Notification

Esophagogastroduodenoscopy (EGD) and Endoscopic Retrograde Cholangiopancreatography (ERCP)


Notification Issue Date: 10/16/2018

This version of the policy will become effective 01/14/2019.

The following new policy has been developed to communicate the Company’s coverage criteria for EGD and ERCP.



Medical Policy Bulletin


Title:Esophagogastroduodenoscopy (EGD) and Endoscopic Retrograde Cholangiopancreatography (ERCP)

Policy #:07.02.22

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

MEDICALLY NECESSARY

ESOPHAGOGASTRODUODENOSCOPY (EGD)

Esophagogastroduodenoscopy (EGD) is considered medically necessary and, therefore, covered in the following situations when any of the medical necessity criteria listed below under diagnostic, therapeutic, or surveillance/periodic EGD are met:
  • As the initial method of evaluation of symptoms as an alternative to radiographic studies
  • Following an unsuccessful empirical trial of therapy for a suspected benign digestive disorder
  • If a change in management is probable based on results of EGD
  • When a primary therapeutic procedure is contemplated

Diagnostic EGD
  • Upper abdominal symptoms that persist despite an appropriate trial of therapy
  • Upper abdominal symptoms associated with other symptoms or signs suggesting structural disease (e.g., anorexia and weight loss) or new-onset symptoms in individuals older than 50 years of age
  • Dysphagia (difficulty swallowing) or odynophagia (painful swallowing)
  • Esophageal reflux symptoms that persist or recur despite appropriate therapy
  • Persistent vomiting of unknown cause
  • Other diseases in which the presence of upper gastrointestinal (GI) pathology might modify other planned management. Examples include individuals who have a history of ulcer or GI bleeding who are scheduled for organ transplantation, long-term anticoagulation or nonsteroidal anti-inflammatory drug therapy for arthritis, and those with cancer of the head and neck.
  • Familial adenomatous polyposis syndromes
  • Confirmation and specific histologic diagnosis of radiologically demonstrated lesions:
    • Suspected neoplastic lesion
    • Gastric or esophageal ulcer
    • Upper tract stricture or obstruction
  • Active or recent GI bleeding
  • Presumed chronic blood loss and iron deficiency anemia when the clinical situation suggests an upper GI source or when colonoscopy does not provide an explanation
  • When sampling of tissue or fluid is indicated
  • Acute injury after caustic ingestion
  • Diarrhea in individuals suspected of having small-bowel disease (e.g., celiac disease)
  • Intraoperative evaluation of anatomic reconstructions typical of modern foregut surgery (e.g., evaluation of anastomotic leak and patency, fundoplication formation, pouch configuration during bariatric surgery)
  • Pernicious anemia 6 months after diagnosis or at the development of upper GI symptoms

Therapeutic EGD
  • Suspected portal hypertension or cirrhosis to document or treat esophageal varices
  • Bleeding lesions such as ulcers, tumors, vascular abnormalities (e.g., electrocoagulation, heater probe, laser photocoagulation, or injection therapy)
  • Removal of foreign-bodies
  • Esophageal stricture dilation/management of achalasia (e.g., botulinum toxin, balloon dilation)
  • Removal of selected lesions
  • Placement of feeding or drainage tubes (e.g., peroral, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy)
  • Dilation and stenting of stenotic lesions (e.g., with transendoscopic balloon dilators or dilation systems using guidewires)
  • Palliative treatment of stenosing neoplasms (e.g., laser, multipolar electrocoagulation, stent placement)
  • Endoscopic therapy of intestinal metaplasia
  • Management of operative complications (e.g., dilation of anastomotic strictures, stenting of anastomotic disruption, fistula, or leak in selected circumstances)

SURVEILLANCE/PERIODIC EGD

Premalignant Condition
  • Barretts Esophagus (BE):
    • Without dysplasia, every 3 to 5 years
    • Indeterminate for dysplasia, a repeat EGD to clarify presence and grade of dysplasia
    • Low-grade dysplasia (LGD), a repeat EGD in 6 months to confirm LGD, then yearly
    • High-grade dysplasia (HGD), every 3 months for 1 year; after 1 year of no cancer detection, repeat EGD at lengthened intervals.
  • Caustic ingestion: beginning at 15 to 20 years following the acute injury, at an interval of every 1 to 3 years
  • Tylosis: beginning at 30 years of age, at an interval of every 1 to 3 years
  • Gastric epithelial polyps:
    • Beginning at one year after removal of adenomatous gastric polyps to assess recurrence at the prior excision site, new or previously missed polyps, and/or supervening early carcinoma:
      • If the results of this examination are negative, every 3 to 5 years
      • High-grade dysplasia and early gastric cancer, EGD at individualized intervals
  • Familial adenomatous polyposis (FAP) and hereditary nonpolyposis colorectal cancer (HNPCC):
    • Beginning at the time of a colectomy or after 30 years of age:
      • If no adenomas, repeat EGD in 5 years
      • Duodenal and periampullary adenomas, at intervals based on stage of disease
      • Papillary adenomas in individuals with advanced adenomas or dysplasia after complete excision, EGD with multiple biopsies every 6 months for a minimum of 2 years; thereafter every 3 years
    • HNPCC, EGD surveillance will be covered
  • Gastric intestinal metaplasia:
    • Confirmed gastric intestinal metaplasia with high-grade dysplasia
  • MALT Lymphoma:
    • Every 3 to 6 months for the first 2 years after H. pylori eradication; after the first two years, every 6 to 12 months.

Esophageal Varices
  • Compensated cirrhosis with no varices on initial screening EGD, another EGD every 2 to 3 years. If the individual has small varices, another endoscopy every 1 to 2 years.
  • Cirrhosis secondary to alcohol abuse or decompensated liver disease with no findings of varices on the initial screening endoscopy, periodic EGD yearly for the screening of development of esophageal varices.
  • A yearly endoscopy for small varices accompanied by high-risk stigmata (red wale marks or red spots) on screening endoscopy.

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)

Endoscopic retrograde cholangiopancreatography (ERCP) is considered medically necessary and, therefore, covered in the following situations when any of the medical necessity criteria listed below are met:
  • As the initial method of evaluation of symptoms as an alternative to radiographic studies
  • Following an unsuccessful empirical trial of therapy for a suspected benign digestive disorder
  • If a change in management is probable based on results of ERCP
  • When a primary therapeutic procedure is contemplated

Indications
  • Acute biliary pancreatitis with concomitant cholangitis or biliary obstruction
  • Benign biliary strictures requiring dilation and stent placement
  • First-line therapy for postoperative biliary leaks
  • Type I sphincter of Oddi dysfunction (SOD) requiring a sphincterotomy
  • Pancreatic divisum
  • Tissue sampling from the papilla or from the bile or pancreatic ducts to check for cancer
  • Clinical and biochemical or imaging results suggestive of pancreatic duct disease or biliary tract without jaundic.
  • Signs or symptoms suggesting pancreatic malignancy when results of direct imaging (e.g. endoscopic ultrasound, ultrasound, computed tomography, magnetic resonance imaging) are equivocal or normal
  • Pancreatitis of unknown etiology
  • Preoperative evaluation of an individual with chronic pancreatitis and/or pseudocyst
  • Evaluation of the sphincter of Oddi by manometry
  • When an endoscopic sphincterotomy is required for any of the following indications:
    • Choledocholithiasis
    • Papillary stenosis or type 1 sphincter of Oddi dysfunction
    • Facilitate placement of biliary stents or dilation of biliary strictures
    • Sump syndrome
    • Choledochocele involving the major papilla
    • Ampullary carcinoma in individuals who are not candidates for surgery
    • Facilitate access to pancreatic duct
  • When dilation and/or stent placement is required across benign or malignant strictures, fistulae, postoperative bile leak, or in high-risk individuals with large unremovable common duct stones
  • When balloon dilation of the papilla is required
  • When nasobiliary drain placement is required
  • When pancreatic pseudocyst drainage is required
  • Ampullectomy of adenomatous neoplasms of the major papilla
  • Therapy of disorders of the biliary and pancreatic ducts
  • Facilitation of cholangioscopy and/or pancreatoscopy


NOT MEDICALLY NECESSARY

ESOPHAGOGASTRODUODENOSCOPY (EGD)

Diagnostic EGD

An EGD is considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support its use in the treatment of conditions such as the following.
  • For the evaluation of symptoms that are considered functional in origin (i.e., no physiologic cause for GI complaints is found, even after extensive evaluation
  • Metastatic adenocarcinoma of unknown primary site when the results will not alter management.
  • Radiographic findings of:
    • Asymptomatic or uncomplicated sliding hiatal hernia.
    • Uncomplicated duodenal ulcer that has responded to therapy.
    • Deformed duodenal bulb when symptoms are absent or respond adequately to ulcer therapy.
  • Prior to bariatric surgery in asymptomatic individuals
  • Routine screening in asymptomatic individuals
  • Screening or evaluation of colorectal cancer not associated with familial adenomatous polyposis (FAP) syndrome

SURVEILLANCE OR PERIODIC EGD

Sequential or periodic EGD is considered not medically necessary and, therefore, not covered for the following indications because the available published peer-reviewed literature does not support its use in the treatment of illness or injury.
  • Surveillance for malignancy in individuals with gastric atrophy, pernicious anemia, fundic gland or hyperplastic polyps, gastric intestinal metaplasia, or previous gastric operations for benign disease (ASGE)
  • Surveillance of healed benign disease, such as esophagitis and gastric or duodenal ulcer (ASGE)
  • Repeat EGD for individuals with a prior normal or negative EGD, if symptoms remain unchanged
  • Surveillance EGD for individuals with adequate sampling or removal of nondysplastic gastric polyps

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)

An ERCP is considered not medically necessary and, therefore, not covered for the following indications because the available published peer-reviewed literature does not support its use:
  • For the evaluation of pancreaticobiliary-type pain in the absence of objective abnormalities on other pancreaticobiliary imaging or laboratory studies
  • Before a laparoscopic cholecystectomy in the absence of objective signs (e.g., biliary colic, obstructive jaundice, pancreatitis, cholangitis) of biliary obstruction or stone
  • For the evaluation or treatment of type III sphincter of Oddi dysfunction (SOD)
  • For further evaluation of documented pancreatic malignancy unless management will be altered
  • Empirical biliary sphincterotomy without sphincter of Oddi manometry in individuals with suspected type III sphincter of Oddi dysfunction (ASGE)

EXPERIMENTAL/INVESTIGATIONAL

Transesophageal radiofrequency ablation and transesophageal endoscopic fundoplication for the treatment of gastroesophageal reflux disease (GERD) are considered experimental/investigational and, therefore, not covered because the safety and effectiveness of these procedures cannot be established by review of the available published peer-reviewed literature. Refer to medical policy 11.03.11n, Procedures for the Treatment of Gastroesophageal Reflux Disease (GERD), for additional information.

Confocal laser endomicrosopy is considered experimental/investigational and, therefore, not covered because the safety and effectiveness of these procedures cannot be established by review of the available published peer-reviewed literature.

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.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, upper gastrointestinal endoscopy is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

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

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

Cellvixio (Mauna Kea Technologies) was approved by the FDA through the 510(k) process on October 23, 2015 for imaging of the internal microstructure of tissues during an endoscopic and laparoscopic surgical procedures.

Optiscan confocal endoscopic imaging system was approved by the FDA through the 510(k) process on March 5, 2010 for imaging of the internal microstructure of tissues in the anatomical track access by video endoscope, during endoscopic medical examination procedures.

Description

ESOPHAGOGASTRODUODENOSCOPY

Esophagogastroduodenoscopy (EGD), also known as an upper gastrointestinal (GI) endoscopy, involves examining the lining of the upper part of the gastrointestinal (GI) tract, which includes the esophagus, stomach, and duodenum (first portion of the small intestine). EGD involves the use of a thin, flexible tube called an endoscope, which has its own lens and light source and projects images on a video monitor.

An EGD is often indicated for evaluation and treatment of abdominal symptoms. Some diagnostic indications may include abdominal symptoms, difficulty and/or painful swallowing, GI bleed, esophageal reflux, and suspected neoplasm. Therapeutic indications may include stricture dilation, removal of foreign body, treatment of bleeding lesions, sclerotherapy of varices, and removal of selected lesions.

An EGD can evaluate, diagnosis, and manage various GI problems, including difficult or painful swallowing, pain in the stomach or abdomen, GI bleed, ulcers, and tumors. Tiny instruments can be passed through an opening in the endoscope to obtain tissue samples, coagulate bleeding sites, dilate or stretch a narrowed area, or perform other treatments.

EGD can be used to periodically monitor individuals with esophageal varices or premalignant conditions (i.e., Barrett’s esophagus, caustic ingestion, tylosis, gastric epithelial polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer).

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)

An endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that combines upper gastrointestinal (GI) endoscopy and x-rays to treat problems of the gallbladder, bile, and pancreatic ducts.

An endoscopic retrograde cholangiopancreatography (ERCP) is used to diagnose, evaluate, and treat problems that affect the pancreas and bile duct system, and to study the ducts that drain the liver and pancreas. Ducts are drainage routes into the bowel. The bile or biliary ducts drain the liver and gallbladder, and the pancreatic duct drains the pancreas. The bile and pancreatic ducts join together just before they drain into the upper bowel, about 3 inches from the stomach. The drainage opening is called the papilla. The papilla is surrounded by a circular muscle, called the sphincter of Oddi.

An ERCP can be used when there is a blockage of the bile ducts by gallstones, tumors, scarring or other conditions that cause obstruction or narrowing of the ducts. Similarly, blockage of the pancreatic ducts from stones, tumors, or stricture can also be evaluated or treated by ERCP, which is useful in assessing causes of pancreatitis.

There are several risk factors and complications that can develop from having an ERCP. Pancreatitis is the most common serious complication, also known as post-ERCP pancreatitis (PEP). This condition consists of worsened abdominal pain and elevated serum amylase resulting in a hospitalization.

PROCEDURES PERFORMED WITH ERCP
Sphincterotomy

Shincterotomyis a procedure that incorporates the use of endoscopic as well as fluoroscopic guidance. The technique involves deep cannulation of the bile duct followed by severance of the sphincter of Oddi with the electrocautery, a small wire on a specialized catheter that uses electric current to cut the tissue. The actual cut is quite small, usually less than a 1/2 inch. This small cut, or sphincterotomy, allows various treatments in the ducts.

Stone Removal

The most common treatment through an ERCP scope is removal of bile duct stones. These stones may form in the gallbladder and travel into the bile duct or may form in the duct itself years after the gallbladder has been removed. After a sphincterotomy is performed to enlarge the opening of the bile duct, stones can be pulled from the duct into the bowel. A variety of balloons and baskets attached to specialized catheters can be passed through the ERCP scope into the ducts allowing stone removal. Very large stones may require crushing in the duct with a specialized basket so the fragments can be pulled out through the sphincterotomy.

Stent Placement

Stents are placed into the bile or pancreatic ducts to bypass strictures, or narrowed parts of the duct. These narrowed areas of the bile or pancreatic duct are due to scar tissue or tumors that cause blockage of normal duct drainage. There are two types of stents that are commonly used. The first is made of plastic and looks like a small straw. A plastic stent can be pushed through the ERCP scope into a blocked duct to allow normal drainage. The second type of stent is made of metal wires, appearing like the cross wires of a fence. The metal stent is flexible and springs open to a larger diameter than plastic stents. Both plastic and metal stents tend to clog up after several months, and another ERCP may be required to place a new stent. Metal stents are permanent, while plastic stents are easily removed at a repeat procedure.

Balloon Dilation

Balloon dilation involves the use of catheters fitted with dilating balloons that can be placed across a narrowed area or stricture. The balloon is then inflated to stretch out the narrowing. Dilation with balloons is often performed when the cause of the narrowing is benign (not a cancer). After balloon dilation, a temporary stent may be placed for a few months to help maintain the dilation.

Tissue Sampling

Tissue sampling from the papilla or from the bile or pancreatic ducts via the ERCP scope is commonly performed . There are several different sampling techniques, although the most common is to brush the area with subsequent examination of the cells obtained. Tissue samples can be used to decide whether a stricture or narrowing is due to cancer. Positive results for cancer are very accurate; however, negative results may not be accurate.

CONFOCAL LASER ENDOMICROSCOPY

Confocal laser endomicrosopy (also known as confocal fluorescent endomicrosopy and optic endomicrosopy) is an in vivo microscopic imaging of the mucosal epithelium during endoscopy to assess the gastrointestinal mucosal histology. A light for a low-power laser illuminates the tissue. The same lens detects light reflected from the tissue through a pinhole. The term confocal refers to having both illumination and collection systems in the same focal plan. Light reflected and scattered that is not reflected through the pinhole is excluded from detection. This dramatically increases the resolution of the confocal laser endomicroscopy (CLE) images.

There are two CLE devices that have been cleared for marketing by the U.S Food and Drug Administration (FDA) through the 510k process. One is an endoscope-based system with a confocal probe incorporated onto the tip of a conventional endoscope. The other is a probe-based system where the probe is placed through the biopsy channel of a conventional endoscope. The depth of view with the endoscopic system is up to 250 m and about 120m with the probe-based system.

BARRETT'S ESOPHAGUS

In a meta-analysis, Gupta et al. (2014) evaluated the diagnostic accuracy of the CLE-based targeted biopses detecting high-grade dysplasia/adenocarcinoma compared with four-quadrant random biopsies. Seven studies with 345 individuals and 3080 lesions were included in the meta-analysis. For the diagnosis of high-grade dysplasia/adenocarcinoma, the pooled sensitivity was 68% (95% confidence interval [CI], 64% to 73%), and pooled specificity was 88% (95% [CI] 87% to 89%). The per-patient analysis among four studies was a pooled sensitivity of 86% (95% CI of 74% to 96%) and a pooled specificity of 83% (95% CI of 77% to 88%). The meta-analysis concluded that CLE is not an acceptable replacement for biopsy techniques for the diagnosis of high-grade dysplasia/esophageal adenocarcinoma in Barrett's esophagus.

In a meta-analysis, Xiong et al. (2016) evaluated the accuracy of CLE for diagnosis of neoplasia in Barrett's esophagus. Fourteen studies were included covering 789 with 4047 lesions. The per-patient analysis among seven studies was a pooled sensitivity of 89% (95% CI, 82% to 94%) and a pooled specificity of 83% (95% CI, 78% to 86%). The per-lesion analysis among 10 studies was a pooled sensitivity of 77% (95% CI, 73% to 81%) and a pooled specificity of 89% (95% CI, 87% to 90%).

In the American Society for Gastrointestinal Endoscopy (ASGE) technology status evaluation report, confocal laser endomicroscopy is considered an emerging technology with the potential to significantly reduce the number of biopsies in Barrett's esophagus and irritable bowel disorder. Confocal laser endomicroscopy can provide surrogate real-time histological information of the bile duct and within the pancreatic cysts. ASGE concluded, "Before the technology can be widely accepted, many further studies are needed to determine its clinical efficacy and evaluate its cost-effectiveness and its utilization in both academic and community settings."
References


American Gastroenterological Association. American Gastroenterological Association Institute Guideline on the Role of Upper Gastrointestinal Biopsy to Evaluate Dyspepsia in the Adult Patient in the Absence of Visible Mucosal Lesions. Gastroenterology. 2015.149:1082-1087. Available at: http://www.gastrojournal.org/article/S0016-5085%2815%2901065-3/pdf. Accessed on January 26, 2018.

American Gastroenterological Association. American Gastroenterological Association Medical Position Statement on the Management of Barrett’s Esophagus. Gastroenterology. 2011.140:1084-1091. Available at: http://www.gastrojournal.org/article/S0016-5085(11)00084-9/pdf. Accessed on January 26, 2018.

American Society for Gastrointestinal Endoscopy. Confocal laser endomicroscopy. Technology Status Evaluation Report. Gastronintestinal Endoscopy.2014;80(6):928-938. Available at: http://www.giejournal.org/article/S0016-5107(14)01856-2/pdf. Accessed on January 26, 2018.

American Society for Gastrointestinal Endoscopy (ASGE) guidelines. Appropriate use of GI endoscopy. Gastrointestinal Endoscopy journal.2012. 75(6) Available at: https://www.asge.org/docs/default-source/education/practice_guidelines/appropriate_use_of_gi_endoscopy.pdf?sfvrsn=2. Accessed January 9, 2018.

American Society for Gastrointestinal Endoscopy (ASGE) guidelines. Quality indicators for EGD. Gastrointestinal Endoscopy. 2015. 81(1):17-30. Available at: https://www.asge.org/docs/default-source/education/practice_guidelines/doc-b68366e5-03fd-429d-8150-77193bec8873.pdf?sfvrsn=6. Accessed December 21, 2017.

American Society for Gastrointestinal Endoscopy (ASGE). The role of endoscopy in Barrett's esophagus and other premalignant conditions of the esophagus. Gastrointestinal Endoscopy. 2012. 76(6):1087-1094. Available at: https://www.asge.org/docs/default-source/education/practice_guidelines/doc-the-role-of-endoscopy-in-barretts-esophagus-and-other-premalignant-conditions-of-the-esophagus.pdf?sfvrsn=8.

American Society for Gastrointestinal Endoscopy (ASGE). The role of endoscopy in the evaluation and management of dysphagia. Gastrointestinal Endoscopy. 2014. 79(2):191-201. Available at: https://www.asge.org/docs/default-source/education/practice_guidelines/doc-3c0fc1c6-37ac-4906-9301-74f813979375.pdf?sfvrsn=6. Accessed on January 26, 2018.

American Society for Gastrointestinal Endoscopy (ASGE). The role of endoscopy in the evaluation and treatment of patients with biliary neoplasia. Gastrointestinal Endoscopy. 2013. 77(2):167-174. Available at: https://www.asge.org/docs/default-source/education/practice_guidelines/doc-the-role-of-endoscopy-in-the-evaluation-and-treatment-of-patients-with-biliary-neoplasia.pdf?sfvrsn=6. Accessed on January 26, 2018.

American Society for Gastrointestinal Endoscopy (ASGE). The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointestinal Endoscopy. 2010. 71(1):1-9. Available at: https://www.asge.org/docs/default-source/education/practice_guidelines/doc-piis0016510709025504.pdf?sfvrsn=6. Accessed on January 26, 2018.

American Society for Gastrointestinal Endoscopy (ASGE) guidelines. The role of endoscopy in the management of GERD. Gastrointestinal Endoscopy. 2015. 81(6):1305-1310. Available at: https://www.asge.org/docs/default-source/education/practice_guidelines/doc-endoscopy_in_the_managment_of_gerd.pdf?sfvrsn=6. Accessed on January 26, 2018.

American Society for Gastrointestinal Endoscopy (ASGE) guidelines. The role of endoscopy in the management of premalignant and malignant conditions of the stomach. Gastrointestinal Endoscopy. 2015. 82(1):1-8. Available at: https://www.asge.org/docs/default-source/education/practice_guidelines/doc-endoscopy_premalignant_malignant_conditions.pdf?sfvrsn=6.

American Society for Gastrointestinal Endoscopy (ASGE) guidelines. The role of endoscopy in the management of variceal hemorrhage. Gastrointestinal Endoscopy. 2014. 80(2):221-227. Available at: https://www.asge.org/docs/default-source/education/practice_guidelines/doc-2014_the-role-of-endoscopy-in-the-management-of-variceal-hemorrhage.pdf?sfvrsn=8.

American Society for Gastrointestinal Endoscopy (ASGE) guidelines. The role of ERCP in benign disease of the biliary tract. Gastrointestinal Endoscopy. 2015. 81(4):795-803. Available at: https://www.asge.org/docs/default-source/education/practice_guidelines/doc-ercp_benign_diseases_biliary_tract.pdf?sfvrsn=6.

Badillo R and Francis D. Diagnosis and treatment of gastroesophageal reflux disease. World J Gastrointest Pharmacol Ther. 2014.5(3):105-112. Available at:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4133436/.

Baron T, Petersen B, Mergener K, et. al. Quality indicators for endoscopic retrograde cholangiopancreatography. Gastrointestinal Endoscopy. 2006;63(4):S29-S38.

Baucom R and Wise P. Endoscopic and surgical management of hereditary non-polyposis colorectal cancer. Clin Colon Rectal Surg.2012.25(2):90-96. Available at:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3423886/.

Bazaldua O and Schneider D. Evaluation and management of dyspepsia. Am Fam Physician. 1999.60(6):1773-1784. Available at: http://www.aafp.org/afp/1999/1015/p1773.html.

Cohen D. Esophagoscopy. [Medscape Web site]. Updated 10/05/2015. Available at: http://emedicine.medscape.com/article/1891879-overview [via subscription only]. Accessed January 20, 2016.

Cohen J, Safdi M, Deal S, et. al. Quality indicators for esophagogastroduodenoscopy. Am J of Gastroenterology.2006;101:886-891.

Ellis A, Risk JM, Maruthappu T, Kelsell DP. Tylosis with oesophageal cancer: Diagnosis, management and molecular mechanisms. Orphanet J Rare Dis. 2015.10:126. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4589029/pdf/13023_2015_Article_346.pdf.

Gupta A., Attar BM., and Koduru P. et. al. Utility of confocal laser endomicroscopy in identifying high-grade dysplasia and adenocarcinoma in Barrett's esophagus: a systemic review and meta-analysis. Eur J Gastroenterol Hepatol. 2014;26(4):367-77.

Jamidar P. Endoscopic Sphincterotomy. Medscape [website]. Updated 12/03/2015. Available at: http://emedicine.medscape.com/article/1891681-overview. Accessed April 4, 2017.

Kapetanos D.J. ERCP in acute biliary pancreatitis. World J Gastrointest Endosc. 2010 Jan 16; 2(1): 25–28.Published online 2010 Jan 16. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2999082/ Accessed January 20, 2016.

Katz P, Gerson L, and Vela M. Diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013.108:308-328. Available at: http://gi.org/guideline/diagnosis-and-managemen-of-gastroesophageal-reflux-disease/.

Munoz J. Hereditary nonpolyposis colorectal cancer. Updated 03/23/2017.[Medscape website]. Available at:http://emedicine.medscape.com/article/188613-overview. Accessed 04/10/2017.

Schlosser W, Rau BM, Beger HG. Surgical treatment of pancreas divisum causing chronic pancreatitis: the outcome benefits of duodenum-preserving pancreatic head resection. J Gastrointest Surg. 2005.9(5):710-5.

Triadafilopoulos G. Caustic esophageal injury in adults. 04/07/2016. [Uptodate website]. Available at:
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US National Library of Medicine. Genetics Home Reference [website]. Familial adenomatous polyposis. Updated 10/2013. Available at: file:///C:/Users/ibx1940/Downloads/familial-adenomatous-polyposis.pdf. Accessed April 10, 2017.

US Food and Drug Administration. Optiscan Pty Ltd. 510(k) Summary of Safety and Effectiveness Optiscan Confocal Endoscopic Imaging System. 3/5/2010. Available at: https://www.accessdata.fda.gov/cdrh_docs/pdf9/K093624.pdf. Accessed January 26, 2018.

Xiong YQ, MA SJ, Zhou JH, et. al. A meta-analysis of confocal laser endomicroscopy for the detection of neoplasia in patients with Barrett's esophagus. J Gastroenterol Hepatol. 2016;31(6):1102-1110.





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


ESOPHAGOGASTRODUODENOSCOPY (EGD)

43233, 43235, 43236, 43237, 43238, 43239, 43240, 43241, 43242, 43243, 43244, 43245, 43246, 43247, 43248, 43249, 43250, 43251, 43253, 43254, 43255, 43259, 43266, 43270

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)

43260, 43261, 43262, 43263, 43264, 43265, 43274, 43275, 43276, 43277, 43278


EXPERIMENTAL/INVESTIGATIONAL

THE FOLLOWING CODE IS USED TO REPRESENT TRANSESOPHAGEAL RADIOFREQUENCY ABLATION:

43257

THE FOLLOWING CODE IS USED TO REPRESENT TRANSORAL INCISIONLESS FUNDOPLICATION (TIF):

43210

THE FOLLOWING CODES ARE USED TO REPRESENT CONFOCAL LASER ENDOMICROSCOPY:

43252, 0397T



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)

NOT MEDICALLY NECESSARY

ESOPHAGOGASTRODUODENOSCOPY (EGD)

Screening or evaluation of colorectal cancer not associated with Familial Adenomatous Polyposis (FAP) syndrome is considered not medically necessary.

B18.1 Chronic viral hepatitis b without delta-agent
B37.5 Candidal meningitis
C09.9 Malignant neoplasm of tonsil, unspecified
C10.9 Malignant neoplasm of oropharynx, unspecified
C17.1 Malignant neoplasm of jejunum
C18.0 Malignant neoplasm of cecum
C18.1 Malignant neoplasm of appendix
C18.2 Malignant neoplasm of ascending colon
C18.3 Malignant neoplasm of hepatic flexure
C18.4 Malignant neoplasm of transverse colon
C18.5 Malignant neoplasm of splenic flexure
C18.6 Malignant neoplasm of descending colon
C18.7 Malignant neoplasm of sigmoid colon
C18.8 Malignant neoplasm of overlapping sites of colon
C18.9 Malignant neoplasm of colon, unspecified
C19 Malignant neoplasm of rectosigmoid junction
C20 Malignant neoplasm of rectum
C67.9 Malignant neoplasm of bladder, unspecified
C7A.020 Malignant carcinoid tumor of the appendix
D09.8 Carcinoma in situ of other specified sites
D12.0 Benign neoplasm of cecum
D12.2 Benign neoplasm of ascending colon
D12.3 Benign neoplasm of transverse colon
D12.4 Benign neoplasm of descending colon
D12.5 Benign neoplasm of sigmoid colon
D12.7 Benign neoplasm of rectosigmoid junction
D12.8 Benign neoplasm of rectum
D12.9 Benign neoplasm of anus and anal canal
D13.6 Benign neoplasm of pancreas
D17.5 Benign lipomatous neoplasm of intra-abdominal organs
D37.8 Neoplasm of uncertain behavior of other specified digestive organs
D49.1 Neoplasm of unspecified behavior of respiratory system
D64.89 Other specified anemias
E04.9 Nontoxic goiter, unspecified
E16.4 Increased secretion of gastrin
E80.6 Other disorders of bilirubin metabolism
G04.81 Other encephalitis and encephalomyelitis
G47.33 Obstructive sleep apnea (adult) (pediatric)
G93.40 Encephalopathy, unspecified
I20.8 Other forms of angina pectoris
I61.0 Nontraumatic intracerebral hemorrhage in hemisphere, subcortical
I63.8 Other cerebral infarction
I63.9 Cerebral infarction, unspecified
I86.8 Varicose veins of other specified sites
I87.2 Venous insufficiency (chronic) (peripheral)
J02.9 Acute pharyngitis, unspecified
J31.2 Chronic pharyngitis
J38.01 Paralysis of vocal cords and larynx, unilateral
J39.1 Other abscess of pharynx
J39.2 Other diseases of pharynx
J69.0 Pneumonitis due to inhalation of food and vomit
J84.9 Interstitial pulmonary disease, unspecified
J95.821 Acute postprocedural respiratory failure
J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.01 Acute respiratory failure with hypoxia
K44.9 Diaphragmatic hernia without obstruction or gangrene
K52.9 Noninfective gastroenteritis and colitis, unspecified
K56.1 Intussusception
K56.41 Fecal impaction
K57.30 Diverticulosis of large intestine without perforation or abscess without bleeding
K58.9 Irritable bowel syndrome without diarrhea
K59.00 Constipation, unspecified
K59.03 Drug induced constipation
K59.09 Other constipation
K62.1 Rectal polyp
K62.3 Rectal prolapse
K62.5 Hemorrhage of anus and rectum
K62.89 Other specified diseases of anus and rectum
K63.5 Polyp of colon
K64.0 First degree hemorrhoids
K64.1 Second degree hemorrhoids
K64.2 Third degree hemorrhoids
K64.4 Residual hemorrhoidal skin tags
K64.8 Other hemorrhoids
K64.9 Unspecified hemorrhoids
K75.9 Inflammatory liver disease, unspecified
K76.89 Other specified diseases of liver
K86.9 Disease of pancreas, unspecified
N18.9 Chronic kidney disease, unspecified
Q44.6 Cystic disease of liver
Q45.3 Other congenital malformations of pancreas and pancreatic duct
Q85.8 Other phakomatoses, not elsewhere classified
R06.02 Shortness of breath
R06.83 Snoring
R07.0 Pain in throat
R09.89 Other specified symptoms and signs involving the circulatory and respiratory systems
R10.2 Pelvic and perineal pain
R10.30 Lower abdominal pain, unspecified
R10.31 Right lower quadrant pain
R10.32 Left lower quadrant pain
R14.0 Abdominal distension (gaseous)
R15.0 Incomplete defecation
R15.2 Fecal urgency
R16.0 Hepatomegaly, not elsewhere classified
R18.8 Other ascites
R19.4 Change in bowel habit
R19.5 Other fecal abnormalities
R53.1 Weakness
R58 Hemorrhage, not elsewhere classified
R74.0 Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase ldh
R74.8 Abnormal levels of other serum enzymes
R76.0 Raised antibody titer
R76.8 Other specified abnormal immunological findings in serum
R79.89 Other specified abnormal findings of blood chemistry
R88.0 Cloudy (hemodialysis) (peritoneal) dialysis effluent
R89.4 Abnormal immunological findings in specimens from other organs, systems and tissues
R91.1 Solitary pulmonary nodule
R91.8 Other nonspecific abnormal finding of lung field
R93.2 Abnormal findings on diagnostic imaging of liver and biliary tract
R93.6 Abnormal findings on diagnostic imaging of limbs
R94.5 Abnormal results of liver function studies
R94.8 Abnormal results of function studies of other organs and systems
S06.5X9A Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter
S06.9X0A Unspecified intracranial injury without loss of consciousness, initial encounter
T14.90 Injury, unspecified
Z00.00 Encounter for general adult medical examination without abnormal findings
Z11.1 Encounter for screening for respiratory tuberculosis
Z12.10 Encounter for screening for malignant neoplasm of intestinal tract, unspecified
Z12.11 Encounter for screening for malignant neoplasm of colon
Z15.01 Genetic susceptibility to malignant neoplasm of breast
Z68.43 Body mass index (bmi) 50-59.9 , adult
Z84.89 Family history of other specified conditions
Z85.038 Personal history of other malignant neoplasm of large intestine
Z86.010 Personal history of colonic polyps



HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

07.02.22
01/14/2019This version of the policy will become effective 01/14/2019.

The following new policy has been developed to communicate the Company’s coverage criteria for EGD and ERCP.


Version Effective Date: 01/14/2019
Version Issued Date: 01/14/2019
Version Reissued Date: N/A

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2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.