About this policy
Jurisdiction: J9 MAC Part B. States: Florida, Puerto Rico, US Virgin Islands. Type: Active LCD
Coverage indications
History/Background and/or General Information Upper intestinal endoscopy is performed with a lighted, flexible, fiberoptic instrument passed through the cricopharynx. The patient receives conscious sedation. A topical anesthetic is sometimes applied to the posterior pharynx. Direct visualization of the entire esophagus, stomach, and duodenum (to the junction of the second and third portions) can be accomplished easily with modern instruments that are less than 12mm in diameter. Esophagogastroduodenoscopy (EGD) is a technique utilized to examine, obtain samples, and in some instances, to treat pathological conditions. Diagnostic observations are made concerning focal benign or malignant lesions, diffuse mucosal changes, luminal obstruction, motility, and extrinsic compression by contiguous structures. A diagnostic EGD allows the examiner to visualize abnormalities detectable by the technique and to photograph, biopsy, and/or remove lesions as appropriate. The purpose of the therapeutic EGD is to manage hemorrhage; remove foreign bodies and neoplastic growths; to relieve obstruction due to stricture, malignancy, or other causes through dilatation or the placement of stents; and to assist in the placement of percutaneous gastrostomy tubes. Covered Indications EGD(s)will be considered medically reasonable and necessary under the following diagnostic conditions: Patient has upper abdominal distress (e.g., gastroesophageal reflux disease) which persists despite an appropriate trial of symptomatic therapy; Patient has upper abdominal distress associated with a short history of signs and symptoms suggesting significant associated disease or illness (e.g., weight loss, anorexia, vomiting, nonsteroidal anti-inflammatory drug [NSAID] intake, other gastric irritant intake); Patients over the age of 40 who have experienced a significant history of heartburn that returns after a course of symptomatic therapy; Patients who have dysphagia or odynophagia; Patient has persistent, unexplained vomiting; Patient has upper gastrointestinal x-ray findings of: any lesion that requires biopsy for diagnosis; or gastric ulcer suspicious of cancer; or evidence of stricture or obstruction; To assess acute injury after caustic agent ingestion; When anti-reflux surgery is contemplated; or Patient has gastrointestinal bleeding: in most actively bleeding patients; or for presumed chronic blood loss and iron deficiency anemia when investigation of large bowel is negative. EGD(s) will be considered medically reasonable and necessary for the following therapeutic purposes: Treatment of bleeding lesions; Removal of foreign bodies; Sclerotherapy and/or band ligation for bleeding from esophageal or gastric varices; Dilatation of strictures in the upper intestinal tract; Removal of selected polypoid lesions; Placement of feeding tubes; or Palliative therapy of stenosing neoplasms (e.g., laser, stent placement). Gastrointestinal bleeding may be treated with a variety of methods. Direct contact heater probes and hemostatic injections into or around the bleeding vessels are both effective therapy for acute bleeding. Foreign body removal from the stomach or esophagus is usually successful with these flexible instruments. The foreign bodies can be retrieved by either of two methods. The first method is to capture the foreign body with a snare device/grasping forceps and pull the item out with the endoscope. The second method is accomplished by piecemeal destruction and pushing the bolus through the esophagus into the stomach. Esophageal varices may be injected with a variety of sclerosing solutions. Eradication of varices requires, on the average, five sclerotherapy sessions, with multiple injections given during each session. Dilatation of strictures may be accomplished with a balloon placed through the endoscope and inflated using hydrostatic pressure. Bougies are rubber dilators available in various sizes up to approximately 2.0cm. Plastic bougies and other dilating probes are usually passed over a guide wire. This procedure involves placing the guide wire into the stomach through the endoscope. The endoscope is then withdrawn leaving the guide wire in place. The dilating probes and plastic bougies are then passed over the guide wire. After the largest dilator is used, the dilator and guide wire are removed. Esophageal dilation is performed after a definitive diagnosis has been established in patients exhibiting dysphagia. The goal in most cases is a lumenal diameter of 16-17mm which allows passage of solid food. A series of dilators may be passed over the guide wire to reach the goal of therapy. Follow-up EGD(s)will be considered medically reasonable and necessary for the following indications: Biopsy surveillance of patients with Barrett’s esophagus every 12 to 24 months. However, if dysplasia is present, earlier surveillance intervals of from three to six months may be required; Follow-up of gastric ulcers to healing or satisfaction that they are benign; Follow-up and treatment of esophageal strictures requiring guidewire dilation; Follow-up of duodenal ulcer or other lesions of the upper gastrointestinal tract that have resulted in serious consequences (e.g., hemorrhage); Follow-up of patients having a previous gastric polypectomy for adenoma; or Follow-up and treatment of patients with esophageal varices or bleeding lesions requiring recurrent therapy (e.g., esophageal varices, gastric varices, angiodysplastic or watermelon stomach lesions, radiation gastritis). Follow-up for removal of percutaneous gastrostomy tube (PEG) Limitations Periodic EGD is NOT usually indicated in the following situations: Surveillance of healed, benign disease such as gastric or duodenal ulcer or benign esophageal strictures; or Cancer surveillance in patients with pernicious anemia, treated achalasia, or prior gastric resection. EGD is generally contraindicated for patients with recent myocardial infarction. As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual , Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.