify any ongoing or unpublished trials that would likely influence this policy.]
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Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

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Index:
Human Leukocyte Antigen Testing for Celiac Disease
HLA Testing for Celiac Disease
Celiac Disease, HLA Testing
HLA-DQ2 Testing for Celiac Disease
HLA-DQ8 Testing for Celiac Disease

References:
1. Hadithi M, Pena AS. Current methods to diagnose the unresponsive and complicated forms of coeliac disease. Eur J Intern Med. Aug 2010;21(4):247-253. PMID 20603030.

2. Megiorni F, Pizzuti A. HLA-DQA1 and HLA-DQB1 in Celiac disease predisposition: practical implications of the HLA molecular typing. J Biomed Sci. Oct 11 2012;19:88. PMID 23050549.

3. Revised criteria for diagnosis of coeliac disease. Report of Working Group of European Society of Paediatric Gastroenterology and Nutrition. Arch Dis Child. Aug 1990;65(8):909-911. PMID 2205160.

4. NIH consensus development conference on celiac disease. Consensus development conference statement. 2004; http://consensus.nih.gov/2004/2004celiacdisease118html.htm. Accessed September 20, 2019.

5. AGA Institute Medical Position Statement on the Diagnosis and Management of Celiac Disease. Gastroenterology. Dec 2006;131(6):1977-1980. PMID 17087935.

6. Hill ID, Dirks MH, Liptak GS, et al. Guideline for the diagnosis and treatment of celiac disease in children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. Jan 2005;40(1):1-19. PMID 15625418.

7. Maglione MA, Okunogbe A, Ewing B, et al. Diagnosis of Celiac Disease (Comparative Effectiveness Review No. 162). Rockville (MD): Agency for Healthcare Research and Quality; 2016.

8. Rubio-Tapia A, Hill ID, Kelly CP, et al. ACG clinical guidelines: diagnosis and management of celiac disease. Am J Gastroenterol. May 2013;108(5):656-676; quiz 677. PMID 23609613.

9. Pallav K, Kabbani T, Tariq S, et al. Clinical utility of celiac disease-associated HLA testing. Dig Dis Sci. Sep 2014;59(9):2199-2206. PMID 24705698.

10. Hadithi M, von Blomberg BM, Crusius JB, et al. Accuracy of serologic tests and HLA-DQ typing for diagnosing celiac disease. Ann Intern Med. Sep 4 2007;147(5):294-302. PMID 17785484.

11. National Institute for Health and Care Excellence (NICE). Coeliac Disease: Recognition, assessment, and management [NG20]. 2015; https://www.nice.org.uk/guidance/ng20/resources/coeliac-disease-recognition- assessment-and-management-pdf-1837325178565. Accessed September 20, 2019.

12. U. S. Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, et al. Screening for celiac disease: US Preventive Services Task Force Recommendation Statement. JAMA. Mar 28 2017;317(12):1252-1257. PMID 28350936.

Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*

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