Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Premera BCBS Obscure GI bleed OGIB: Prior inconclusive upper AND lower gastrointestinal endoscopic studiesSuspected Crohn's disease
https://www.premera.com/stellent/groups/public/documents/medicalpolicy/cmi_003621.htm
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
http://www.aetna.com/cpb/medical/data/500_599/0588.html
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
Wireless Capsule Endoscopy as a
Diagnostic Technique in the Disorders of the Small
Bowel, Esophagus and Colon
Hereditary GI polyposis syndromes including familial adenomatous polyposis and Peutz-Jeghers syndrome
Crohn's: Without evidence of disease on conventional diagnostics tests such as SBFT and upper and lower endoscopy
211.2, 555.0, 555.1, 555.2, 555.9, 578.0, 578.1. 578.9, 759.6
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
ALASKA
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: Noridian Administrative Services
No published LCD for capsule endoscopy. Claims will be manually reviewed.
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Obscure GI bleedCrohn's diseaseSuspected small intestinal tumors
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS AL Recurrent, obscure GI bleed UnlistedSuspected Crohn's diseaseKnown Crohn's disease
https://www.bcbsal.org/providers/policies/final/017.pdf
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
ALABAMA
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: Cahaba Government Benefit
Administrators
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopy
Lynch syndrome or inherited polyposis syndromes such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Crohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleeding
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the test
http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=30045&ContrId=213&ver=20&ContrVer=1&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=Alabama&CptHcpcsCode=91110&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAAAAA&
152.0-152.9, 197.4, 211.2, 211.3, 230.7, 235.2, 259.2, 280.0, 280.9, 285.1, 555.0, 555.2, 555.9, 557.0-557.9, 558.1, 558.2, 558.41, 558.42, 558.9, 562.02-562.03, 569.84, 569.86, 578.1-578.9, 579.0, 579.1, 579.8, 579.9, 792.1, V10.09
OGIB: Documented GI blood loss and anemia secondary to bleeding. Site not previously identified by upper GI endoscopy, colonoscopy, push enteroscopy or radiological procedureCrohn's: Suspected but undiagnosed Crohn's or when necessary to determine whether there is small bowel involvement** It is expected that this test will be performed only once during any episode of illness
Medicine: Wireless Capsule Imaging
Suspected or refractory malabsorptive syndromes (eg, Celiac disease)
Crohn's: Without evidence of disease on conventional diagnostic tests such as upper GI, EGD, or colonoscopy
Wireless Capsule Endoscopy
Hereditary GI polyposis syndromes including familial adenomatous polyposis and Peutz-Jeghers syndrome
Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
http://www.aetna.com/cpb/medical/data/500_599/0588.html
OGIB: Must have negative diagnostic work-up (e.g., upper GI, EGD, or colonoscopy)
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Occult GI bleedSuspected Angiodysplasias of the GI tractKnown Crohn's disease
Capsule Endoscopy
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS AR Suspected Crohn's disease UnlistedObscure GI bleedingIron deficiency anemia
http://www.arkansasbluecross.com/members/report.aspx?policyNumber=2002008
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
Crohn's: Without evidence of disease on conventional diagnostic tests such as SBFT, and/or upper and lower endoscopyOGIB: Not found on upper and lower GI endoscopic studies, although bleeding has been noted in the stool by direct observation or immunohistochemical testing
Iron deficiency anemia: Not diagnosed by upper and lower GI endoscopy, and bleeding has not been detected by direct observation from the colon or rectum, or by immunohistochemical testing, and yet the cause is of suspected small bowel originGI polyposis syndromes: Surveillance is allowed no more frequently than annually in patients in whom polyps are detected in the small bowel distal to the first portion of the duodenum, and no more frequently than biennially in patients in whom polyps are not detected
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
http://www.aetna.com/cpb/medical/data/500_599/0588.html
Wireless Capsule Endoscopy, Small Bowel
StudyHereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
ARKANSAS
Capsule Endoscopy Payer Guidelines - CPT 91110
Carrier: Pinnacle Business Solutions, Inc.
OGIB: Not previously identified by upper GI endoscopy, colonoscopy, push endoscopy or other radiologic procedure
280.9, 555.0-555.9, 578.1, 578.9, 792.1
http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=13429&ContrId=5&ver=12&ContrVer=1&CntrctrSelected=5*1&Cntrctr=5&name=Pinnacle+Business+Solutions%2c+Inc.+-+Arkansas+(00520%2c+Carrier)&LCntrctr=219*1%7c58*1%7c5*1%7c3*1&bc=AgACAAIAAAAA&
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS AZ Obscure gastrointestinal bleeding UnlistedSuspected Crohn's disease
https://secure.azblue.com/pdf/medpol/o272.pdf
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
HealthNet Obscure GI bleedSmall bowel neoplasmSuspected Crohn's disease
https://www.healthnet.com/static/general/unprotected/pdfs/national/policies/Wireless_Capsule_Endoscopy_Jul_11.pdf
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
http://www.aetna.com/cpb/medical/data/500_599/0588.html
OGIB: Iron deficiency anemia, postive fecal occult blood test, or visible bleeding with no source found on original endoscopy, hematocrit < 34, failure of previous diagnostics to diagnose source of GI bleeding and GI bleeding is thought to be in the small intestine
152.0-152.9, 197.4, 211.1, 230.7, 280.0, 280.9, 555.0-555.9, 558.1, 558.2, 558.9, 560.02, 560.03, 569.85, 569.86, 571.2, 571.5, 578.1, 578.9, 792.1
Small Bowel Neoplasm: Diagnosis not previously confirmed by upper GI, colonoscopy, push enteroscopy, nuclear imaging or radiological procedures. Patient must be symptomatic for neoplasm (e.g. GI bleeding)
OGIB: Bleeding of unknown origin that persists or recurs after a negative initial upperand lower endoscopy (may be visible or occult)Crohn's: Negative upper and lower endoscopy and documentation of ANY of the following: abdominal pain, persistent; bleeding; diarrhea; negative stool cultures; weight loss
Endoscopy by Video Capsule Hereditary GI polyposis syndromes including familial
adenomatous polyposis and Peutz-Jeghers syndrome
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
No published LCD for capsule endoscopy. Claims will be manually reviewed.
ARIZONA
Capsule Endoscopy Payer Guidelines - CPT 91110
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
MAC: Noridian Administrative Services
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
Wireless Capsule Endoscopy
Crohn's: Patient has diarrhea, GI bleeding, abdominal pain, weight loss, negative stool cultures and negative upper and lower endoscopy
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy
Payer / Policy Name
Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes
(listed in policy)
Medicare Part BMAC: Palmetto GBA
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsy
Capsule Endoscopy Celiac disease
Suspected Crohn's disease
Suspected small intestinal bleeding
Anthem Blue Cross Obscure GI bleeding
Suspected Crohn's disease
Diagnostic re-evaluation of Crohn's disease
Suspected small intestinal tumors
Lynch syndrome or polyposis syndromes
Refractory undiagnosed malabsorptive syndromes
Iron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
Cigna Obscure GI bleed
Capsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumor
Celiac disease
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
HealthNet Obscure GI bleed
Small bowel neoplasm
Suspected Crohn's disease
https://www.healthnet.com/static/general/unprotected/pdfs/national/policies/Wireless_Capsule_Endoscopy_Jul_11.pdf
United Healthcare GI blood loss and/or iron-deficiency anemia
Suspected or known Crohn's disease
Celiac disease
Suspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnostic
Small bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
CALIFORNIA
Capsule Endoscopy Payer Guidelines - CPT 91110
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever,
elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without
evidence of disease on conventional diagnostic tests, including SBFT, abdominal
CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a
bleeding source
No published LCD for capsule endoscopy. Claims will be manually reviewed.
Crohn's: Patient has diarrhea, GI bleeding, abdominal pain, weight loss, negative
stool cultures and negative upper and lower endoscopy.
http://www.aetna.com/cpb/medical/data/500_599/0588.html
Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of
the test
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-
US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Wireless Capsule
Endoscopy
Lynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-
Jeghers syndrome
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy
are negative for source of bleeding
152.0, 152.1, 152.2, 152.3,
152.8, 152.9, 209.00, 209.01,
209.02, 209.03, 211.2, 235.2,
280.0, 280.9, 555.0, 555.1,
555.2, 555.9, 558.1, 558.2,
558.3, 558.9, 562.02, 562.03,
569.85, 759.6, 578.0, 578.1,
578.9, 579.0, 792.1, V84.09
Wireless Capsule
Endoscopy
152.0-152.9, 211.2, 235.2,
280.0, 280.8, 280.9, 281.9,
285.9, 555.0-555.9, 558.9,
578.1-578.9, 579.0
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule
to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more
intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and
comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report
and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses,
claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Wireless Capsule
Endoscopy for
Esophageal and Small
Bowel Imaging and the
Patency Capsule
OGIB: Upper and lower endoscopy excluded a source of bleeding in the upper GI
tract or colon
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no
suspected or confirmed GI obstruction, stricture, or fistulae
OGIB: Iron deficiency anemia, postive fecal occult blood test, or visible bleeding
with no source found on original endoscopy, hematocrit < 34, failure of previous
diagnostics to diagnose source of GI bleeding and GI bleeding is thought to be in
the small intestine
Small Bowel Neoplasm: Diagnosis not previously confirmed by upper GI,
colonoscopy, push enteroscopy, nuclear imaging or radiological procedures. Patient
must be symptomatic for neoplasm (e.g. GI bleeding)
152.0-152.9, 197.4, 211.1,
230.7, 280.0, 280.9, 555.0-
555.9, 558.1, 558.2, 558.9,
560.02, 560.03, 569.85,
569.86, 571.2, 571.5, 578.1,
578.9, 792.1
http://www.anthem.com/ca/medicalpolicies/policies/mp_pw_a050543.htm
All diagnoses: Standard endoscopic and imaginag evaluations (i.e., upper and
lower endoscopy) are inconclusive
209.00-209.03, 209.40-
209.43, 211.2, 280.0, 280.9,
285.1, 288.8, 555.0-555.9,
558.1-558.9, 578.0-578.9,
579.0, 759.6, 780.60, 780.61,
783.21, 787.91, 789.00-
789.09, 790.1
Crohn's re-evaluation: Symptomatic after appropriate treatment has occurred and
there is no suspected or confirmed GI obstruction, stricture or fistulae
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g.
suspected celiac disease with prior negative biopsy)
Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with
urinalysis and examination of abdomen and pelvis) has excluded a source of
anemia from the GU region, upper GI tract and colon
152.0-152.9, 153.0-153.9,
154.0-154.1, 154.8, 209.00-
209.03, 211.2, 235.2, 280.0-
280.9, 555.0-555.9, 578.0-
578.9, 579.0-579.9, V12.72,
V71.1, V71.89
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Occult GI bleedingCeliac diseaseSuspected or known Crohn's diseaseColitis
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Anthem BCBS Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
http://www.anthem.com/medicalpolicies/policies/mp_pw_a050543.htm
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease with prior negative biopsy)Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Wireless Capsule Endoscopy
OGIB: Source of bleeding not previously identified by upper GI and colonoscopy and any of the following: push enteroscopy, nuclear imaging or radiological procedures; medical record must indicate if anemia is present
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
http://www.aetna.com/cpb/medical/data/500_599/0588.html
OGIB: After appropriate evalution (at minimum upper and lower endoscopy) has excluded a source of bleeding in the upper GI tract or colon
152.0-152.9, 153.0-153.9, 154.0-154.1, 154.8, 209.00-209.03, 211.2, 235.2, 280.0-280.9, 555.0-555.9, 578.0-578.9, 579.0-579.9, V12.72, V71.1, V71.89
Wireless Capsule Endoscopy for
Esophageal and Small Bowel Imaging and the
Patency Capsule
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulaeCrohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=26816&ContrId=157&ver=29&ContrVer=1&Date=04%2f15%2f2012&DocID=L26816&bc=iAAAAAgAAAAA&
COLORADO
Capsule Endoscopy Payer Guidelines - CPT 91110
014.80-014.86, 152.0-152.3, 152.8, 152.9, 197.4, 211.2, 230.7, 251.5, 280.9, 447.6, 537.83-537.84, 555.0-555.2, 555.9, 557.1, 558.1, 562.02-562.03, 569.85-569.86, 578.1, 579.0, 792.1
MAC: Trailblazer Health Enterprises, LLC
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Anthem BCBS Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
http://www.anthem.com/medicalpolicies/policies/mp_pw_a050543.htm
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
Oxford Health Plans GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac Disease: Prior serology or GI endoscopy are not diagnosticSmall Bowel Tumor: Imaging studies or GI endoscopy failed to confirm tumor
April 2012
CONNECTCUIT
Capsule Endoscopy Payer Guidelines - CPT 91110
No published LCD for capsule endoscopy. Claims will be manually reviewed.MAC: National Government Services
http://www.aetna.com/cpb/medical/data/500_599/0588.html
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopy
Wireless Capsule Endoscopy for
Esophageal and Small Bowel Imaging and the
Patency Capsule
Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease with prior negative biopsy)
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulae
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 578.0, 578.1, 578.9, 579.0, 759.6, 792.1, V84.09
Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel
Crohn's: Imaging studies and/or upper or lower GI endoscopic examination fail to reveal the location or extent of the pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
OGIB: After appropriate evalution (at minimum upper and lower endoscopy) has excluded a source of bleeding in the upper GI tract or colon
Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
GI blood loss/Iron-deficiency anemia: Other diagnostic methods (upper endoscopy and colonoscopy) failed to identify source of bleeding
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
Wireless Capsule Endoscopy
Crohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
https://www.oxhp.com/secure/policy/wireless_capsule_endoscopy_212.html
152.0-152.9, 153.0-153.9, 154.0-154.1, 154.8, 209.00-209.03, 211.2, 235.2, 280.0-280.9, 555.0-555.9, 578.0-578.9, 579.0-579.9, V12.72, V71.1, V71.89
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS DE Angiodysplasias of the GI tract
Suspected Crohn's diseaseOccult GI bleedingPeutz-Jeghers syndrome Suspected or refractory malabsorptive syndromesSuspected small bowel tumors
https://www.bcbsde.com/ProviderPolicies/public_site/7.01.76_Wireless_Capsule_Endoscopy.htm
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
Wireless Capsule Endoscopy
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location or extent of pathology, and treatment decisions would be affected by the results of the test
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Wireless Capsule Endoscopy (Enteral
Camera)
Hereditary GI polyposis syndromes including familial polyposis
All diagnoses: Conventional endoscopic and diagnostic imaging evaluations (e.g. upper GI endoscopy, colonoscopy, push enteroscopy, nuclear imaging, or radiological procedure) are inconclusive
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Lynch syndrome or inherited polyposis syndromes such as familial adenomatous polyposis and Peutz-Jeghers syndrome
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
DELAWARE
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: Novitas Solutions Inc.
No published LCD for capsule endoscopy. Claims will be manually reviewed.
http://www.aetna.com/cpb/medical/data/500_599/0588.html
152.0-152.9, 209.00-209.03, 211.2, 211.3, 280.0, 280.9, 285.1, 555.0-555.9, 562.02, 562.03, 569.85, 569.86, 578.0-578.9, 579.0-579.9, 759.6, 792.1
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Carefirst BCBS Obscure gastrointestinal bleeding Unlisted UnlistedSuspected Crohn's disease
http://notesnet.carefirst.com/ecommerce/medicalpolicy.nsf/vwwebtablex/cd17ab70a3b3f608852578d10055d47b?OpenDocument
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Wireless Capsule Endoscopy (Enteral
Camera)Hereditary GI polyposis syndromes including familial adenomatous polyposis and Peutz-Jeghers syndrome
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
DISTRICT OF COLUMBIA
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: Novitas Solutions Inc.
No published LCD for capsule endoscopy. Claims will be manually reviewed.
http://www.aetna.com/cpb/medical/data/500_599/0588.html
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel
Payer / Policy Name
Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes
(listed in policy)
Medicare Part B
Suspected Crohn's disease
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsy
Capsule Endoscopy Celiac disease
Suspected Crohn's disease
Suspected small intestinal bleeding
BCBS FL Suspected Crohn's disease
Obscure GI bleed
OGIB: Prior inconclusive upper and lower GI endoscopic studies
Cigna Obscure GI bleed
Capsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumor
Celiac disease
Humana Obscure GI bleed Unlisted
Capsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromes
Suspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemia
Suspected or known Crohn's disease
Celiac disease
Suspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnostic
Small bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
March 2012
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more
intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and
comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report
and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses,
claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
152.0, 152.1, 152.2, 152.3,
152.8, 152.9, 209.00, 209.01,
209.02, 209.03, 211.2, 235.2,
280.0, 280.9, 555.0, 555.1,
555.2, 555.9, 558.1, 558.2,
558.3, 558.9, 562.02, 562.03,
569.85, 759.6, 578.0, 578.1,
578.9, 579.0, 792.1, V84.09
http://www.aetna.com/cpb/medical/data/500_599/0588.html
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
152.0-152.9, 211.2, 235.2,
280.0, 280.8, 280.9, 281.9,
285.9, 555.0-555.9, 558.9,
578.1-578.9, 579.0
Hereditary GI polyposis syndromes, including familial
adenomatous polyposis and Peutz-Jeghers
syndromehttp://mcgs.bcbsfl.com/
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule
to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower
endoscopy) are inconclusive
MAC: First Coast Service
Options
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify
source of bleeding
Crohn's or Celiac disease: No evidence of disease found via standard diagnostic
tests such as SBFT
http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=29310&ContrId=197&ver=3&ContrVer=1&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=Florida&CptHcpcsCode=91110&bc=gAAAABAAAAAA&
Continuous blood loss and anemia secondary to
obscure bleeding of the small bowel
280.0, 280.9, 555.0, 555.2,
555.9, 562.02, 562.03, 569.85,
578.9
Wireless Capsule
Endoscopy
Blood Loss: Colonoscopy, endoscopy or radiographic exams failed to reveal a
source of bleeding, or interaoperative enteroscopy is being considered
Crohn's: No evidence provided by conventional diagnostic tests such as small
bowel follow-through (SBFT) and upper and lower endoscopy
Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of
the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-
Jeghers syndrome
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-
US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Wireless Capsule
Endoscopy
Crohn's: Without evidence on conventional diagnostic tests such as SBFT, and
upper and lower endoscopy
555.0, 555.2, 555.9, 562.02,
562.03, 569.85, 578.9
FLORIDA
Capsule Endoscopy Payer Guidelines - CPT 91110
209.00-209.03, 209.40-
209.43, 211.2, 280.0, 280.9,
285.1, 288.8, 555.0-555.9,
558.1-558.9, 578.0-578.9,
579.0, 759.6, 780.60, 780.61,
783.21, 787.91, 789.00-
789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever,
elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without
evidence of disease on conventional diagnostic tests, including SBFT, abdominal
CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
** Documented reason why patient is not a candidate for conventional endoscopy.
There must be specific co-morbidities and complicating medical conditions that lead
the performing provider of the conventional endoscopy to believe that the
risk/benefit ratio of a conventional endoscopy was not maintained. Medical record
must also support how capsule endoscopy would contribute to the patient’s care
Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a
bleeding source
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy
are negative for source of bleedingWireless Capsule
Endoscopy
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Obscure GI bleedCrohn's diseaseSuspected small intestinal tumors
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS GA Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
http://www.bcbsga.com/medicalpolicies/policies/mp_pw_a050543.htm
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
March 2012
GEORGIA
Capsule Endoscopy Payer Guidelines - CPT 91110
Suspected or refractory malabsorptive syndromes (eg, Celiac disease)
MAC: Cahaba Government Benefit
AdministratorsMedicine: Wireless Capsule Imaging ** It is expected that this test will be performed only once during any episode of
illness
152.0-152.9, 197.4, 211.2, 211.3, 230.7, 235.2, 259.2, 280.0, 280.9, 285.1, 555.0, 555.2, 555.9, 557.0-557.9, 558.1, 558.2, 558.41, 558.42, 558.9, 562.02-562.03, 569.84, 569.86, 578.1-578.9, 579.0, 579.1, 579.8, 579.9, 792.1, V10.09
OGIB: Documented GI blood loss and anemia secondary to bleeding. Site not previously identified by upper GI endoscopy, colonoscopy, push enteroscopy or radiological procedureCrohn's: Suspected but undiagnosed Crohn's or when necessary to determine whether there is small bowel involvement
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleeding
http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=30045&ContrId=216&ver=20&ContrVer=1&SearchType=Advanced&CoverageSelection=Local&ArticleType=Ed|Key|SAD|FAQ&PolicyType=Final&s=14&CntrctrType=9&CptHcpcsCode=91110&kq=true&bc=IAAAA
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
http://www.aetna.com/cpb/medical/data/500_599/0588.html
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
OGIB: After appropriate evaluation (at minimum upper and lower endoscopy) has excluded a source of bleeding in the upper GI tract or colon
152.0-152.9, 153.0-153.9, 154.0-154.1, 154.8, 209.00-209.03, 211.2, 235.2, 280.0-280.9, 555.0-555.9, 578.0-578.9, 579.0-579.9, V12.72, V71.1, V71.89
Wireless Capsule Endoscopy for
Esophageal and Small Bowel Imaging and the
Patency Capsule
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulaeCrohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease with prior negative biopsy)Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
Crohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Occult GI bleedingSuspected angiodysplasias
Capsule EndoscopySuspected or known Crohn's diseaseColitisSuspected small bowel neoplasm
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Wellmark BCBS Suspected Crohn's disease UnlistedCapsule Endoscopy Obscure GI bleed
OGIB: Prior inconclusive upper and lower GI endoscopic studies
http://www.wellmark.com/Provider/MedPoliciesAndAuthorizations/MedicalPolicies/policies/capsule_endoscopy.aspx
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
IOWA
Capsule Endoscopy Payer Guidelines - CPT 91110
OGIB: Anemic patient when site of bleeding is not previously identified by upper GI, colonoscopy, push endoscopy or other radiologic procedure, and EGD endoscopy and colonoscopy have been performed during same episode of illness; documented GI bleeding and anemia secondary to blood loss
152.0-152.9, 235.2, 280.0, 280.9, 537.82, 537.83, 555.0, 555.1, 555.2, 555.9, 558.9, 562.02, 562.03, 569.82, 569.84, 569.85, 578.1, 578.9, 579.0, 579.1, 579.9, 787.91, 792.1, 793.4
MAC: Wisconsin Physicians Service Continued GI blood loss and anemia secondary to
bleeding
Angiodysplasias: EGD and colonoscopy performed during same episode of illness
Blood Loss: EGD and colonoscopy have been performed during same episode of illnessCrohn's: Documented suspicion of diagnosis or procedure was necessary to determine small bowel involvement** Medical records must document the need for the test, contain reports of previous diagnostic procedures prior to capsule endoscopy but during the same episode of illness
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=30141&ContrId=147&ver=15&ContrVer=1&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=Iowa&CptHcpcsCode=91110&bc=gAAAABAAAAAA&
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Lynch syndrome or inherited polyposis syndromes such as familial adenomatous polyposis and Peutz-Jeghers syndrome
http://www.aetna.com/cpb/medical/data/500_599/0588.html
Crohn's: Without evidence of disease on one or more conventional diagnostic tests such as SBFT, upper endoscopy and lower endoscopy
Hereditary GI polyposis syndromes, including familiar adenomatous polyposis and Petz-Jeghers syndrome
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleeding
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Crohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the test
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Regence BCBS Obscure GI bleed OGIB: Prior inconclusive upper and lower GI endoscopic studies UnlistedSuspected Crohn's disease
http://blue.regence.com/trgmedpol/radiology/rad38.html
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Wireless Capsule Endoscopy as a
Diagnostic Technique inDisorders of the
Esophagus, Small Bowel, and Colon
Hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
Crohn's: Without evidence of disease on conventional diagnostic tests such as SBFT and upper and lower endoscopy
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
http://www.aetna.com/cpb/medical/data/500_599/0588.html
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
IDAHO
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: Noridian Administrative Services
No published LCD for capsule endoscopy. Claims will be manually reviewed.
Payer / Policy Name
Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes
(listed in policy)
Medicare Part B Occult GI bleeding
Suspected angiodysplasias
Capsule Endoscopy
Suspected or known Crohn's disease
Colitis
Suspected small bowel neoplasm
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsy
Capsule Endoscopy Celiac disease
Suspected Crohn's disease
Suspected small intestinal bleeding
http://www.aetna.com/cpb/medical/data/500_599/0588.html
BCBS IL Suspected Crohn's disease 211.2, 555.0-555.9, 759.6
Obscure GI bleeding
Cigna Obscure GI bleed
Suspected Crohn's disease
Suspected small bowel tumor
Celiac disease
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
Humana Obscure GI bleed Unlisted
Capsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromes
Suspected small intestinal tumors
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
United Healthcare GI blood loss and/or iron-deficiency anemia
Suspected or known Crohn's disease
Celiac disease
Suspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnostic
Small bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
March 2012
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower
endoscopy) are inconclusive
Capsule Endoscopy
OGIB: Cause undetected by standard diagnostic methods and evidenced by iron-
deficiency anemia not attributable to other etiology
OGIB: Anemic patient when site of bleeding is not previously identified by upper GI,
colonoscopy, push endoscopy or other radiologic procedure, and EGD endoscopy
and colonoscopy have been performed during same episode of illness; documented
GI bleeding and anemia secondary to blood loss
Crohn's: Documented suspicion of diagnosis or procedure was necessary to
determine small bowel involvement
Blood Loss: EGD and colonoscopy have been performed during same episode of
illness
Angiodysplasias: EGD and colonoscopy performed during same episode of illness
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule
to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more
intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and
comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report
and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses,
claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Carrier: Wisconsin
Physicians Service
152.0, 152.1, 152.2, 152.3,
152.8, 152.9, 209.00, 209.01,
209.02, 209.03, 211.2, 235.2,
280.0, 280.9, 555.0, 555.1,
555.2, 555.9, 558.1, 558.2,
558.3, 558.9, 562.02, 562.03,
569.85, 759.6, 578.0, 578.1,
578.9, 579.0, 792.1, V84.09
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy
are negative for source of bleeding
Crohn's: Negative for evidence of disease on conventional diagnostic tests, such
as endoscopy and SBFT
152.0-152.9, 211.2, 235.2,
280.0, 280.8, 280.9, 281.9,
285.9, 555.0-555.9, 558.9,
578.1-578.9, 579.0
http://medicalpolicy.hcsc.net/medicalpolicy/home?corpEntCd=IL1&path=/templatedata/medpolicies/POLICY/data/RADIOLOGY/RAD601.042_2011-09-15&ctype=POLICY&cat=Radiology#hlink
Wireless Capsule
Endoscopy (WCE) Hereditary GI polyposis syndromes, including familial
adenomatous polyposis and Peutz-Jegher's
syndrome
ILLINOIS
Endo Capsule Capsule Endoscopy Payer Guidelines - CPT 91110
209.00-209.03, 209.40-
209.43, 211.2, 280.0, 280.9,
285.1, 288.8, 555.0-555.9,
558.1-558.9, 578.0-578.9,
579.0, 759.6, 780.60, 780.61,
783.21, 787.91, 789.00-
789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever,
elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without
evidence of disease on conventional diagnostic tests, including SBFT, abdominal
CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a
bleeding source
** Medical records must document the need for the test, contain reports of previous
diagnostic procedures prior to capsule endoscopy but during the same episode of
illness
Continued GI blood loss and anemia secondary to
bleeding
152.0-152.9, 235.2, 280.0,
280.9, 537.82, 537.83, 555.0,
555.1, 555.2, 555.9, 558.9,
562.02, 562.03, 569.82,
569.84, 569.85, 578.1, 578.9,
579.0, 579.1, 579.9, 787.91,
792.1, 793.4
http://www.cms.gov/medicare-coverage-database/details/lcd-
details.aspx?LCDId=30141&ContrId=48&ver=15&ContrVer=1&SearchType=Advanced&CoverageSelection=Local&ArticleType=Ed%7cKey%7cSAD%7cFAQ&PolicyType=Final&s=19&KeyWord=capsule&KeyWordLookUp=Title&KeyWordSearchType=
Exact&kq=true&bc=IAAAABAAAAAA&
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Wireless Capsule
Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of
the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-
Jeghers syndrome
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-
US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify
source of bleeding
Crohn's or Celiac disease: No evidence of disease found via standard diagnostic
tests such as SBFT
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Anthem BCBS Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
http://www.anthem.com/medicalpolicies/policies/mp_pw_a050543.htm
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease with prior negative biopsy)
Crohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulae
Wireless Capsule Endoscopy for
Esophageal and Small Bowel Imaging and the
Patency Capsule
http://www.aetna.com/cpb/medical/data/500_599/0588.html
OGIB: After appropriate evaluation (at minimum upper and lower endoscopy) has excluded a source of bleeding in the upper GI tract or colon
152.0-152.9, 153.0-153.9, 154.0-154.1, 154.8, 209.00-209.03, 211.2, 235.2, 280.0-280.9, 555.0-555.9, 578.0-578.9, 579.0-579.9, V12.72, V71.1, V71.89
INDIANA
Capsule Endoscopy Payer Guidelines - CPT 91110
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Carrier: National Government Services
No published LCD for capsule endoscopy. Claims will be manually reviewed.
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Occult GI bleedingSuspected angiodysplasias
Capsule EndoscopySuspected or known Crohn's diseaseColitisSuspected small bowel neoplasm
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS KS Suspected Crohn's diseaseObscure GI bleeding
OGIB: Prior inconclusive upper and lower GI endoscopic studies
http://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/policies/policies/WirelessCapsuleEndoscopy_DT_Disorders_SmallBowel_Esophagus_Colon_2011-08-19.pdf
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
211.2, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 578.0, 578.1, 578.9, 759.6, 780.60, 783.21, 787.91, 789.00, 789.01, 789.02, 789.03, 789.04, 789.05, 789.06, 789.07, 789.09
152.0-152.9, 235.2, 280.0, 280.9, 537.82, 537.83, 555.0, 555.1, 555.2, 555.9, 558.9, 562.02, 562.03, 569.82, 569.84, 569.85, 578.1, 578.9, 579.0, 579.1, 579.9, 787.91, 792.1, 793.4
http://www.aetna.com/cpb/medical/data/500_599/0588.html
Crohn's: Without evidence of disease on conventional diagnostic tests such as SBFT, and upper and lower endoscopyWireless Capsule
Endoscopy as a Diagnostic Technique in Disorders of the Small
Bowel, Esophagus, and Colon
Hereditary GI polyposis syndromes, including familial adenomatous polposis and Peutz-Jeghers syndrome
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostics tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
KANSAS
Capsule Endoscopy Payer Guidelines - CPT 91110
http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=30141&ContrId=148&ver=15&ContrVer=1&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=Kansas&KeyWord=capsule&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAAAAA&
MAC: Wisconsin Physicians Service Continued GI blood loss and anemia secondary to
bleeding
OGIB: Anemic patient when site of bleeding is not previously identified by upper GI, colonoscopy, push endoscopy or other radiologic procedure, and EGD endoscopy and colonoscopy have been performed during same episode of illness; documented GI bleeding and anemia secondary to blood loss
Angiodysplasias: EGD and colonoscopy performed during same episode of illness
Blood Loss: EGD and colonoscopy have been performed during same episode of illnessCrohn's: Documented suspicion of diagnosis or procedure was necessary to determine small bowel involvement** Medical records must document the need for the test, contain reports of previous diagnostic procedures prior to capsule endoscopy but during the same episode of illness
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B GI bleedingSmall bowel neoplasmCrohn's disease
Endoscopy by Capsule
Evaluation prior to surgery
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Anthem BCBS Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
http://www.anthem.com/medicalpolicies/policies/mp_pw_a050543.htm
Bluegrass Family Health Obscure GI bleedCrohn's diseaseSuspected small bowel tumor
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopy
Other conditions: Suspected to originate in the small intestinal mucosa. Prior negative or non-diagnostic evaluations of the stomach, duodenum/small intestine, and colon by flexible endoscopy, and complementary radiologic procedures and/or microbiologic studies must be documented
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease with prior negative biopsy)
Crohn's: Following inconclusive SBFT and upper and lower endoscopy [EGD] and colonoscopy
http://www.aetna.com/cpb/medical/data/500_599/0588.html
OGIB: After appropriate evalution (at minimum upper and lower endoscopy) has excluded a source of bleeding in the upper GI tract or colon
152.0-152.9, 153.0-153.9, 154.0-154.1, 154.8, 209.00-209.03, 211.2, 235.2, 280.0-280.9, 555.0-555.9, 578.0-578.9, 579.0-579.9, V12.72, V71.1, V71.89
Wireless Capsule Endoscopy for
Esophageal and Small Bowel Imaging and the
Patency Capsule
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulaeCrohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
KENTUCKY
Capsule Endoscopy Payer Guidelines - CPT 91110
GI bleed: Site of bleeding not previously identified by any of the following: upper GI endoscopy, colonoscopy, push enteroscopy, nuclear imaging, or radiological procedures. Documented continuing GI blood loss or anemia secondary to bleeding or iron deficiency anemia
MAC: CGS Administrators, LLC
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=31838&ContrId=228&ver=11&ContrVer=2&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=Kentucky&CptHcpcsCode=91110&Date=04%2f15%2f2012&bc=gAAAABAAAAAA&
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 197.4, 209.00, 209.01, 209.02, 209.03, 209.40, 209.41, 209.42, 209.43, 211.2, 211.3, 230.7, 235.2, 280.0, 457.1, 555.0, 555.1, 555.2, 555.9, 558.41, 558.42, 558.9, 560.0, 560.9, 562.02, 562.03, 564.1, 569.82, 569.84, 569.85, 569.86, 578.0, 578.1, 578.9, 579.8, 759.6, 787.91, 789.01, 789.02, 789.03, 789.04, 789.05, 789.06, 789.07, 789.09, 792.1, 793.4, V45.89
Surgery: Coverage limited to patients who are contemplated for surgical resection of the small bowel to control recurrent bleeding or protein loss is reasonable
Other conditions (malabsorption syndrome, chronic diarrhea, or protein-losing enteropathy) Small bowel neoplasm: Diagnosis not previously confirmed by other studies (e.g.,
upper GI endoscopy, colonoscopy, push enteroscopy, nuclear imaging, or radiological procedures). Patient must be symptomatic for neoplasm (e.g., GI bleeding) or have a documented polyposis syndrome associated with small bowel neoplasia or there is other history suggesting presence of small bowel neoplasia and other diagnostic testing to assess these symptoms (i.e., upper GI endoscopy and/or colonoscopy) must have been performedCrohn's: Condition not been previously confirmed or when a diagnosis of colitis of an indeterminate type affecting the colon is known, and a more specific diagnosis is sought by evaluating for small bowel involvement
Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
Crohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
OGIB: When there is iron deficiency anemia, a positive fecal occult blood test, or visible bleeding
152.0-152.9, 211.2, 235.2, 555.0-555.9, 578.0-578.9, 579.0-579.9, V12.72, V71.1, V71.89
Video Capsule Endoscopy
http://www.healthcare-resolutions.com/DocMgt/ClientView/viewdocs/DocDisplay.aspx?T=20120406130354
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleeding
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part BMAC: NHIC, Corp
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS MA Obscure GI bleed OGIB: Upper GI endoscopy and colonoscopy failed to reveal source of bleedingSmall bowel neoplasmCrohn's disease
https://www.bluecrossma.com/common/en_US/medical_policies/185_Wireless_Capsule_Endoscopy_as_a_Diagnostic_Technique_in_Disorders_of_the_Small_Bowel,_Esophagus,_and_Colon_prn.pdf
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
No published LCD for capsule endoscopy. Claims will be manually reviewed.
MASSACHUSETTS
Capsule Endoscopy Payer Guidelines - CPT 91110
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
http://www.aetna.com/cpb/medical/data/500_599/0588.html
Wireless Capsule Endoscopy as a
Diagnostic Technique in Disorders of the Small
Bowel, Esophagus, and Colon
152.0-152.9, 197.4, 211.2, 230.7, 280.0, 555.0, 560.9, 562.02, 562.03, 569.85, 569.86, 578.1, 578.9, 787.91, 789.00-789.09, 792.1
Neoplasm: Upper GI endoscopy, colonoscopy, push enteroscopy, nuclear imaging or radiological procedures have failed to identify a tumorCrohn's: Complete lower GI studies have failed to reveal the source of the patient's symptoms
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleeding
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Carefirst BCBS Obscure gastrointestinal bleeding Unlisted UnlistedSuspected Crohn's disease
http://notesnet.carefirst.com/ecommerce/medicalpolicy.nsf/vwwebtablex/cd17ab70a3b3f608852578d10055d47b?OpenDocument
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
http://www.aetna.com/cpb/medical/data/500_599/0588.html
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
Hereditary GI polyposis syndromes including familial adenomatous polyposis and Peutz-Jeghers syndrome
Wireless Capsule Endoscopy (Enteral
Camera)
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
MARYLAND
Capsule Endoscopy Payer Guidelines - CPT 91110
No published LCD for capsule endoscopy. Claims will be manually reviewed.
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
MAC: Novitas Solutions Inc
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part BMAC: NHIC, Corp
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Anthem BCBS Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
http://www.anthem.com/medicalpolicies/policies/mp_pw_a050543.htm
Harvard Pilgrim Obscure GI bleed UnlistedSuspected or known Crohn's diseaseIron deficiency anemia
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
280.0, 280.1, 280.8, 280.9, 280.9, 555.0, 555.1, 555.2, 555.9, 555.9, 578.0, 578.1, 578.9
Reimbursement for Wireless Capsule
Endoscopy
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
No published LCD for capsule endoscopy. Claims will be manually reviewed.
http://www.aetna.com/cpb/medical/data/500_599/0588.html
OGIB: After appropriate evaluation (at minimum upper and lower endoscopy) has excluded a source of bleeding in the upper GI tract or colon
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
https://www.harvardpilgrim.org/portal/page?_pageid=253,280120&_dad=portal&_schema=PORTAL
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
152.0-152.9, 153.0-153.9, 154.0-154.1, 154.8, 209.00-209.03, 211.2, 235.2, 280.0-280.9, 555.0-555.9, 578.0-578.9, 579.0-579.9, V12.72, V71.1, V71.89
Wireless Capsule Endoscopy for
Esophageal and Small Bowel Imaging and the
Patency Capsule
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulaeCrohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease with prior negative biopsy)
MAINE
Capsule Endoscopy Payer Guidelines - CPT 91110
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Occult GI bleedSuspected angiodysplasias of the GI tractAnemia secondary to bleeding
Capsule Endoscopy Crohn's diseaseColitis
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS MI Suspected Crohn's disease UnlistedObscure GI bleed
Angiodysplasia of intestine with hemorrhage
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
Priority Health Occult GI bleedCapsule Endoscopy Crohn's disease
Known Crohn's: When necessary to determine small bowel involvement
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
March 2012
Suspected small bowel neoplasm, regional enteritis, or malabsorption syndrome
MICHIGAN
Endo Capsule Capsule Endoscopy Payer Guidelines - CPT 91110
Carrier: Wisconsin Physicians Service
OGIB: Site of bleeding not previously identified by upper GI endoscopy, colonoscopy, push endoscopy or other radiologic procedure, and EGD endoscopy and colonoscopy were performed during same episode of illness in anemic patientAngiodysplasias: EGD endoscopy and colonoscopy have been performed during same episode of illnessAnemia: Documented continuing GI blood loss, anemia secondary to bleeding, and EGD and colonoscopy were performed during same episode of illness
152.0-152.9, 235.2, 280.0, 280.9, 537.82, 537.83, 555.0, 555.1, 555.2, 555.9, 558.9, 562.02, 562.03, 569.82, 569.84, 569.85, 578.1, 578.9, 579.0, 579.1, 579.9, 787.91, 792.1, 793.4
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://www.aetna.com/cpb/medical/data/500_599/0588.html
http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=30141&ContrId=49&ver=15&ContrVer=1&SearchType=Advanced&CoverageSelection=Local&ArticleType=Ed|Key|SAD|FAQ&PolicyType=Final&s=27&CptHcpcsCode=91110&kq=true&bc=IAAAABAAAAAA&
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel
http://www.bcbsm.com/mprApp/MedicalPolicyDocument?fileId=2040202
Wireless Capsule Endoscopy as a
Diagnostic Technique in Disorders of the Small
Bowel, Esophagus, and Colon
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Colitis: colitis of an indeterminate type, affecting the colon, is known and a more specific diagnosis is sought by evaluating possible small bowel involvement
http://www.priorityhealth.com/provider/manual/auths/~/media/documents/medical-policies/91476.ashx
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
OGIB: Documented continuing GI blood loss and anemia secondary to bleeding. Siteof bleeding not identified by upper GI endoscopy, colonoscopy within the same episode of illness
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleedingWireless Capsule
Endoscopy
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
Crohns: Suspected Crohn's disease or when diagnosis is known but it is necessary to determine whether there is involvement of the small bowel
Lynch syndrome or inherited polyposis syndromes such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location or extent of pathology, and treatment decisions would be affected by the results of the test
152.0-152.9, 235.2, 280.0, 280.9, 285.9, 537.82, 537.83, 555.0, 555.1, 555.2, 555.9, 558.9, 562.02, 562.03, 569.82, 569.84, 569.85, 578.1, 578.9, 579.0, 792.1, 793.4
Surveillance of small bowel in patients with hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome
Crohn's: No evidence of disease on conventional diagnostic tests such as SBFT and upper and lower endoscopyOGIB: Suspected to be of small bowel origin, as evidenced by prior inconclusive upper and lower GI endoscopic studies
Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Suspected Crohn's: Upper GI endoscopy, colonoscopy and either push enteroscopy or small bowel radiologic study within the same period of illness which failed to reveal a focus of disease
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Occult GI bleedingSuspected angiodysplasias
Capsule EndoscopySuspected or known Crohn's diseaseColitisSuspected small bowel neoplasm
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS MN Obscure GI bleed OGIB: Evaluation by upper and lower endoscopies has been inconclusive UnlistedSuspected Crohn's disease Crohn's: Conventional diagnostic tests have been inconclusive
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
Continued GI blood loss and anemia secondary to bleeding
Angiodysplasias: EGD and colonoscopy performed during same episode of illness
Blood Loss: EGD and colonoscopy have been performed during same episode of illness
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
http://notes.bluecrossmn.com/web/medpolman.nsf/8178b1c14b1e9b6b8525624f0062fe9f/cb15528d4acadcca86256bc200499aa6/$FILE/Wireless%20Capsule%20Endoscopy.pdf
http://www.aetna.com/cpb/medical/data/500_599/0588.html
Wireless Capsule Endoscopy Hereditary GI polyposis syndromes including familial
adenomatous polyposis and Peutz-Jeghers syndrome
MINNESOTA
Capsule Endoscopy Payer Guidelines - CPT 91110
OGIB: Anemic patient when site of bleeding is not previously identified by upper GI, colonoscopy, push endoscopy or other radiologic procedure, and EGD endoscopy and colonoscopy have been performed during same episode of illness; documented GI bleeding and anemia secondary to blood loss
152.0-152.9, 235.2, 280.0, 280.9, 537.82, 537.83, 555.0, 555.1, 555.2, 555.9, 558.9, 562.02, 562.03, 569.82, 569.84, 569.85, 578.1, 578.9, 579.0, 579.1, 579.9, 787.91, 792.1, 793.4
Carrier: Wisconsin Physicians Service
Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=30141&ContrId=50&ver=15&ContrVer=1&Date=&DocID=L30141&SearchType=Advanced&bc=KAAAAAgAAAAA&
Crohn's: Documented suspicion of diagnosis or procedure was necessary to determine small bowel involvement** Medical records must document the need for the test, contain reports of previous diagnostic procedures prior to capsule endoscopy but during the same episode of illness
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopy
Payer / Policy Name Link to
Policy Coverage Pre-requisites Covered ICD-9 CodesMedicare Part B Occult GI bleeding
Suspected angiodysplasias
Capsule EndoscopySuspected or known Crohn's diseaseColitisSuspected small bowel neoplasm
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Anthem BCBS Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
http://www.anthem.com/medicalpolicies/policies/mp_pw_a050543.htm
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
** Medical records must document the need for the test, contain reports of previous diagnostic procedures prior to capsule endoscopy but during the same episode of illness
MAC: Wisconsin Physicians Service
http://www.aetna.com/cpb/medical/data/500_599/0588.html
http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=30141&ContrId=149&ver=15&ContrVer=1&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=Missouri+-+Entire+State&CptHcpcsCode=91110&bc=gAAAABAAAAAA&
Continued GI blood loss and anemia secondary to bleeding
152.0-152.9, 235.2, 280.0, 280.9, 537.82, 537.83, 555.0, 555.1, 555.2, 555.9, 558.9, 562.02, 562.03, 569.82, 569.84, 569.85, 578.1, 578.9, 579.0, 579.1, 579.9, 787.91, 792.1, 793.4
OGIB: Anemic patient when site of bleeding is not previously identified by upper GI, colonoscopy, push endoscopy or other radiologic procedure, and EGD endoscopy and colonoscopy have been performed during same episode of illness; documented GI bleeding and anemia secondary to blood loss
Angiodysplasias: EGD and colonoscopy performed during same episode of illness
Crohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulae
MISSOURI
Capsule Endoscopy Payer Guidelines - CPT 91110
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Blood Loss: EGD and colonoscopy have been performed during same episode of illnessCrohn's: Documented suspicion of diagnosis or procedure was necessary to determine small bowel involvement
Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
Wireless Capsule Endoscopy for
Esophageal and Small Bowel Imaging and the
Patency Capsule
OGIB: After appropriate evaluation (at minimum upper and lower endoscopy) has excluded a source of bleeding in the upper GI tract or colon
152.0-152.9, 153.0-153.9, 154.0-154.1, 154.8, 209.00-209.03, 211.2, 235.2, 280.0-280.9, 555.0-555.9, 578.0-578.9, 579.0-579.9, V12.72, V71.1, V71.89
Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease with prior negative biopsy)
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Obscure GI bleedCrohn's diseaseSuspected small intestinal tumors
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS MS Suspected Crohn's diseaseObscure GI bleeding
OGIB: Prior inconclusive upper and lower gastrointestinal endoscopic studies
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
209.40, 209.41, 209.42, 209.43, 211.2, 280.0, 280.8, 280.8, 280.9, 555.0, 555.1, 555.2, 555.9, 578.0, 578.1, 578.9, 759.6
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
Suspected or refractory malabsorptive syndromes (eg, Celiac disease)
OGIB: Documented GI blood loss and anemia secondary to bleeding. Site not previously identified by upper GI endoscopy, colonoscopy, push enteroscopy or radiological procedureCrohn's: Suspected but undiagnosed Crohn's or when necessary to determine whether there is small bowel involvement** It is expected that this test will be performed only once during any episode of illness
http://www.bcbsms.com/index.php?q=provider-medical-policy-search.html&action=viewPolicy&path=policy%2Femed%2FWireless+Capsule+Endoscopy+as+a+Diagnositc+Technique+in+Disorders+of+the+Small+Bowel+Esophagus.html&keywords=capsule
http://www.aetna.com/cpb/medical/data/500_599/0588.html
Crohn's: Without evidence of disease on conventional diagnostic tests such as SBFT and upper and lower endoscopyWireless Capsule
Endoscopy for Esophageal and Small Bowel Imaging and the
Patency Capsule
Hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
MISSISSIPPI
Capsule Endoscopy Payer Guidelines - CPT 91110
152.0-152.9, 197.4, 211.2, 211.3, 230.7, 235.2, 259.2, 280.0, 280.9, 285.1, 555.0, 555.2, 555.9, 557.0-557.9, 558.1, 558.2, 558.41, 558.42, 558.9, 562.02-562.03, 569.84, 569.86, 578.1-578.9, 579.0, 579.1, 579.8, 579.9, 792.1, V10.09
http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=30626&ContrId=10&ver=9&ContrVer=1&CntrctrSelected=10*1&Cntrctr=10&name=Cahaba+Government+Benefit+Administrators%24*%24sup*%24*%u00ae%24*%24%2fsup*%24*%2c+LLC+(00512%2c+Carrier)&s=31&bc=AggAAAIAAAAA&
Carrier: Cahaba Government Benefit
AdministratorsMedicine: Wireless
Capsule Imaging
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS MT Suspected Crohn's disease UnlistedObscure GI bleeding
OGIB: Prior inconclusive upper and lower GI endoscopic studies
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
MONTANA
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: Noridian Administrative Services
No published LCD for capsule endoscopy. Claims will be manually reviewed.
https://www.bcbsmt.com/MedReview/Policies/WirelessCapsuleEndoscopySmallBowel/v101.aspx
http://www.aetna.com/cpb/medical/data/500_599/0588.html
Crohn's: Without evidence of disease on conventional diagnostic tests such as SBFT, and upper and lower endoscopyWireless Capsule
Endoscopy as a Diagnostic Technique in Disorders of the Small
Bowel, Esophagus, and Colon
Hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Obscure GI bleedSmall bowel neoplasm or Regional enteritis
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS NC Undiagnosed obscure gastrointestinal bleeding UnlistedCrohn's disease
http://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/capsule_endoscopy_wireless.pdf
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
March 2012
OGIB: Significant GI bleed demonstrated by acute drop in hemoglobin/hematocrit, unexplained recurrent or persistent iron deficiency anemia, persistently positive fecal occult blood test or visible bleeding with no bleeding source found at original endoscopy. Failure of upper and lower GI endoscopy to diagnose source of bleeding
Hereditary GI polyposis syndromes including familial adenomatous polyposis and Peutz-Jeghers syndrome
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleeding
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopy
NORTH CAROLINA
Capsule Endoscopy Payer Guidelines - CPT 91110
152.0-152.9, 211.2, 230.7, 235.2, 280.0, 280.9, 285.1, 537.82, 537.83, 537.84, 555.0, 555.2, 557.0-557.9, 558.1, 558.2, 562.02, 562.03, 569.82, 569.84, 569.85, 569.86, 578.1, 578.9, 579.8, 579.9, 759.6, 787.91, 792.1, 793.4
MAC: Palmetto Government Benefit
Administrators
OGIB: Anemia secondary to suspected occult blood loss, the origin of which is suspected to be in the small intestinal mucosa, based on documented negative or non-diagnostic prior evaluation of the stomach, duodenum (EGD) and colon (colonoscopy) by conventional instrumental endoscopy
http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=31800&ContrId=233&ver=11&ContrVer=1&SearchType=Advanced&CoverageSelection=Local&ArticleType=Ed|Key|SAD|FAQ&PolicyType=Final&s=34&CntrctrType=9&CptHcpcsCode=91110&kq=true&bc=IAAAABAAAAAA&
Wireless Capsule Endoscopy
Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Lynch syndrome or inherited polyposis syndromes such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Crohn's: Persistent abdominal pain greater than 4 weeks, persistent diarrhea, unintentional weight loss, negative stool cultures and negative upper and lower endoscopy studies
http://www.aetna.com/cpb/medical/data/500_599/0588.html
Capsule Endoscopy, Wireless
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
Crohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the test
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS ND Obscure GI bleeding UnlistedSuspected Crohn's diseaseKnown Crohn's disease
https://bb.thor.org/Bulletins/Blue_Cross_Blue_Shield_ND_Medical_Policy/Wireless_Capsule_Endoscopy.htm
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
NORTH DAKOTA
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: Noridian Administrative Services
No published LCD for capsule endoscopy. Claims will be manually reviewed.
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
Hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome or Lynch syndrome
OGIB: Prior inconclusive upper and lower GI endoscopic studies must be documented
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
http://www.aetna.com/cpb/medical/data/500_599/0588.html
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Wireless Capsule Endoscopy
Monitoring and surveillance of small bowel mucosal healing for response to treatment
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Occult GI bleedingSuspected angiodysplasias
Capsule EndoscopySuspected or known Crohn's diseaseColitisSuspected small bowel neoplasm
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS NE Obscure GI bleeding UnlistedSuspected Crohn's disease
https://www.nebraskablue.com/~/media/pdf/Provider/Policy%20Procedure%20Manuals/MedicalPolicies.pdf
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=30141&ContrId=151&ver=15&ContrVer=1&SearchType=Advanced&CoverageSelection=Local&ArticleType=Ed%7cKey%7cSAD%7cFAQ&PolicyType=Final&s=36&KeyWord=capsule+endoscopy&KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=IAAAABAAAAAA&
Wireless Capsule Endoscopy and GI
Monitoring Systems
OGIB: Must have recurrent or persistent iron-deficiency anemia; positive fecal occult blood test; or visible bleeding with no bleeding source found at original endoscopy
Crohn's: Without evidence of disease on conventional diagnostic tests such as SBFT, and upper and lower endoscopy
Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Crohn's: Documented suspicion of diagnosis or procedure was necessary to determine small bowel involvement** Medical records must document the need for the test, contain reports of previous diagnostic procedures prior to capsule endoscopy but during the same episode of illness
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
http://www.aetna.com/cpb/medical/data/500_599/0588.html
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopy
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
Wireless Capsule Endoscopy
NEBRASKA
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: Wisconsin Physicians Service Continued GI blood loss and anemia secondary to
bleeding
OGIB: Anemic patient when site of bleeding is not previously identified by upper GI, colonoscopy, push endoscopy or other radiologic procedure, and EGD endoscopy and colonoscopy have been performed during same episode of illness; documented GI bleeding and anemia secondary to blood loss
152.0-152.9, 235.2, 280.0, 280.9, 537.82, 537.83, 555.0, 555.1, 555.2, 555.9, 558.9, 562.02, 562.03, 569.82, 569.84, 569.85, 578.1, 578.9, 579.0, 579.1, 579.9, 787.91, 792.1, 793.4
Angiodysplasias: EGD and colonoscopy performed during same episode of illness
Blood Loss: EGD and colonoscopy have been performed during same episode of illness
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part BMAC: NHIC, Corp
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Anthem BCBS Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
http://www.anthem.com/medicalpolicies/policies/mp_pw_a050543.htm
Harvard Pilgrim Obscure GI bleed UnlistedSuspected or known Crohn's diseaseIron deficiency anemia
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy
https://www.harvardpilgrim.org/portal/page?_pageid=253,280120&_dad=portal&_schema=PORTAL
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
NEW HAMPSHIRE
Capsule Endoscopy Payer Guidelines - CPT 91110
OGIB: After appropriate evaluation (at minimum upper and lower endoscopy) has excluded a source of bleeding in the upper GI tract or colon
152.0-152.9, 153.0-153.9, 154.0-154.1, 154.8, 209.00-209.03, 211.2, 235.2, 280.0-280.9, 555.0-555.9, 578.0-578.9, 579.0-579.9, V12.72, V71.1, V71.89
Wireless Capsule Endoscopy for
Esophageal and Small Bowel Imaging and the
Patency Capsule
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulaeCrohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
http://www.aetna.com/cpb/medical/data/500_599/0588.html
No published LCD for capsule endoscopy. Claims will be manually reviewed.
Reimbursement for Wireless Capsule
Endoscopy
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease with prior negative biopsy)Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
280.0, 280.1, 280.8, 280.9, 280.9, 555.0, 555.1, 555.2, 555.9, 555.9, 578.0, 578.1, 578.9
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
http://www.aetna.com/cpb/medical/data/500_599/0588.html
Horizon BCBS Obscure GI bleed OGIB: Prior inconclusive upper AND lower gastrointestinal endoscopic studies UnlistedSuspected Crohn's disease
https://services3.horizon-bcbsnj.com/hcm/MedPol2.nsf
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
Oxford Health Plans GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac Disease: Prior serology or GI endoscopy are not diagnosticSmall Bowel Tumor: Imaging studies or GI endoscopy failed to confirm tumor
https://www.oxhp.com/secure/policy/wireless_capsule_endoscopy_212.html
April 2012
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
GI blood loss/Iron-deficiency anemia: Other diagnostic methods (upper endoscopy and colonoscopy) failed to identify source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 578.0, 578.1, 578.9, 579.0, 759.6, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopic examination fail to
reveal the location or extent of the pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
No published LCD for capsule endoscopy. Claims will be manually reviewed.
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
Hereditary GI polyposis syndromes including familial adenomatous polyposis and Peutz-Jeghers syndrome
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
NEW JERSEY
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: Novitas Solutions Inc.
Wireless Capsule Endoscopy as a
Diagnostic Technique in Disorders of the Small
Bowel and Colon
Crohn's: Without evidence of disease on conventional diagnostic tests such as SBFT and upper and lower endoscopy
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopy
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Occult GI bleedingCeliac diseaseSuspected or known Crohn's diseaseColitis
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS NM Suspected Crohn's disease 211.2, 555.0-555.9, 759.6Obscure GI bleed
http://medicalpolicy.hcsc.net/medicalpolicy/home?corpEntCd=NM1&path=/templatedata/medpolicies/POLICY/data/RADIOLOGY/RAD601.042_2011-09-15&ctype=POLICY&cat=Radiology#hlink
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Wireless Capsule Endoscopy (WCE)
Hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome
OGIB: Cause has been undetected by standard diagnostic methods (i.e. colonoscopy and upper gastric endoscopy), AND that is evidenced by recurrent or persistent iron deficiency anemia, positive fecal occult blood test, or visible bleeding
http://www.aetna.com/cpb/medical/data/500_599/0588.html
Crohn's: Without evidence of disease on conventional diagnostic tests, such as endoscopy and SBFT
NEW MEXICO
Capsule Endoscopy Payer Guidelines - CPT 91110
http://cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=26816&ContrId=158&ver=29&ContrVer=1&SearchType=Advanced&CoverageSelection=Local&ArticleType=Ed%7cKey%7cSAD%7cFAQ&PolicyType=Final&s=39&KeyWord=capsule+endoscopy&KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=IAAAABAAAAAA&
MAC: Trailblazer Health Enterprises, LLCWireless Capsule
Endoscopy
OGIB: Source of bleeding not previously identified by upper GI and colonoscopy and any of the following: push enteroscopy, nuclear imaging or radiological procedures; medical record must indicate if anemia is present
014.80-014.86, 152.0-152.3, 152.8, 152.9, 197.4, 211.2, 230.7, 251.5, 280.9, 447.6, 537.83-537.84, 555.0-555.2, 555.9, 557.1, 558.1, 562.02-562.03, 569.85-569.86, 578.1, 579.0, 792.1
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part BMAC: Palmetto GBA
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Anthem BCBS Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
http://www.anthem.com/medicalpolicies/policies/mp_pw_a050543.htm
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease with prior negative biopsy)Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
OGIB: After appropriate evalution (at minimum upper and lower endoscopy) has excluded a source of bleeding in the upper GI tract or colon
152.0-152.9, 153.0-153.9, 154.0-154.1, 154.8, 209.00-209.03, 211.2, 235.2, 280.0-280.9, 555.0-555.9, 578.0-578.9, 579.0-579.9, V12.72, V71.1, V71.89
Wireless Capsule Endoscopy for
Esophageal and Small Bowel Imaging and the
Patency Capsule
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulaeCrohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
NEVADA
Capsule Endoscopy Payer Guidelines - CPT 91110
No published LCD for capsule endoscopy. Claims will be manually reviewed.
http://www.aetna.com/cpb/medical/data/500_599/0588.html
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Payer / Policy Name
Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes
(listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsy
Capsule Endoscopy Celiac disease
Suspected Crohn's disease
Suspected small intestinal bleeding
http://www.aetna.com/cpb/medical/data/500_599/0588.html
Emblem (HIP/GHI) Occult GI bleeding Unlisted
Iron deficiency anemia with confirmed blood loss
Suspected or known Crohn's disease Iron Deficiency Anemia: Documented anemia secondary to blood loss
Colitis
Small bowel neoplasm
Infammatory bowel disease
Colitis: Documented that test is necessary to evaluate small bowel involvement
Arteriovenous malformations of lymphangiectasia
Inflammatory Bowel: Presence of abdominal pain, occult or overt GI bleeding,
http://www.emblemhealth.com/pdf/med_guidelines/radio/MG_Wireless_Capsule_Endoscopy_b.pdf
Empire BCBS Obscure GI bleed
Crohn's disease
Diagnostic re-evaluation of Crohn's disease
Suspected small intestinal tumors
Lynch syndrome or polyposis syndromes
Refractory undiagnosed malabsorptive syndromes
Iron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
http://www.empireblue.com/medicalpolicies/policies/mp_pw_a050543.htm
Excellus BCBS Obscure GI bleed Unlisted
Suspected Crohn’s disease
https://www.excellusbcbs.com/wps/wcm/connect/9a1f84804e8eb72092f9bfe420b83c88/mp+wireless_endo+tac+11.pdf?MOD=AJPERES
Oxford Health Plans GI blood loss and/or iron-deficiency anemia
Suspected or known Crohn's disease
Celiac disease
Suspected small bowel tumor
Celiac Disease: Prior serology or GI endoscopy are not diagnostic
Small Bowel Tumor: Imaging studies or GI endoscopy failed to confirm tumorhttps://www.oxhp.com/secure/policy/wireless_capsule_endoscopy_212.html
March 2012
Capsule Endoscopy
(Camera Pill)
152.0, 152.1, 152.2, 152.3,
152.8, 152.9, 209.00, 209.01,
209.02, 209.03, 211.2, 235.2,
280.0, 280.9, 555.0, 555.1,
555.2, 555.9, 558.1, 558.2,
558.3, 558.9, 562.02, 562.03,
569.85, 578.0, 578.1, 578.9,
579.0, 759.6, 792.1, V84.09
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule
to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Crohn's: Prior radiological study to exclude stricture, which did not demonstrate the
presence of Crohn's disease. Abdominal pain, occult or overt GI bleeding, diarrhea
and weight loss must all be present
Small Bowel Neoplasm: Diagnosis not previously confirmed by other studies.
Abdominal pain, occult or overt GI bleeding, diarrhea and weight loss must all be
present; or documented associated polyposis syndrome; or other history suggesting
the presence of small bowel neoplasia and have undergone prior diagnostic testing
to assess these symptoms
Evaluation of malabsorptions syndrome or protein-
losing enteropathy of obscure origin
Malabsorptions Syndrome: Diarrhea with greasy voluminous foul smelling stool,
and weight loss despite adequate food intake or anorexia, flatulence and abdominal
distention
Lymphangiectasia: For surgical resection of the small bowel to control recurrent
bleeding or protein loss is reasonable
OGIB: After appropriate evaluation (at minimum upper and lower endoscopy) has
excluded a source of bleeding in the upper GI tract or colon
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more
intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and
comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report
and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses,
claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
No published LCD for capsule endoscopy. Claims will be manually reviewed.
Wireless Capsule
Endoscopy
Wireless Capsule
Endoscopy for the
Examination of the GI
Tract
Wireless Capsule
Endoscopy for
Esophageal and Small
Bowel Imaging and the
Patency Capsule
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no
suspected or confirmed GI obstruction, stricture, or fistulae
Lynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-
Jeghers syndrome
GI blood loss/Iron-deficiency anemia: Other diagnostic methods (upper
endoscopy and colonoscopy) failed to identify source of bleeding
Crohn's: Imaging studies and/or upper or lower GI endoscopic examination fail to
reveal the location or extent of the pathology, and treatment decisions would be
affected by the results of the test
OGIB: Documented presence of GI bleeding and negative upper and lower
endoscopies performed during current episode of illness
NEW YORK
Endo Capsule Capsule Endoscopy Payer Guidelines - CPT 91110
209.00-209.03, 209.40-
209.43, 211.2, 280.0, 280.9,
285.1, 288.8, 555.0-555.9,
558.1-558.9, 578.0-578.9,
579.0, 759.6, 780.60, 780.61,
783.21, 787.91, 789.00-
789.09, 790.1
Peutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever,
elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without
evidence of disease on conventional diagnostic tests, including SBFT, abdominal
CT scan/CT enterography and upper and lower endoscopy
Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a
bleeding source
MAC: National
Government Services
**Procedure should be performed under the supervision of a gastroenterologist or
general surgeon with expertise in this technology
Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with
urinalysis and examination of abdomen and pelvis has excluded a source of anemia
from the GU region, upper GI tract and colon
OGIB: Conventional diagnostic work-up (colonoscopy, upper endoscopy, and in
some situations, a small bowel series) that has not revealed source of bleeding
Crohn's: Conventional diagnostic work-up failed to reveal lesions consistent with
disease and there remains strong clinical suspicion of CD (fever, weight loss,
anemia, elevated WBC, and/or elevated sedimentation rate)
Hereditary GI polyposis syndromes such as familial
adenomatosis polyposis (FAP) or Peutz-Jeghers
syndrome
152.0-152.9, 153.0-153.9,
154.0-154.1, 154.8, 209.00-
209.03, 211.2, 235.2, 280.0-
280.9, 555.0-555.9, 578.0-
578.9, 579.0-579.9, V12.72,
V71.1, V71.89
Crohn's re-evaluation: Symptomatic after appropriate treatment has occurred and
there is no suspected or confirmed GI obstruction, stricture or fistulae
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g.
suspected celiac disease with prior negative biospy)
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B GI bleedingSmall bowel neoplasmCrohn's disease
Endoscopy by Capsule
Evaluation prior to surgery
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Anthem BCBS Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
http://www.anthem.com/medicalpolicies/policies/mp_pw_a050543.htm
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Medical Mutual of Ohio Suspected occult blood loss UnlistedIron deficiency anemiaSmall bowel neoplasm or regional enteritis (Crohn's)Refractory undiagnosed malabsorptive syndromes
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
March 2012
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease)All diagnoses: At least one of the following clinical conditions present: Malignant neoplasm of small intestine, including duodenum; Secondary malignant neoplasm of small intestine, including duodenum; Malignant carcinoid tumor of small intestine, unspecific portion; Malignant carcinoid tumor of the duodenum; Malignant carcinoid tumor of the jejunum; Malignant carcinoid tumor of the ileum; Benign carcinoid tumor of the small intestine, unspecified portion; Benign carcinoid tumor of the duodenum; Benign carcinoid tumor of the jejunum; Benign carcinoid tumor of the ileum; Benign neoplasm of duodenum, jejunum, and ileum; Benign neoplasm of colon; Carcinoma in situ of other and unspecified parts of intestine; Neoplasm of uncertain behavior of stomach, intestines, and rectum; Iron deficiency anemias secondary to blood loss (chronic); Iron deficiency anemia, unspecified; Acute posthemorrhagic anemia; Other lymphedema; Regional enteritis of large intestine; Other specified disorders of stomach and duodenum; Regional enteritis of small intestine; Regional enteritis of small intestine with largeintestine; Vascular insufficiency of intestine; Gastroenteritis and colitis due to radiation; Toxic gastroenteritis and colitis; Other and unspecified noninfectious gastroenteritis and colitis; Intussusception; Unspecified intestinal obstruction; Diverticula of small intestine; Irritable bowel syndrome; Other specified disorders of intestine; GI hemorrhage; Other specified intestinal malabsorption; Unspecified intestinal malabsorption; Other hamartoses, not elsewhere classified; Diarrhea; Abdominal pain; Nonspecific abnormal findings in stool contents; Nonspecific abnormal findings in radiological and other examinations of GI tract
Other conditions (malabsorption syndrome, chronic diarrhea, or protein-losing enteropathy)
http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=29310&ContrId=197&ver=3&ContrVer=1&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=Florida&CptHcpcsCode=91110&bc=gAAAABAAAAAA&
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
OHIO
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: CGS Administrators, LLC
GI bleed: Site of bleeding not previously identified by any of the following: upper GI endoscopy, colonoscopy, push enteroscopy, nuclear imaging, or radiological procedures. Documented continuing GI blood loss or anemia secondary to bleeding or iron deficiency anemia
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 197.4, 209.00, 209.01, 209.02, 209.03, 209.40, 209.41, 209.42, 209.43, 211.2, 211.3, 230.7, 235.2, 280.0, 457.1, 555.0, 555.1, 555.2, 555.9, 558.41, 558.42, 558.9, 560.0, 560.9, 562.02, 562.03, 564.1, 569.82, 569.84, 569.85, 569.86, 578.0, 578.1, 578.9, 579.8, 759.6, 787.91, 789.01, 789.02, 789.03, 789.04, 789.05, 789.06, 789.07, 789.09, 792.1, 793.4, V45.89
Small bowel neoplasm: Diagnosis not previously confirmed by other studies (e.g., upper GI endoscopy, colonoscopy, push enteroscopy, nuclear imaging, or radiological procedures). Patient must be symptomatic for neoplasm (e.g., GI bleeding) or have a documented polyposis syndrome associated with small bowel neoplasia or there is other history suggesting presence of small bowel neoplasia and other diagnostic testing to assess these symptoms (i.e., upper GI endoscopy and/or colonoscopy) must have been performed.Crohn's: Condition not been previously confirmed or when a diagnosis of colitis of an indeterminate type affecting the colon is known, and a more specific diagnosis is sought by evaluating for small bowel involvementOther conditions: Suspected to originate in the small intestinal mucosa. Prior negative or non-diagnostic evaluations of the stomach, duodenum/small intestine, and colon by flexible endoscopy, and complementary radiologic procedures and/or microbiologic studies must be documented.
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
http://www.aetna.com/cpb/medical/data/500_599/0588.html
OGIB: After appropriate evaluation (at minimum upper and lower endoscopy) has excluded a source of bleeding in the upper GI tract or colon
152.0-152.9, 153.0-153.9, 154.0-154.1, 154.8, 209.00-209.03, 211.2, 235.2, 280.0-280.9, 555.0-555.9, 578.0-578.9, 579.0-579.9, V12.72, V71.1, V71.89
Wireless Capsule Endoscopy for
Esophageal and Small Bowel Imaging and the
Patency Capsule
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulaeCrohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease with prior negative biopsy)Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location or
extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Surgery: Coverage limited to patients who are contemplated for surgical resection of the small bowel to control recurrent bleeding or protein loss is reasonable
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
https://provider.medmutual.com/TOOLS_and_RESOURCES/Care_Management/MedPolicies/PDF/200214.pdf#xml=http://dmzsearch.antaressolutions.com/texis/search/pdfhi.txt?query=capsule+endoscopy&pr=MedPolicies&prox=page&rorder=500&rprox=500&rdfreq=500&rwfreq=500&rlead=500&rdepth=0&sufs=0&order=r&cq=&id=4ede59f67
Wireless Capsule Endoscopy - Esophagus
through Ileum
Blood loss: GI blood loss or anemia where small bowel is suspected bleeding source and investigation of the stomach, duodenum and colon were unremarkable or non-diagnostic by EGD or colonoscopyIron deficiency anemia: Unexplained by other factors (e.g., menstrual history, blood donation history)Small bowel neoplasm/Crohn's: Primary evaluation demonstrates signs and symptoms
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Occult GI bleedingCeliac diseaseSuspected or known Crohn's diseaseColitis
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS OK Suspected Crohn's disease 211.2, 555.0-555.9, 759.6Obscure GI bleed
http://medicalpolicy.hcsc.net/medicalpolicy/home?ctype=POLICY&cat=Radiology&path=/templatedata/medpolicies/POLICY/data/RADIOLOGY/RAD601.042_2011-09-15#hlink
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
OKLAHOMA
Capsule Endoscopy Payer Guidelines - CPT 91110
014.80-014.86, 152.0-152.3, 152.8, 152.9, 197.4, 211.2, 230.7, 251.5, 280.9, 447.6, 537.83-537.84, 555.0-555.2, 555.9, 557.1, 558.1, 562.02-562.03, 569.85-569.86, 578.1, 579.0, 792.1
MAC: Trailblazer Health Enterprises, LLCWireless Capsule
Endoscopy
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=26816&ContrId=159&ver=29&ContrVer=1&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=Oklahoma&CptHcpcsCode=91110&Date=04%2f15%2f2012&bc=gAAAABAAAAAA&
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
OGIB: Source of bleeding not previously identified by upper GI and colonoscopy and any of the following: push enteroscopy, nuclear imaging or radiological procedures; medical record must indicate if anemia is present
Crohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
http://www.aetna.com/cpb/medical/data/500_599/0588.html
Wireless Capsule Endoscopy (WCE)
Hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome
Crohn's: Without evidence of disease on conventional diagnostic tests, such as endoscopy and SBFT
OGIB: Cause has been undetected by standard diagnostic methods (i.e. colonoscopy and upper gastric endoscopy), AND that is evidenced by recurrent or persistent iron deficiency anemia, positive fecal occult blood test, or visible bleeding
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleeding
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Regence BCBS Obscure GI bleed OGIB: Prior inconclusive upper and lower GI endoscopic studies UnlistedSuspected Crohn's disease
http://blue.regence.com/trgmedpol/radiology/rad38.html
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
http://www.aetna.com/cpb/medical/data/500_599/0588.html
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
OREGON
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: Noridian Administrative Services
No published LCD for capsule endoscopy. Claims will be manually reviewed.
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Wireless Capsule Endoscopy as a
Diagnostic Technique inDisorders of the
Esophagus, Small Bowel, and Colon
Hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome
Crohn's: Without evidence of disease on conventional diagnostic tests such as SBFT and upper and lower endoscopy
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
Payer / Policy Name
Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes
(listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsy
Capsule Endoscopy Celiac disease
Suspected Crohn's disease
Suspected small intestinal bleeding
http://www.aetna.com/cpb/medical/data/500_599/0588.html
Cigna Obscure GI bleed
Capsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumor
Celiac disease
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
Highmark BCBS Angiodysplasias of the GI tract
Suspected Crohn's disease
Occult GI bleed
Peutz-Jeghers syndrome
Celiac Disease: Negative biopsy
Suspected small bowel turmorshttps://secure.highmark.com/ldap/medicalpolicy/wpa-highmark/G-41-015.html
Occult/Obscure GI bleeding
Small bowel neoplasm
Crohn's disease
Evaluation prior to surgery
http://medpolicy.ibx.com/policies/mpi.nsf/88c0c50066c9d059852574d300564913/126c59e615c110a085257837004df09c!OpenDocument
United Healthcare GI blood loss and/or iron-deficiency anemia
Suspected or known Crohn's disease
Celiac disease
Suspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnostic
Small bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
March 2012
Suspected or refractory malabsorptive syndromes
(Celiac disease)
All diagnoses: Inconclusive conventional endoscopy and diagnostic imaging
evaluations (upper GI endoscopy, colonoscopy, push enteroscopy, nuclear imaging,
or radiological procedure)
Independence Blue
Cross Wireless Capsule
Endoscopy (WCE) using
the Given® Diagnostic
Imaging and PillCam™
Capsule Systems
Small bowel neoplasm: Diagnosis previously unconfirmed by upper GI endoscopy,
push enteroscopy, nuclear imaging or radiological procedures. Must be symptomatic
for neoplasm (GI bleeding), documented hereditary polyposis syndrome associated
with small bowel neoplasia, or have other history suggesting presence of small
bowel neoplasia. Other diagnostic testing to assess these symptoms (upper GI
endoscopy and/or colonoscopy) have have been performed
Other conditions (Suspected or refractory
malabsorption syndromes (eg, Celiac disease),
chronic diarrhea, or protein-losing enteropathy)
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule
to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more
intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and
comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report
and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses,
claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower
endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2,
280.0, 280.8, 280.9, 281.9,
285.9, 555.0-555.9, 558.9,
578.1-578.9, 579.0
Wireless Capsule
Endoscopy
152.0-152.9, 209.00-209.03,
211.2, 211.3, 280.0, 280.9,
285.1, 555.0-555.9, 562.02,
562.03, 569.85, 569.86, 578.0-
578.9, 579.0-579.9, 759.6,
792.1
Hereditary GI polyposis syndromes including familial
polyposis
Crohn's: Suspected but unconfirmed, without evidence of disease on conventional
diagnostic test, such as SBFT and upper and lower endoscopy
Surgery: Limited to individuals who are being considered for surgical resection of
the small bowel to control recurrent bleeding or protein loss is appropriate
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-
US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
152.0, 152.1, 152.2, 152.3,
152.8, 152.9, 197.4, 209.00,
209.01, 209.02, 209.03,
209.40, 209.41, 209.42,
209.43, 211.2, 211.3, 230.7,
235.2, 280.0, 280.9, 538,
555.0, 555.1, 555.2, 555.9,
558.9, 560.89, 560.9, 562.02,
562.03, 564.1, 569.82, 569.84,
569.85, 569.86, 569.9, 571.2,
571.5, 571.6, 572.3, 578.0,
578.1, 578.9, 579.8, 579.9,
759.6, 787.91, 789.00, 789.01,
789.02, 789.03, 789.04,
789.05, 789.06, 789.07,
789.09, 792.1, 793.4
OGIB: Recurrent or persistent iron-defiency anemia suspected of being of small
bowel origin, as evidence by prior inconclusive upper and lower endoscopic studies
OGIB: Iron deficiency anemia or acute posthemorrhagic anemia, the site of which
has not been previously identified; positive fecal occult blood test or visible bleeding
with no bleeding source found at original endoscopy
152.0, 152.1, 152.2, 152.3,
152.8, 152.9, 209.00, 209.01,
209.02, 209.03, 211.2, 235.2,
280.0, 280.9, 555.0, 555.1,
555.2, 555.9, 558.1, 558.2,
558.3, 558.9, 562.02, 562.03,
569.85, 759.6, 578.0, 578.1,
578.9, 579.0, 792.1, V84.09
Other conditions: Suspected to originate in the small intestinal mucosa. Prior
negative or non-diagnostic evaluations of the stomach, duodenum/small intestine,
and colon by flexible endoscopy and complementary radiologic procedures and/or
microbiologic studies must be documented
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy
are negative for source of bleedingWireless Capsule
Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of
the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-
Jeghers syndrome
209.00-209.03, 209.40-
209.43, 211.2, 280.0, 280.9,
285.1, 288.8, 555.0-555.9,
558.1-558.9, 578.0-578.9,
579.0, 759.6, 780.60, 780.61,
783.21, 787.91, 789.00-
789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever,
elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without
evidence of disease on conventional diagnostic tests, including SBFT, abdominal
CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a
bleeding source
PENNSYLVANIA
Endo Capsule Capsule Endoscopy Payer Guidelines - CPT 91110
No published LCD for capsule endoscopy. Claims will be manually reviewed.MAC: Novitas Solutions
Inc
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Suspected Crohn's disease
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
Triple S Salud
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=29409&ContrId=198&ver=2&ContrVer=1&DocID=L29409&bc=gAAAAAgAAAAA&
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
No published medical policy for capsule endscopy. Claims will be manually reviewed.
http://www.aetna.com/cpb/medical/data/500_599/0588.html
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
PUERTO RICO
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: First Coast Service Options
Wireless Capsule Endoscopy
Continuous blood loss and anemia secondary to obscure bleeding of the small bowel
Blood Loss: Colonoscopy, endoscopy or radiographic exams failed to reveal a source of bleeding, or interaoperative enteroscopy is being consideredCrohn's: No evidence provided by conventional diagnostic tests such as small bowel follow-through (SBFT) and upper and lower endoscopy** Documented reason why patient is not a candidate for conventional endoscopy. There must be specific co-morbidities and complicating medical conditions that lead the performing provider of the conventional endoscopy to believe that the risk/benefit ratio of a conventional endoscopy was not maintained. Medical record must also support how capsule endoscopy would contribute to the patient’s care
280.0, 280.9, 555.0, 555.2, 555.9, 562.02, 562.03, 569.85, 578.9
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part BMAC: NHIC, Corp
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS RI Obscure GI bleeding UnlistedSuspected Crohn's disease
https://www.bcbsri.com/BCBSRIWeb/pdf/medical_policies/WirelessCapsuleEndoscopy.pdf
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
Neighborhood Health Occult GI bleeding and anemia UnlistedCapsule Endoscopy Suspected Angiodysplasia of the GI tract
Suspected Crohn's diseaseKnown Crohn's diseaseColitisSmall bowel neoplasmRegional enteritisMalabsorption syndromeCeliac disease
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
http://www.aetna.com/cpb/medical/data/500_599/0588.html
OGIB: Upper and lower GI endoscopies (EGD and colonoscopy) that have failed to identify a bleeding sourceWireless Capsule
Endoscopy-PREAUTH Hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
http://www.nhpri.org/matriarch/documents/CMP-011.02%20Capsule%20Endoscopy.7-11.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleeding
Crohn's: Without evidence of disease on conventional diagnostic tests, including upper and lower endoscopy (EGD, colonoscopy), and small-bowel evaluation such as upper GI with SBFT or MR enterography or CT enterography
Crohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
OGIB: Upper endoscopy and colonoscopy, or push endoscopy or other radiologic procedures, and EGD endoscopy and colonoscopy have been performed during the same episode of illnessAngiodysplasia: EGD endoscopy and colonoscopy have been performed during the same episode of illness
RHODE ISLAND
Capsule Endoscopy Payer Guidelines - CPT 91110
No published LCD for capsule endoscopy. Claims will be manually reviewed.
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Obscure GI bleedMAC: Palmetto GBA Small bowel neoplasm or Regional enteritis
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS SC Suspected Crohn's disease UnlistedObscure GI bleed
OGIB: Prior inconclusive upper and lower gastrointestinal endoscopic studies
http://www.cam-policies.com/internet/cmpd/cmp/mdclplcy.nsf/DispContent/7CA11E51C222C4018525717100479185?opendocument
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location or extent of pathology, and treatment decisions would be affected by the results of the test
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
Wireless Capsule Endoscopy
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Lynch syndrome or inherited polyposis syndromes such as familial adenomatous polyposis and Peutz-Jeghers syndrome
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
Crohn's: Without evidence of disease on conventional diagnostic tests such as SBFT, and upper and lower endoscopyWireless Capsule
Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus and
Colon
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=31800&ContrId=234&ver=11&ContrVer=1&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=South+Carolina&CptHcpcsCode=91110&Date=04%2f15%2f2012&bc=gAAAABAAAAAA&
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome
SOUTH CAROLINA
Capsule Endoscopy Payer Guidelines - CPT 91110
OGIB: Anemia secondary to suspected occult blood loss, the origin of which is suspected to be in the small intestinal mucosa, based on documented negative or non-diagnostic prior evaluation of the stomach, duodenum (EGD) and colon (colonoscopy) by conventional instrumental endoscopy
152.0-152.9, 211.2, 230.7, 235.2, 280.0, 280.9, 285.1, 537.82, 537.83, 537.84, 555.0, 555.2, 557.0-557.9, 558.1, 558.2, 562.02, 562.03, 569.82, 569.84, 569.85, 569.86, 578.1, 578.9, 579.8, 579.9, 759.6, 787.91, 792.1, 793.4
Wireless Capsule Endoscopy
http://www.aetna.com/cpb/medical/data/500_599/0588.html
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Wellmark BCBS Suspected Crohn's disease UnlistedCapsule Endoscopy Obscure GI bleed
OGIB: Prior inconclusive upper and lower GI endoscopic studies
ttp://www.wellmark.com/Provider/MedPoliciesAndAuthorizations/MedicalPolicies/policies/capsule_endoscopy.aspx
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
Hereditary GI polyposis syndromes, including familiar adenomatous polyposis and Petz-Jeghers syndrome
http://www.aetna.com/cpb/medical/data/500_599/0588.html
Crohn's: Without evidence of disease on one or more conventional diagnostic tests such as SBFT, upper endoscopy and lower endoscopy
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
SOUTH DAKOTA
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: Noridian Administrative Services
No published LCD for capsule endoscopy. Claims will be manually reviewed.
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Obscure GI bleedCrohn's diseaseSuspected small intestinal tumors
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS TN Obscure GI bleed UnlistedSuspected Crohn's disease
http://www.bcbst.com/mpmanual/!SSL!/WebHelp/Ingestible_Video_Capsule_Imaging_of_the_Gastrointestinal_Tract.htm
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
http://www.aetna.com/cpb/medical/data/500_599/0588.html
Hereditary GI polyposis syndromes including familial adenomatous polyposis and Peutz-Jeghers syndrome
Ingestible Video Capsule Imaging of the
Gastrointestinal Tract
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
OGIB: Positive fecal occult blood tests, visible bleeding, or recurrent or persistent iron-deficient anemia despite treatment AND inconclusive results from two or more standard accepted diagnostic tests Crohn's: Inconclusive results from two or more standard accepted diagnostic tests
TENNESSEE
Capsule Endoscopy Payer Guidelines - CPT 91110
152.0-152.9, 197.4, 211.2, 211.3, 230.7, 235.2, 259.2, 280.0, 280.9, 285.1, 555.0, 555.2, 555.9, 557.0-557.9, 558.1, 558.2, 558.41, 558.42, 558.9, 562.02-562.03, 569.84, 569.86, 578.1-578.9, 579.0, 579.1, 579.8, 579.9, 792.1, V10.09
MAC: Cahaba Government Benefit
Administrators Suspected or refractory malabsorptive syndromes (eg, Celiac disease)
OGIB: Documented GI blood loss and anemia secondary to bleeding. Site not previously identified by upper GI endoscopy, colonoscopy, push enteroscopy or radiological procedureCrohn's: Suspected but undiagnosed Crohn's or when necessary to determine whether there is small bowel involvement** It is expected that this test will be performed only once during any episode of illness
Medicine:Wireless Capsule Endoscopy
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=30045&ContrId=218&ver=20&ContrVer=1&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=Tennessee&CptHcpcsCode=91110&bc=gAAAABAAAAAA&
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
Payer / Policy Name
Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes
(listed in policy)
Medicare Part B Occult GI bleeding
Celiac disease
Suspected or known Crohn's disease
Colitis
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsy
Capsule Endoscopy Celiac disease
Suspected Crohn's disease
Suspected small intestinal bleeding
http://www.aetna.com/cpb/medical/data/500_599/0588.html
BCBS TX Crohn's disease 211.2, 555.0-555.9, 759.6
Obscure GI bleeding
Cigna Obscure GI bleed
Capsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumor
Celiac disease
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
Humana Obscure GI bleed Unlisted
Capsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromes
Suspected small intestinal tumors
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
United Healthcare GI blood loss and/or iron-deficiency anemia
Suspected or known Crohn's disease
Celiac disease
Suspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnostic
Small bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
March 2012
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule
to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more
intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and
comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report
and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses,
claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
152.0, 152.1, 152.2, 152.3,
152.8, 152.9, 209.00, 209.01,
209.02, 209.03, 211.2, 235.2,
280.0, 280.9, 555.0, 555.1,
555.2, 555.9, 558.1, 558.2,
558.3, 558.9, 562.02, 562.03,
569.85, 759.6, 578.0, 578.1,
578.9, 579.0, 792.1, V84.09
TEXAS
Capsule Endoscopy Payer Guidelines - CPT 91110
Wireless Capsule
Endoscopy (WCE)
209.00-209.03, 209.40-
209.43, 211.2, 280.0, 280.9,
285.1, 288.8, 555.0-555.9,
558.1-558.9, 578.0-578.9,
579.0, 759.6, 780.60, 780.61,
783.21, 787.91, 789.00-
789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever,
elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without
evidence of disease on conventional diagnostic tests, including SBFT, abdominal
CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a
bleeding source
Crohn's or Celiac disease: No evidence of disease found via standard diagnostic
tests such as SBFT
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy
are negative for source of bleeding
MAC: Trailblazer Health
Enterprises, LLC
OGIB: Source of bleeding not previously identified by upper GI and colonoscopy
and any of the following: push enteroscopy, nuclear imaging or radiological
procedures; medical record must indicate if anemia is present
http://medicalpolicy.hcsc.net/medicalpolicy/home?corpEntCd=TX1&path=/templatedata/medpolicies/POLICY/data/RADIOLOGY/RAD601.042_2011-09-15&ctype=POLICY&cat=Radiology#hlink
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower
endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2,
280.0, 280.8, 280.9, 281.9,
285.9, 555.0-555.9, 558.9,
578.1-578.9, 579.0
014.80-014.86, 152.0-152.3,
152.8, 152.9, 197.4, 211.2,
230.7, 251.5, 280.9, 447.6,
537.83-537.84, 555.0-555.2,
555.9, 557.1, 558.1, 562.02-
562.03, 569.85-569.86, 578.1,
579.0, 792.1
Wireless Capsule
Endoscopy
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
http://www.cms.gov/medicare-coverage-database/details/lcd-
details.aspx?LCDId=26816&ContrId=160&ver=29&ContrVer=1&SearchType=Advanced&CoverageSelection=Local&PolicyType=Final&s=51&CntrctrType=9&CptHcpcsCode=91110&kq=true&bc=IAAAABAAAAAA&
Hereditary GI polyposis syndromes, including familial
adenomatous polyposis and Peutz-Jeghers
syndrome
Crohn's: Negative for evidence of disease on conventional diagnostic tests, such
as endoscopy and SBFT
OGIB: Cause undetected by standard diagnostic methods and evidenced by iron-
deficiency anemia not attributable to other etiology
Wireless Capsule
Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of
the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-
Jeghers syndrome
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-
US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify
source of bleeding
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Regence BCBS Obscure GI bleed OGIB: Prior inconclusive upper and lower GI endoscopic studies UnlistedSuspected Crohn's disease
http://blue.regence.com/trgmedpol/radiology/rad38.html
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
http://www.aetna.com/cpb/medical/data/500_599/0588.html
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
Wireless Capsule Endoscopy as a
Diagnostic Technique inDisorders of the
Esophagus, Small Bowel, and Colon
Hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome
Crohn's: Without evidence of disease on conventional diagnostic tests such as SBFT and upper and lower endoscopy
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
UTAH
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: Noridian Administrative Services
No published LCD for capsule endoscopy. Claims will be manually reviewed.
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Obscure GI bleedSmall bowel neoplasm or regional enteritis
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Anthem BCBS Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
http://www.anthem.com/medicalpolicies/policies/mp_pw_a050543.htm
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=31800&ContrId=229&ver=11&ContrVer=1&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=Virginia&KeyWord=capsule+endoscopy&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAAAAA
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulaeCrohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopy
http://www.aetna.com/cpb/medical/data/500_599/0588.html
OGIB: After appropriate evaluation (at minimum upper and lower endoscopy) has excluded a source of bleeding in the upper GI tract or colon
152.0-152.9, 153.0-153.9, 154.0-154.1, 154.8, 209.00-209.03, 211.2, 235.2, 280.0-280.9, 555.0-555.9, 578.0-578.9, 579.0-579.9, V12.72, V71.1, V71.89
Wireless Capsule Endoscopy for
Esophageal and Small Bowel Imaging and the
Patency Capsule
VIRGINIA
Capsule Endoscopy Payer Guidelines - CPT 91110
OGIB: Anemia secondary to suspected occult blood loss, the origin of which is suspected to be in the small intestinal mucosa, based on documented negative or non-diagnostic prior evaluation of the stomach, duodenum (EGD) and colon (colonoscopy) by conventional instrumental endoscopy
152.0-152.9, 211.2, 230.7, 235.2, 280.0, 280.9, 285.1, 537.82, 537.83, 537.84, 555.0, 555.2, 557.0-557.9, 558.1, 558.2, 562.02, 562.03, 569.82, 569.84, 569.85, 569.86, 578.1, 578.9, 579.8, 579.9, 759.6, 787.91, 792.1, 793.4
MAC: Palmetto Government Benefit
AdministratorsWireless Capsule
Endoscopy
Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease with prior negative biopsy)
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
Crohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleeding
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part BMAC: NHIC, Corp
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS VT Suspected Crohn's disease UnlistedObscure GI bleeding
OGIB: Prior inconclusive upper and lower GI endoscopic studies
http://www.bcbsvt.com/export/sites/BCBSVT/provider/medicalpolicies/PDFs/Capsule_Endoscopy.pdf
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Crohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the test
Hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
Lynch syndrome or inherited polyposis syndromes such as familial adenomatous polyposis and Peutz-Jeghers syndrome
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleeding
http://www.aetna.com/cpb/medical/data/500_599/0588.html
Crohn's: Without evidence of disease on conventional diagnostic tests such as SBFT, and upper and lower endoscopyWireless Capsule
Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel and Esophagus
VERMONT
Capsule Endoscopy Payer Guidelines - CPT 91110
No published LCD for capsule endoscopy. Claims will be manually reviewed.
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Occult GI bleedingSuspected angiodysplasias
Capsule EndoscopySuspected or known Crohn's diseaseColitisSuspected small bowel neoplasm
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Anthem BCBS Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
http://www.anthem.com/medicalpolicies/policies/mp_pw_a050543.htm
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
WISCONSIN
Capsule Endoscopy Payer Guidelines - CPT 91110
http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=30141&ContrId=47&ver=15&ContrVer=1&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=Wisconsin&CptHcpcsCode=91110&bc=gAAAABAAAAAA&
OGIB: Anemic patient when site of bleeding is not previously identified by upper GI, colonoscopy, push endoscopy or other radiologic procedure, and EGD endoscopy and colonoscopy have been performed during same episode of illness; documented GI bleeding and anemia secondary to blood loss
Angiodysplasias: EGD and colonoscopy performed during same episode of illness
Blood Loss: EGD and colonoscopy have been performed during same episode of illnessCrohn's: Documented suspicion of diagnosis or procedure was necessary to determine small bowel involvement
Carrier: Wisconsin Physicians Service Continued GI blood loss and anemia secondary to
bleeding
152.0-152.9, 235.2, 280.0, 280.9, 537.82, 537.83, 555.0, 555.1, 555.2, 555.9, 558.9, 562.02, 562.03, 569.82, 569.84, 569.85, 578.1, 578.9, 579.0, 579.1, 579.9, 787.91, 792.1, 793.4
** Medical records must document the need for the test, contain reports of previous diagnostic procedures prior to capsule endoscopy but during the same episode of illness
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopy
http://www.aetna.com/cpb/medical/data/500_599/0588.html
Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease with prior negative biopsy)Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
OGIB: After appropriate evaluation (at minimum upper and lower endoscopy) has excluded a source of bleeding in the upper GI tract or colon
152.0-152.9, 153.0-153.9, 154.0-154.1, 154.8, 209.00-209.03, 211.2, 235.2, 280.0-280.9, 555.0-555.9, 578.0-578.9, 579.0-579.9, V12.72, V71.1, V71.89
Wireless Capsule Endoscopy for
Esophageal and Small Bowel Imaging and the
Patency Capsule
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulaeCrohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Obscure GI bleedSmall bowel neoplasm or regional enteritis
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Highmark BCBS Angiodysplasias of the GI tract
Suspected Crohn's diseaseOccult GI bleedPeutz-Jeghers syndrome
Celiac Disease: Negative biopsy
Suspected small bowel turmors
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
http://www.aetna.com/cpb/medical/data/500_599/0588.html
Hereditary GI polyposis syndromes including familial polyposis
Suspected or refractory malabsorptive syndromes (Celiac disease)
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
All diagnoses: Inconclusive conventional endoscopy and diagnostic imaging evaluations (upper GI endoscopy, colonoscopy, push enteroscopy, nuclear imaging, or radiological procedure)OGIB: Iron deficiency anemia or acute posthemorrhagic anemia, the site of which has not been previously identified; positive fecal occult blood test or visible bleeding with no bleeding source found at original endoscopy
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
https://www.highmarkbcbswv.com/west-virginia-commercial-medical-policy/G-41-013.html
Wireless Capsule Endoscopy
152.0-152.9, 209.00-209.03, 211.2, 211.3, 280.0, 280.9, 285.1, 555.0-555.9, 562.02, 562.03, 569.85, 569.86, 578.0-578.9, 579.0-579.9, 759.6, 792.1
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopy
http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=31800&ContrId=235&ver=11&ContrVer=1&CntrctrSelected=235*1&Cntrctr=235&name=Palmetto+GBA+(11402%2c+MAC+-+Part+B)&LCntrctr=235*1&bc=AgACAAIAAAAA&
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
WEST VIRGINIA
Capsule Endoscopy Payer Guidelines - CPT 91110
152.0-152.9, 211.2, 230.7, 235.2, 280.0, 280.9, 285.1, 537.82, 537.83, 537.84, 555.0, 555.2, 557.0-557.9, 558.1, 558.2, 562.02, 562.03, 569.82, 569.84, 569.85, 569.86, 578.1, 578.9, 579.8, 579.9, 759.6, 787.91, 792.1, 793.4
MAC: Palmetto Government Benefit
AdministratorsWireless Capsule
Endoscopy
OGIB: Anemia secondary to suspected occult blood loss, the origin of which is suspected to be in the small intestinal mucosa, based on documented negative or non-diagnostic prior evaluation of the stomach, duodenum (EGD) and colon (colonoscopy) by conventional instrumental endoscopy
Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS WY Suspected Crohn's diseaseObscure GI bleeding
OGIB: Prior inconclusive upper and lower GI endoscopic studies
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
211.2, 555.0-555.9, 578.0-578.9, 759.6
https://bb.noridian.com/Bulletins/Blue_Cross_Blue_Shield_WY_Medical_Policy/Wireless_Capsule_Endoscopy.htm
http://www.aetna.com/cpb/medical/data/500_599/0588.html
Crohn's: Without evidence of disease on conventional diagnostic tests such as SBFT and upper and lower endoscopyWireless Capsule
Endoscopy as a Diagnostic Technique in Disorders of the Small
Bowel, Esophagus, and Colon
Hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
WYOMING
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: Noridian Administrative Services
No published LCD for capsule endoscopy. Claims will be manually reviewed.
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part BMAC: Palmetto GBA
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
HMSACigna Obscure GI bleed
Capsule Endoscopy Suspected Crohn's diseaseSuspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
http://www.aetna.com/cpb/medical/data/500_599/0588.html
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
No published medical policy for capsule endscopy. Claims will be manually reviewed.
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
HAWAII
Capsule Endoscopy Payer Guidelines - CPT 91110
No published LCD for capsule endoscopy. Claims will be manually reviewed.
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Occult GI bleedSuspected Angiodysplasias of the GI tractKnown Crohn's disease
Capsule Endoscopy
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS LA Suspected Crohn's diseaseObscure GI bleed
OGIB: Prior inconclusive upper and lower GI endoscopic studies
http://www.bcbsla.com/MedicalPolicies/0013720110914WirelessCapsuleEndoscopyasaDiagnosticTechniqueinDisordersoftheEsophagus,SmallBowel_11267.pdf
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
LOUISIANA
Capsule Endoscopy Payer Guidelines - CPT 91110
Carrier: Pinnacle Business Solutions, Inc.
http://www.aetna.com/cpb/medical/data/500_599/0588.html
OGIB: Not previously identified by upper GI endoscopy, colonoscopy, push endoscopy or other radiologic procedure
280.9, 555.0-555.9, 578.1, 578.9, 792.1
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=13489&ContrId=3&ver=13&ContrVer=1&CoverageSelection=Local&ArticleType=All&PolicyType=Final&s=Louisiana&CptHcpcsCode=91110&Date=04%2f15%2f2012&bc=gAAAABAAAAAA&
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Hereditary gastrointestinal polyposis syndromes, including familiar adenomatous polyposis and Peutz-Jeghers
Crohn's: Without evidence of disease on conventional diagnostic tests such as SBFT, and upper and lower endoscopy
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
Wireless Capsule Endoscopy as a
Diagnostic Technique inDisorders of the
Esophagus, Small Bowel and Colon
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
211.2, 555.0-556.9, 578.0-578.9, 759.6
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Premera BCBS Obscure GI bleed OGIB: Prior inconclusive upper AND lower gastrointestinal endoscopic studiesSuspected Crohn's disease
https://www.premera.com/stellent/groups/public/documents/medicalpolicy/cmi_003621.htm
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
HealthNet Obscure GI bleedSmall bowel neoplasmSuspected Crohn's
Crohn's: Patient has diarrhea, GI bleeding, abdominal pain, weight loss, negativestool cultures and negative upper and lower endoscopy
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf
http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C
Wireless Capsule Endoscopy
152.0-152.9, 197.4, 211.1, 230.7, 280.0, 280.9, 555.0-555.9, 558.1, 558.2, 558.9, 560.02, 560.03, 569.85, 569.86, 571.2, 571.5, 578.1, 578.9, 792.1
OGIB: Iron deficiency anemia, postive fecal occult blood test, or visible bleeding with no source found on original endoscopy, hematocrit < 34, failure of previous diagnostics to diagnose source of GI bleeding and GI bleeding is thought to be in the small intestineSmall Bowel Neoplasm: Diagnosis not previously confirmed by upper GI, colonoscopy, push enteroscopy, nuclear imaging or radiological procedures. Patient must be symptomatic for neoplasm (e.g. GI bleeding)
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf
Wireless Capsule Endoscopy as a
Diagnostic Technique in the Disorders of the Small
Bowel, Esophagus and Colon
Hereditary GI polyposis syndromes including familial adenomatous polyposis and Peutz-Jeghers syndrome
Crohn's: Without evidence of disease on conventional diagnostics tests such as SBFT and upper and lower endoscopy
211.2, 555.0, 555.1, 555.2, 555.9, 578.0, 578.1. 578.9, 759.6
Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
http://www.aetna.com/cpb/medical/data/500_599/0588.html
152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09
Wireless Capsule Endoscopy
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0
209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1-558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopy
WASHINGTON
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: Noridian Administrative Services
No published LCD for capsule endoscopy. Claims will be manually reviewed.
Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a bleeding source