Medicare Advantage

This policy uses coverage criteria developed solely based on applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals and other applicable Medicare coverage documents.

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.​

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• Upper abdominal distress (pain or discomfort) that persists despite an appropriate trial of therapy (e.g., acid suppression with proton-pump inhibitors [PPIs])
• Upper abdominal distress (pain or discomfort) associated with symptoms and/or signs suggesting serious organic disease (e.g., prolonged anorexia and weight loss)
• Dysphagia (difficulty or discomfort in swallowing) or odynophagia (painful swallowing)
• Esophageal reflux symptoms that are persistent or recurrent despite appropriate therapy
• Persistent vomiting of unknown cause
• Other systemic diseases in which the presence of upper gastrointestinal (GI) pathology might modify other planned management (e.g., individuals with a history of GI bleeding who are scheduled for organ transplantation, long-term anticoagulation, and chronic nonsteroidal therapy for arthritis; Barrett esophagus)
• X-ray findings for any of the following:
  • A suspected neoplastic lesion, for confirmation and specific histologic diagnosis
  • Gastric or esophageal ulcer
  • Evidence of upper GI tract stricture or obstruction
• The presence of GI bleeding for any of the following:
  • In individuals actively bleeding or those recently stopped
  • When surgical therapy is contemplated
  • When re-bleeding occurs after acute self-limited blood loss or after endoscopic therapy
  • When portal hypertension or aortoenteric fistula is suspected
  • For presumed chronic blood loss and for iron deficiency anemia when a colonoscopy is negative
• When sampling of duodenal or jejunal tissue or fluid is indicated
• To assess acute injury after caustic agent ingestion

• Intraoperatively to clarify a location or pathology of a lesion
  

• Treatment of bleeding lesions, such as ulcers, tumors, vascular malformations (e.g., electrocoagulation, heater probe, laser photocoagulation or injection therapy)

• Sclerotherapy treatment of bleeding from esophageal or proximal gastric varices or banding of varices

• Removal of a foreign body
• Removal of selected polypoid lesions
• Placement of feeding tubes (oral, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy)
• Dilation of stenotic lesions (e.g., with transendoscopic balloon dilators or dilating systems using guidewires)
• Palliative therapy for stenosing neoplasms (e.g., laser, bipolar electrocoagulation, stent placement)

• Gastric distress that is chronic, nonprogressive, atypical for known organic disease, and considered functional in origin (there are occasional exceptions in which an endoscopic examination may be necessary once to rule out organic disease, especially if symptoms are unresponsive to therapy)
• Uncomplicated heartburn responsive to medical therapy
• Metastatic adenocarcinoma of unknown primary site when the results will not alter management
• X-ray findings of:
  • Asymptomatic or uncomplicated sliding hiatus hernia
  • Uncomplicated duodenal bulb ulcer that has responded to therapy, or
  • Deformed duodenal bulb when symptoms are absent or respond adequately to ulcer therapy
• Routine screening of the upper GI tract

• Without current GI symptoms about to undergo elective surgery for non-upper GI disease​ 

• When a lower GI endoscopy reveals the cause of symptoms, abnormal signs or laboratory tests (e.g., colonic neoplasm with iron deficiency anemia). Exceptions can be considered if medical necessity for this procedure can be demonstrated.
• Sequential or periodic diagnostic EGD for the following:
  • Surveillance for malignancy in individuals with gastric atrophy, pernicious anemia, treated achalasia, or prior gastric operation
  • Surveillance of healed benign disease such as esophagitis, gastric or duodenal ulcer
  • Surveillance during chronic repeated dilations of benign strictures unless there is a change in status

• For individuals with traumatic pancreatitis to accurately localize the injury and provide endoscopic drainage
• For pancreatic duct stricture evaluation
• For the extraction of bile duct stones in severe gallstone-induced pancreatitis
• For the detection of pancreatic ductal changes in chronic pancreatitis and also the presence of calcified stones in the ductal system. A pancreatogram may be performed and is likely to be abnormal in chronic alcoholic pancreatitis, but less so in nonalcoholic-induced types.
• For detecting gallstones in symptomatic individuals whose oral cholecystogram and gallbladder ultrasonograms are normal
• For individuals with radiologic imaging that is suggestive of common bile duct stones or other potential pathology

An ERCP is typically not indicated for the following conditions:

• For the diagnosis of pancreatitis except for suspected gallstone pancreatitis
• For use in early stages or in acute pancreatitis, because of the possibility of exacerbation