alaska capsule endoscopy payer guidelines - … capsule endoscopy payer guidelines - cpt 91110 mac:...

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.



Medicare Part B Obscure GI bleedCrohn's diseaseSuspected small intestinal tumors



BCBS AL Recurrent, obscure GI bleed UnlistedSuspected Crohn's diseaseKnown Crohn's disease

https://www.bcbsal.org/providers/policies/final/017.pdf







April 2012



ALABAMA


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





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


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


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


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


OGIB: Must have negative diagnostic work-up (e.g., upper GI, EGD, or colonoscopy)



Medicare Part B Occult GI bleedSuspected Angiodysplasias of the GI tractKnown Crohn's disease

Capsule Endoscopy



BCBS AR Suspected Crohn's disease UnlistedObscure GI bleedingIron deficiency anemia

http://www.arkansasbluecross.com/members/report.aspx?policyNumber=2002008







April 2012







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: 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


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, 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



ARKANSAS


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&



Medicare Part B



BCBS AZ Obscure gastrointestinal bleeding UnlistedSuspected Crohn's disease

https://secure.azblue.com/pdf/medpol/o272.pdf



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



April 2012


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


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



ARIZONA


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: Patient has diarrhea, GI bleeding, abdominal pain, weight loss, negative stool cultures and negative upper and lower 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


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


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


HealthNet Obscure GI bleed

Small bowel neoplasm



United Healthcare GI blood loss and/or iron-deficiency anemia

Suspected or known Crohn's disease

Celiac disease


Celiac disease: Prior serology or GI endoscopy are not diagnostic

Small bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor

CALIFORNIA


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: Patient has diarrhea, GI bleeding, abdominal pain, weight loss, negative

stool cultures and negative 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 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


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




https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools and Resources/Policies and Protocols/Medical Policies/Medical Policies/Wireless_Capsule_Endoscopy.pdf


http://www.anthem.com/ca/medicalpolicies/policies/mp_pw_a050543.htm



Medicare Part B Occult GI bleedingCeliac diseaseSuspected or known Crohn's diseaseColitis



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







April 2012



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







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, 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: 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



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



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


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



Medicare Part B









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


No published LCD for capsule endoscopy. Claims will be manually reviewed.MAC: National Government Services






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


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




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



Crohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae


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





Medicare Part B



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







April 2012





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



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




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



DELAWARE


MAC: Novitas Solutions Inc.



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





Medicare Part B



Carefirst BCBS Obscure gastrointestinal bleeding Unlisted UnlistedSuspected Crohn's disease

http://notesnet.carefirst.com/ecommerce/medicalpolicy.nsf/vwwebtablex/cd17ab70a3b3f608852578d10055d47b?OpenDocument







April 2012







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






Camera)Hereditary GI polyposis syndromes including familial adenomatous polyposis and Peutz-Jeghers syndrome



DISTRICT OF COLUMBIA






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


syndromes affecting the small bowel

Payer / Policy Name

Link to Policy


(listed in policy)

Medicare Part B






BCBS FL Suspected Crohn's disease

Obscure GI bleed

OGIB: Prior inconclusive upper and lower GI endoscopic studies




Celiac disease

Humana Obscure GI bleed Unlisted

Capsule Endoscopy Suspected Crohn's or Celiac disease

Polyposis syndromes




Celiac disease




March 2012






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




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/



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


the testLynch syndrome or inherited polyposis syndromes


Jeghers syndrome



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


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







** 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


bleeding source


are negative for source of bleedingWireless Capsule

Endoscopy



http://mcgs.bcbsfl.com/









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







March 2012

GEORGIA




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.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






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



Patency Capsule









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



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




Medicare Part B Occult GI bleedingSuspected angiodysplasias

Capsule EndoscopySuspected or known Crohn's diseaseColitisSuspected small bowel neoplasm



Wellmark BCBS Suspected Crohn's disease UnlistedCapsule Endoscopy Obscure GI bleed


http://www.wellmark.com/Provider/MedPoliciesAndAuthorizations/MedicalPolicies/policies/capsule_endoscopy.aspx







April 2012

IOWA


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: 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




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








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





Medicare Part B



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







April 2012







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






Diagnostic Technique inDisorders of the

Esophagus, Small Bowel, and Colon

Hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome


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



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



IDAHO




Payer / Policy Name

Link to Policy


(listed in policy)

Medicare Part B Occult GI bleeding

Suspected angiodysplasias

Capsule Endoscopy


Colitis

Suspected small bowel neoplasm






BCBS IL Suspected Crohn's disease 211.2, 555.0-555.9, 759.6

Obscure GI bleeding




Celiac disease




Polyposis syndromes





Celiac disease




March 2012



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









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



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







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&


Wireless Capsule

Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location




Jeghers syndrome




source of bleeding


tests such as SBFT







Medicare Part B











April 2012







Patency Capsule



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


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



Carrier: National Government Services



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






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













BCBS KS Suspected Crohn's diseaseObscure GI bleeding


http://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/policies/policies/WirelessCapsuleEndoscopy_DT_Disorders_SmallBowel_Esophagus_Colon_2011-08-19.pdf







April 2012




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





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






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


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


KANSAS


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&


bleeding



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



Medicare Part B GI bleedingSmall bowel neoplasmCrohn's disease

Endoscopy by Capsule

Evaluation prior to surgery





Bluegrass Family Health Obscure GI bleedCrohn's diseaseSuspected small bowel tumor





April 2012


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


Crohn's: Following inconclusive SBFT and upper and lower endoscopy [EGD] and colonoscopy



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



Patency Capsule


KENTUCKY


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





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










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




Medicare Part BMAC: NHIC, Corp



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







April 2012


MASSACHUSETTS




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





Diagnostic Technique in Disorders of the Small


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


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







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







Medicare Part B



Carefirst BCBS Obscure gastrointestinal bleeding Unlisted UnlistedSuspected Crohn's disease

http://notesnet.carefirst.com/ecommerce/medicalpolicy.nsf/vwwebtablex/cd17ab70a3b3f608852578d10055d47b?OpenDocument







April 2012






Camera)


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



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



MAC: Novitas Solutions Inc







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











Harvard Pilgrim Obscure GI bleed UnlistedSuspected or known Crohn's diseaseIron deficiency anemia





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




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.harvardpilgrim.org/portal/page?_pageid=253,280120&_dad=portal&_schema=PORTAL


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



Patency Capsule



MAINE


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





Medicare Part B Occult GI bleedSuspected angiodysplasias of the GI tractAnemia secondary to bleeding

Capsule Endoscopy Crohn's diseaseColitis



BCBS MI Suspected Crohn's disease UnlistedObscure GI bleed

Angiodysplasia of intestine with hemorrhage



Priority Health Occult GI bleedCapsule Endoscopy Crohn's disease

Known Crohn's: When necessary to determine small bowel involvement



March 2012

Suspected small bowel neoplasm, regional enteritis, or malabsorption syndrome

MICHIGAN


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



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



http://www.bcbsm.com/mprApp/MedicalPolicyDocument?fileId=2040202





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


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



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


Crohns: Suspected Crohn's disease or when diagnosis is known but it is necessary to determine whether there is involvement of the small bowel



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


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







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







April 2012



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










Continued GI blood loss and anemia secondary to bleeding


Blood Loss: EGD and colonoscopy have been performed during same episode of illness


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


Wireless Capsule Endoscopy Hereditary GI polyposis syndromes including familial

adenomatous polyposis and Peutz-Jeghers syndrome

MINNESOTA



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



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


Payer / Policy Name Link to

Policy Coverage Pre-requisites Covered ICD-9 CodesMedicare Part B Occult GI bleeding

Suspected angiodysplasias












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.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





MISSOURI


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



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




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




Patency Capsule


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, 152.1, 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







BCBS MS Suspected Crohn's diseaseObscure GI bleeding

OGIB: Prior inconclusive upper and lower gastrointestinal endoscopic studies







April 2012




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




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


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.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


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


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



MISSISSIPPI


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



Medicare Part B



BCBS MT Suspected Crohn's disease UnlistedObscure GI bleeding








April 2012



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













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




https://www.bcbsmt.com/MedReview/Policies/WirelessCapsuleEndoscopySmallBowel/v101.aspx






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



Medicare Part B Obscure GI bleedSmall bowel neoplasm or Regional enteritis



BCBS NC Undiagnosed obscure gastrointestinal bleeding UnlistedCrohn's disease

http://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/capsule_endoscopy_wireless.pdf







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



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


NORTH CAROLINA


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&






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: Persistent abdominal pain greater than 4 weeks, persistent diarrhea, unintentional weight loss, negative stool cultures and negative upper and lower endoscopy studies


Capsule Endoscopy, Wireless






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






Medicare Part B



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







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




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





NORTH DAKOTA









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




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


Monitoring and surveillance of small bowel mucosal healing for response to treatment







BCBS NE Obscure GI bleeding UnlistedSuspected Crohn's disease

https://www.nebraskablue.com/~/media/pdf/Provider/Policy%20Procedure%20Manuals/MedicalPolicies.pdf







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






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


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


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






152.0-152.9, 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





NEBRASKA



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


Blood Loss: EGD and colonoscopy have been performed during same episode of illness








Harvard Pilgrim Obscure GI bleed UnlistedSuspected or known Crohn's diseaseIron deficiency anemia





April 2012





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.harvardpilgrim.org/portal/page?_pageid=253,280120&_dad=portal&_schema=PORTAL






NEW HAMPSHIRE



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



Patency Capsule




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




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



Medicare Part B




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






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


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







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





NEW JERSEY





Bowel and Colon


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







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







April 2012




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





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



Wireless Capsule Endoscopy (WCE)


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


Crohn's: Without evidence of disease on conventional diagnostic tests, such as endoscopy and SBFT

NEW MEXICO


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


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














April 2012



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









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





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



Patency Capsule


NEVADA




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


(listed in policy)

Medicare Part B






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


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


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


Celiac disease


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




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







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


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


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





CT scan/CT enterography and upper and lower endoscopy

Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and


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)


http://www.emblemhealth.com/pdf/med_guidelines/radio/MG_Wireless_Capsule_Endoscopy_b.pdf

https://www.excellusbcbs.com/wps/wcm/connect/9a1f84804e8eb72092f9bfe420b83c88/mp+wireless_endo+tac+11.pdf?MOD=AJPERES




Medicare Part B GI bleedingSmall bowel neoplasmCrohn's disease

Endoscopy by Capsule








Medical Mutual of Ohio Suspected occult blood loss UnlistedIron deficiency anemiaSmall bowel neoplasm or regional enteritis (Crohn's)Refractory undiagnosed malabsorptive syndromes



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)


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



152.0-152.9, 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


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.




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



Patency Capsule





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


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





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






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







April 2012

OKLAHOMA


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







Wireless Capsule Endoscopy (WCE)


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




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





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







Medicare Part B











April 2012


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



OREGON








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














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


(listed in policy)

Medicare Part B









Celiac disease


Highmark BCBS Angiodysplasias of the GI tract


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


Crohn's disease


http://medpolicy.ibx.com/policies/mpi.nsf/88c0c50066c9d059852574d300564913/126c59e615c110a085257837004df09c!OpenDocument



Celiac disease




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)











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



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


are negative for source of bleedingWireless Capsule





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







bleeding source

PENNSYLVANIA


No published LCD for capsule endoscopy. Claims will be manually reviewed.MAC: Novitas Solutions

Inc



https://secure.highmark.com/ldap/medicalpolicy/wpa-highmark/G-41-015.html

http://medpolicy.ibx.com/policies/mpi.nsf/88c0c50066c9d059852574d300564913/126c59e615c110a085257837004df09c!OpenDocument





Medicare Part B








Triple S Salud



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&






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, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09






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.



PUERTO RICO


MAC: First Coast Service Options


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






BCBS RI Obscure GI bleeding UnlistedSuspected Crohn's disease

https://www.bcbsri.com/BCBSRIWeb/pdf/medical_policies/WirelessCapsuleEndoscopy.pdf



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



April 2012




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





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



http://www.nhpri.org/matriarch/documents/CMP-011.02%20Capsule%20Endoscopy.7-11.pdf


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



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



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





Medicare Part B Obscure GI bleedMAC: Palmetto GBA Small bowel neoplasm or Regional enteritis



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







April 2012









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


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





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




SOUTH CAROLINA



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





Medicare Part B



Wellmark BCBS Suspected Crohn's disease UnlistedCapsule Endoscopy Obscure GI bleed


ttp://www.wellmark.com/Provider/MedPoliciesAndAuthorizations/MedicalPolicies/policies/capsule_endoscopy.aspx







April 2012






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







Hereditary GI polyposis syndromes, including familiar adenomatous polyposis and Petz-Jeghers syndrome


Crohn's: Without evidence of disease on one or more conventional diagnostic tests such as SBFT, upper endoscopy and lower 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

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



SOUTH DAKOTA









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







April 2012



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



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


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


Administrators Suspected or refractory malabsorptive syndromes (eg, Celiac disease)


Medicine:Wireless Capsule 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

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&








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


(listed in policy)

Medicare Part B Occult GI bleeding

Celiac disease


Colitis






BCBS TX Crohn's disease 211.2, 555.0-555.9, 759.6

Obscure GI bleeding




Celiac disease




Polyposis syndromes





Celiac disease




March 2012








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


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







bleeding source


tests such as SBFT



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



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


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





Jeghers syndrome




source of bleeding



http://medicalpolicy.hcsc.net/medicalpolicy/home?corpEntCd=TX1&path=/templatedata/medpolicies/POLICY/data/RADIOLOGY/RAD601.042_2011-09-15&ctype=POLICY&cat=Radiology

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&

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&





Medicare Part B











April 2012





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















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




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





Medicare Part B Obscure GI bleedSmall bowel neoplasm or regional enteritis











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







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



Patency Capsule

VIRGINIA



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


AdministratorsWireless 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











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







BCBS VT Suspected Crohn's disease UnlistedObscure GI bleeding


http://www.bcbsvt.com/export/sites/BCBSVT/provider/medicalpolicies/PDFs/Capsule_Endoscopy.pdf







April 2012





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









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





Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel and Esophagus

VERMONT



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

















April 2012

WISCONSIN


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&



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







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


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



Patency Capsule



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













Medicare Part B Obscure GI bleedSmall bowel neoplasm or regional enteritis



Highmark BCBS Angiodysplasias of the GI tract

Suspected Crohn's diseaseOccult GI bleedPeutz-Jeghers syndrome

Celiac Disease: Negative biopsy

Suspected small bowel turmors







April 2012






Hereditary GI polyposis syndromes including familial polyposis

Suspected or refractory malabsorptive syndromes (Celiac disease)


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



https://www.highmarkbcbswv.com/west-virginia-commercial-medical-policy/G-41-013.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





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.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


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


AdministratorsWireless Capsule

Endoscopy


Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel



Medicare Part B



BCBS WY Suspected Crohn's diseaseObscure GI bleeding








April 2012




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





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






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


Crohn's: Without evidence of disease on conventional diagnostic tests such as SBFT and upper and lower endoscopyWireless Capsule




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



WYOMING









HMSACigna Obscure GI bleed

Capsule Endoscopy Suspected Crohn's diseaseSuspected small bowel tumorCeliac disease





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

No published medical policy for capsule endscopy. Claims will be manually reviewed.






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





HAWAII



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





Medicare Part B Occult GI bleedSuspected Angiodysplasias of the GI tractKnown Crohn's disease

Capsule Endoscopy



BCBS LA Suspected Crohn's diseaseObscure GI bleed


http://www.bcbsla.com/MedicalPolicies/0013720110914WirelessCapsuleEndoscopyasaDiagnosticTechniqueinDisordersoftheEsophagus,SmallBowel_11267.pdf





April 2012

LOUISIANA


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

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



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





Esophagus, Small Bowel and Colon


211.2, 555.0-556.9, 578.0-578.9, 759.6




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







Medicare Part B



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



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



April 2012





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)






Diagnostic Technique in the Disorders of the Small

Bowel, Esophagus and Colon


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




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



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


WASHINGTON






alaska capsule endoscopy payer guidelines - … capsule endoscopy payer guidelines - cpt 91110 mac:...

Documents