Medicare Advantage

Capsule Endoscopy
MA07.022c

Policy

WIRELESS CAPSULE ENDOSCOPY 
MEDICALLY NECESSARY​​​
Wireless capsule endoscopy (WCE) of the esophagus through the ileum 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 
Wireless capsule endoscopy of the esophagus 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. 

NOT MEDICALLY NECESSARY​
Wireless capsule endoscopy is considered not medically necessary 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
All other uses for wireless capsule endoscopy are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the diagnosis of illness or injury.

COLON CAPSULE ENDOSCOPY (CCE) 

MEDICALLY NECESSARY
For diagnostic and/or surveillance purposes, Colon capsule endoscopy (CCE) is medically necessary when EITHER of the following criteria are met:
  • Primary procedure in individuals with major risks for Optical Colonoscopy (OC) or moderate sedation as indicated from an evaluation of the individual by a board certified or board eligible gastroenterologist, a surgeon trained in endoscopy, or a physician with equivalent endoscopic training and any of the following criteria:
    • Fecal Occult Blood Test (FOBT) positive (guaiac or immunochemical) 
    • Multitarget Stool DNA (sDNA) Test positive 
    • Other evidence of lower GI bleeding in hemodynamically stable patient
  • Secondary procedure 
    • For the detection or surveillance of colon polyp(s) if the diagnostic OC was incomplete OR
    • ​When an incomplete diagnostic OC was performed for any of the following criteria:
      • Fecal Occult Blood Test (FOBT) positive (guaiac or immunochemical) 
      • Multitarget Stool DNA (sDNA) Test positive 
      • ​Other evidence of lower GI bleeding in hemodynamically stable individuals
NOT MEDICALLY NECESSARY
Colon capsule endoscopy is considered not medically necessary and, therefore, not covered when any of the following conditions are present:​
  • ​Known or suspected gastrointestinal obstruction, stricture, or fistula
  • Swallowing disorders
  • Cardiac pacemaker or another implanted electro-medical device that emits a radiofrequency or other interfering signal
  • Known contraindication or allergy to any medication or preparation agent used before or during the procedure
  • When performed in conjunction with CT Colonography (CTC)
  • Colorectal cancer screening
All other uses for colon capsule endoscopy are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the diagnosis of illness or injury.

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.

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.


Description

Wireless capsule endoscopy of the esophagus through the ileum 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.

Wireless capsule endoscopy of the esophagus is used for the evaluation of esophageal varices in individuals with portal hypertension, and may be used as an alternative to upper GI endoscopy. 

Colon Capsule Endoscopy (CCE) is a noninvasive procedure that does not require air inflation or sedation and allows for minimally invasive and painless colonic evaluation.

References


Novitas Solutions, Inc. Local Coverage Determination (LCD).L38807: Colon Capsule Endoscopy (CCE). [Novitas Solutions, Inc. Web site]. 03/28/2021. Available at: Local Coverage Determination for Colon Capsule Endoscopy (CCE) (L38807) (cms.gov). Accessed April 30, 2021. 

Novitas Solutions, Inc. Local Coverage Article (LCA).A57753:Billing and Coding: Colon Capsule Endoscopy. [Novitas Solutions, Inc. Web site]. 03/28/2021. Available at: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=57753&ver=9&bc=CAAAAAAAAAAA.  Accessed April 30, 2021. ​


Coding

CPT Procedure Code Number(s)

MEDICALLY NECESSARY
91110, 91111, 0355T

ICD - 10 Procedure Code Number(s)
N/A

ICD - 10 Diagnosis Code Number(s)

MEDICALLY NECESSARY
 
PROCEDURE CODE 91110 IS MEDICALLY NECESSARY WHEN REPORTED WITH THE FOLLOWING DIAGNOSIS CODES:

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
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 
K90.0 Celiac disease
K92.1 Melena
K92.2 Gastrointestinal hemorrhage, unspecified
R19.5 Other fecal abnormalities

PROCEDURE CODE 91111 IS MEDICALLY NECESSARY WHEN REPORTED WITH K76.6 (Portal Hypertension) AND ANY OF THE FOLLOWING DIAGNOSIS CODES: 

I85.10 Secondary esophageal varices without bleeding
I85.11 Secondary esophageal varices with bleeding ​

PROCEDURE CODE 0355T IS MEDICALLY NECESSARY WHEN REPORTED WITH THE FOLLOWING DIANOSIS CODES:

K63.5 Polyp of colon
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

N/A


Coding and Billing Requirements


Policy History

3/28/2021
6/21/2021
MA07.022
Medical Policy Bulletin
Medicare Advantage
No