Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Wireless Capsule Endoscopy
Policy #:MA07.022b

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

Wireless capsule endoscopy (WCE) (91110) using an FDA-approved device is considered medically necessary and, therefore, covered for any of the following indications:
  • For the diagnosis of occult gastrointestinal bleeding (i.e., likely involving the small intestine), the site of which has not been previously identified by any of the following: upper gastrointestinal (GI) endoscopy, colonoscopy, push enteroscopy, nuclear imaging or radiological procedures.
    WCE is limited to those individuals who have undergone GI endoscopy and colonoscopy and these tests have failed to reveal a source of bleeding. Appropriate differential diagnoses for the evaluation of suspected GI bleeding include:
    • Angiodysplasia
    • Neoplasm
    • Iron deficiency anemia, which is unexplained after upper and lower endoscopy
    • Zollinger-Ellison syndrome
    • Tuberculosis
    • Vasculitis
    • Radiation enteritis
    • Meckel's diverticulum
    • Jejunal diverticula
    • Chronic mesenteric ischemia
  • For the management of celiac disease (e.g., surveillance for small intestine cancer)
  • For suspected, undiagnosed Crohn’s disease or when colonic involvement of Crohn’s disease is known, and it is necessary to determine whether there is also involvement of the small bowel
  • When an indeterminate type of colitis exists and a more specific diagnosis is being sought from a small bowel evaluation

ESOPHAGEAL CAPSULE ENDOSCOPY (91111)

Esophageal capsule endoscopy is considered medically necessary and, therefore, covered for the evaluation of esophageal varices in individuals with portal hypertension as an alternative to upper GI endoscopy.

LIMITATIONS

Typically, the administration of a second capsule would not be expected during the same examination, unless it was to ensure an adequate examination (e.g., the initial capsule does not penetrate the pylorus).

Any repeat use of the WCE for an individual must be considered medically necessary for coverage.

EXPERIMENTAL/INVESTIGATIONAL

Wireless capsule endoscopy is considered experimental/investigational and, therefore, not covered for any the following indications:
  • Erosive esophagitis and Barrett’s esophagus
  • Colorectal cancer screening
  • The confirmation of lesions or pathology normally within the reach of upper or lower endoscopes (lesions proximal to the ligament of Treitz or distal to the ileum)
  • Swallowing disorders
  • Known or suspected gastrointestinal (GI) obstruction, strictures or fistulas based on clinical presentation or prior tests

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Documentation in the medical record must indicate that the individual has suspected GI blood loss with or without anemia.
Policy Guidelines

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

Subject to the terms and conditions of the applicable Evidence of Coverage, wireless capsule endoscopy is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as experimental/investigational are not eligible for coverage or reimbursement by the Company.

Description

Wireless capsule endoscopy is used for the diagnosis of occult gastrointestinal bleeding (likely involving the small intestine), the site of which has not previously been identified by any of the following: upper gastrointestinal endoscopy, colonoscopy, push enteroscopy, nuclear imaging, or radiological procedures.
References

Novitas Solutions, Inc. Local Coverage Article (LCA).A57753:Billing and Coding: Wireless Capsule Endoscopy. [Novitas Solutions, Inc. Web site]. 11/21/2019. Available at: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=57753&ver=9&Keyword=wireless+capsule&KeywordSearchType=Or&Date=&PolicyType=Both&ArticleType=BC%7cSAD%7cRTC%7cReg&Cntrctr=323*1&KeyWordLookUp=Doc&SearchType=Advanced&CoverageSelection=Both&kq=true&search_id=&service_date=&bc=IAAAACAAAAAA&. Accessed January 10, 2020.

Novitas Solutions, Inc. Local Coverage Determination (LCD).L35089: Wireless Capsule Endoscopys. [Novitas Solutions, Inc. Web site]. 11/21/2019. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35089&ver=30&Keyword=wireless+capsule&KeywordSearchType=Or&Date=&PolicyType=Both&ArticleType=BC%7cSAD%7cRTC%7cReg&Cntrctr=323*1&KeyWordLookUp=Doc&SearchType=Advanced&CoverageSelection=Both&kq=true&bc=IAAAACAAAAAA&. Accessed January 10, 2020.


Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

MEDICALLY NECESSARY

91110, 91111



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

A18.32 Tuberculous enteritis

A18.39 Retroperitoneal tuberculosis

A18.83 Tuberculosis of digestive tract organs, not elsewhere classified

C17.0 Malignant neoplasm of duodenum

C17.1 Malignant neoplasm of jejunum

C17.2 Malignant neoplasm of ileum

C17.3 Meckel's diverticulum, malignant

C17.8 Malignant neoplasm of overlapping sites of small intestine

C17.9 Malignant neoplasm of small intestine, unspecified

C49.A3 Gastrointestinal stromal tumor of small intestine

C49.A4 Gastrointestinal stromal tumor of large intestine

C78.4 Secondary malignant neoplasm of small intestine

D01.40 Carcinoma in situ of unspecified part of intestine

D01.49 Carcinoma in situ of other parts of intestine

D13.2 Benign neoplasm of duodenum

D13.30 Benign neoplasm of unspecified part of small intestine

D13.39 Benign neoplasm of other parts of small intestine

D37.2 Neoplasm of uncertain behavior of small intestine

D50.0 Iron deficiency anemia secondary to blood loss (chronic)

D50.9 Iron deficiency anemia, unspecified

E16.4 Increased secretion of gastrin

I77.6 Arteritis, unspecified

I85.10 Secondary esophageal varices without bleeding

I85.11 Secondary esophageal varices with bleeding

K31.811 Angiodysplasia of stomach and duodenum with bleeding

K31.82 Dieulafoy lesion (hemorrhagic) of stomach and duodenum

K50.00 Crohn's disease of small intestine without complications

K50.011 Crohn's disease of small intestine with rectal bleeding

K50.018 Crohn's disease of small intestine with other complication

K50.019 Crohn's disease of small intestine with unspecified complications

K50.80 Crohn's disease of both small and large intestine without complications

K50.811 Crohn's disease of both small and large intestine with rectal bleeding

K50.818 Crohn's disease of both small and large intestine with other complication

K50.819 Crohn's disease of both small and large intestine with unspecified complications

K50.90 Crohn's disease, unspecified, without complications

K50.911 Crohn's disease, unspecified, with rectal bleeding

K50.918 Crohn's disease, unspecified, with other complication

K50.919 Crohn's disease, unspecified, with unspecified complications

K52.0 Gastroenteritis and colitis due to radiation

K55.1 Chronic vascular disorders of intestine

K55.21 Angiodysplasia of colon with hemorrhage

K57.11 Diverticulosis of small intestine without perforation or abscess with bleeding

K57.13 Diverticulitis of small intestine without perforation or abscess with bleeding

K57.51 Diverticulosis of both small and large intestine without perforation or abscess with bleeding

K57.53 Diverticulitis of both small and large intestine without perforation or abscess with bleeding

K63.81 Dieulafoy lesion of intestine

K76.6 Portal hypertension

K90.0 Celiac disease

K92.1 Melena

K92.2 Gastrointestinal hemorrhage, unspecified

R19.5 Other fecal abnormalities



HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

Revisions from MA07.022b:
02/12/2020The policy has been reviewed and reissued to communicate the Company’s continuing position on Wireless Capsule Endoscopy.
01/31/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Wireless Capsule Endoscopy.
12/16/2016Policy language was revised regarding the coverage of Wireless Capsule Endoscopy to better reflect Medicare's coverage position.

The following ICD-10 Diagnosis codes have been added to this policy: C49.A3, C49.A4, D37.2, D50.0, K57.51, K57.53

The following ICD-10 Diagnosis codes have been deleted from this policy: K50.10, K50.111, K50.118, K50.119, K58.0, K58.9, K92.0, Q43.0

Revisions from MA07.022a:
10/01/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on Wireless Capsule Endoscopy.

The following ICD-10 diagnosis codes were added: A18.32, A18.39, A18.83, C17.0, C17.1, C17.2, C17.3, C17.8, C17.9, C78.4, D01.40, D01.49, D13.2, D13.30, D13.39, D50.9, E16.4, I77.6, I85.10, I85.11, K31.811, K31.82, K50.00, K50.011, K50.018, K50.019, K50.10, K50.111, K50.118, K50.119, K50.80, K50.811, K50.818, K50.819, K50.90, K50.911, K50.918, K50.919, K52.0, K55.1, K55.21, K57.11, K57.13, K58.0, K58.9, K63.81, K76.6, K90.0, K92.0, K92.1, K92.2, R19.5, Q43.0

Revisions from MA07.022:
02/18/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on Wireless Capsule Endoscopy.
01/01/2015This is a new policy.





Version Effective Date: 12/16/2016
Version Issued Date: 12/16/2016
Version Reissued Date: 02/12/2020