Endoscopy by Capsule

LCD Information Document Information Source LCD ID N/A LCD ID L34081 Original ICD-9 LCD ID Not Applicable LCD Title Endoscopy by Capsule Proposed LCD in Comment Period N/A Source Proposed LCD N/A Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 03/05/2026 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date N/A Notice Period End Date N/A CPT codes, descriptions, and other data only are copyright 2025 American Medical Association. All Rights Reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. 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Issue Issue Description This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity. Issue - Explanation of Change Between Proposed LCD and Final LCD CMS National Coverage Policy Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Code of Federal Regulations:42 CFR 410.32 indicates that diagnostic tests may only be ordered by a treating physician (or other treating practitioner acting within the scope of their license and Medicare requirements) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapterCMS Publications:CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 23: 10.1 - 10.1.7 ICD-9-CM Coding for Diagnostic Tests. Coverage Indications, Limitations, and/or Medical Necessity Abstract:Endooscopy by capsule is carried out by a wireless video capsule that is swallowed and ultimately passed from the rectum. Two capsules are available, one designed for the small bowel and one for the esophagus. This LCD outlines coverage guidelines for conditions involving the small bowel where small bowel capsule use may be helpful for diagnosis. This LCD also defines coverage for the esophageal capsule in a subgroup of patients with hepatic cirrhosis to identify medium-large esophageal varices. Indications:The indications below were derived in part from The American Society for Gastrointestinal Endoscopy (ASGE) Technology Status Evaluation Report:Wireless Capsule Endoscopy Endoscopy by Capsule of the EsophagusThe esophageal capsule is a wireless diagnostic video capsule specifically designed for visualization of the esophagus. The device acquires video images via camera ports at both ends as it travels through the esophagus. No sedation is required for the procedure.There is a high mortality associated with bleeding from esophageal varices. Treatment with beta blockers or variceal ligation is generally accepted to reduce the incidence of first bleeding in patients with medium to large varices. Consequently triage of cirrhotics into those with medium-large varices or none-small varices is reasonable to determine who should be treated. Capsule endoscopy of the esophagus is an alternative to conventional endoscopy in cirrhotic patients who are anticipated to tolerate adequate doses of beta-blockers (see documentation requirements). Cirrhotic patients unlikely to tolerate beta-blockers should be examined with conventional endoscopy so that variceal ligation may be performed if indicated. Since variceal size estimates should be comparable to estimates made by conventional endoscopy the capsule endoscopist should use a previously validated algorithm to estimate variceal size. The recommended algorithm to estimate variceal size by capsule endoscopy was developed from the initial pilot data (Eisen et al. Endoscopy 2006) and subsequently used and validated (compared to conventional endoscopy) in a multi-center international trial (De Franchis et al. presented at Digestive Disease Week 2007). In this algorithm a varix is considered small if the diameter is greater than zero and less than 1/4 of the video circumference for the frame that shows its largest diameter. It is considered medium/large if this measurement is greater than or equal to 1/4 of the circumference. Evaluation for esophageal varices is reasonable in patients with cirrhosis and portal hypertension and no prior variceal bleeding. Cirrhosis and portal hypertension is defined for this policy as a Child's class B or C stage or a class A with a low platelet count (<140,000), an enlarged portal vein diameter (> 13 mm), or evidence of collateral circulation on ultrasound (see Grace ND et al).For those patients diagnosed with medium to large varices subsequent capsule endoscopy would not be reasonable. However, coverage for conventional flexible endoscopy would be available when reasonable and necessary.The American Society for Gastrointestinal Endoscopy suggests repeat evaluation in 3-year intervals for those without varices and in 1 to 2 years for those with small varices. Endoscopy by Capsule of the Small IntestineIt may be an adjunctive tool used in the detection of abnormalities of the small bowel, which is not accessible to standard upper endoscopy and colonoscopy. A small capsule is swallowed and moves through the GI tract propelled by peristalsis, transmitting video pictures. The video images are transmitted to sensors taped to the body and stored on a portable recorder. The strength of the signal is used to calculate the position of the capsule as it passes through the GI tract. Video images are stored on a portable recorder and later downloaded to a computer, from which they may be viewed. The capsule passes naturally from the body with the stool, and since it is disposable, it is not recovered. Gastrointestinal BleedingThe test is indicated for the diagnosis of occult gastrointestinal bleeding, the site of which has not been identified previously by any of the following: upper gastrointestinal endoscopy, colonoscopy, push enteroscopy, nuclear imaging, or radiological procedures. The test is especially helpful in the diagnosis of angiodysplasias of the gastrointestinal tract. Endoscopy by capsule is limited to those patients who have generally undergone both upper GI endoscopy and colonoscopy, and when these tests have failed to reveal a source of bleeding. In rare situations where hemotemesis occurs repeatedly and upper GI endoscopy is repeatedly negative capsule endoscopy may be indicated. Small Bowel NeoplasmThe test is indicated for the detection of neoplasms of the small bowel, when the diagnosis has not been previously confirmed by other studies (e.g., upper gastrointestinal endoscopy, colonoscopy, push enteroscopy, nuclear imaging, or radiological procedures). The patient must be symptomatic for a neoplasm (e.g., GI bleeding) or have a documented polyposis syndrome that is associated with small bowel neoplasia or there is other history suggesting the 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. Endoscopy by capsule may be indicated for the detection of small bowel neoplasm in those patients with documented intussusception of the small bowel, without established etiology. In such instances the requirement for prior examination by upper and lower endoscopies may be waived. Crohn's DiseaseEndoscopy by capsule is indicated for the diagnosis of Crohn's disease when the condition has not been previously confirmed or gastrointestinal capsule imaging is indicated when a diagnosis of colitis of an indeterminate type affecting the colon is known, and a more specific diagnosis is sought by evaluating for possible small bowel involvement. Endoscopy by capsule is reasonable in those patients in whom there is strong clinical suspicion of Crohn's disease (with abdominal pain, weight loss, diarrhea, anorexia, bleeding and biochemical indicators of inflammation) and in whom, in the physician's judgment, there is no intestinal stricture. In these patients with a strong clinical suspicion of Crohn's disease, negative colonoscopy is a prerequisite to the performance of the capsule endoscopy. Other ConditionsEvaluation of malabsorption syndrome, chronic diarrhea, or protein-losing enteropathy of obscure origin is reasonable when it is suspected to originate in the small intestinal mucosa. Appropriate prior negative or non-diagnostic evaluations of the esophagus, stomach, duodenum/small intestine, and colon by flexible endoscopy, and complementary radiologic procedures and/or microbiologic studies must be documented. Evaluation Prior to SurgeryEvaluation of extent of small bowel involvement with arteriovenous malformations or lymphangiectasia for patients who are contemplated for surgical resection of the small bowel to control recurrent bleeding or protein loss is reasonable. Limitations: Endoscopy by Capsule of the Esophagus Medicare contractor local coverage determinations (LCDs) generally cover esophagoscopy in patients with Gastroesophageal Reflux Disease (GERD) symptoms that persist despite appropriate therapy. The American College of Gastroenterology (ACGE) states in regard to empirical therapy for GERD: "Further diagnostic testing should be considered if the patient does not respond to therapy, when there are alarm symptoms suggesting complicated disease (dysphagia, odynophagia, bleeding, weight loss, or anemia) and when patients have a sufficient duration of symptoms to put them at risk for Barrett's esophagus."The American Society for Gastrointestinal Endoscopy states "When there are clinical clues that suggest that reflux may be severe or that other diseases may be present, endoscopy is the diagnostic procedure of choice."The reported frequency of Barrett's esophagus in those with reflux symptoms ranges from 5% to 15%, and these patients without significant inflammatory changes undergo biopsy at the time of endoscopy.Indications for endoscopy in GERD assume that endoscopy has the potential to obtain tissue samples and to examine the stomach and duodenum. Since the capsule does not have these capabilities, the above recommendations cannot be carried over to the capsule. Until a clear description of the population who would benefit from endoscopy by capsule (patients who do not need evaluation of the stomach and duodenum and who do not need initial biopsies) becomes available, endoscopy by capsule is not covered for GERD evaluation. Patency Capsule TestingPatency Capsule Testing will also not be covered. Sufficient peer-reviewed literature supporting its use is not currently available. On occasion Patency Capsule has been reported to cause obstruction requiring urgent intervention.The ASGE Technology Status Evaluation Report Wireless Capsule Endoscopy lists, "Patients with known or suspected gastrointestinal (GI) obstruction, strictures, or fistulas based on the clinical picture or preprocedure testing" under contraindications for the small bowel capsule. Endoscopy by Capsule of the Small IntestineWhen representing chronic stable symptoms, these conditions rarely represent reasonable indications for endoscopy by capsule. When these diagnostic codes are used, the codes must be applicable and the rationale for capsule endoscopy must be carefully documented in the medical record.The ingestion of the capsule is part of the test and an evaluation & management (E&M) service may not be billed for this purpose.Endoscopy by capsule of the small intestine is not covered in the following situations: Colorectal cancer screening When carried out by FDA non-approved devices Confirmation of lesions or pathology normally within the reach of upper or lower endoscopy (lesions proximal to the ligament of Treitz or distal to the ileum) or for the confirmation of lesions or pathology discovered by prior endoscopy (including push enteroscopy), colonoscopy, or radiology When performed by physicians not trained in endoscopy or for independent diagnostic testing facilities, which are not under the general supervision of a physician trained in endoscopy procedures.Endoscopy by capsule performed to diagnose obscure gastrointestinal bleeding, is only covered if it is documented that the beneficiary had continuing GI blood loss or anemia secondary to bleeding or iron deficiency anemia.Endoscopy by capsule is not generally reimbursable when used for management of patients with a confirmed diagnosis of Crohn's disease. Onset of new symptoms suggestive of Crohn's disease at an undiagnosed small bowel region may make endoscopy by capsule reasonable.Endoscopy by capsule for the detection of small bowel malignancies, in the absence of obscure gastrointestinal bleeding, or symptoms suggesting Crohn's disease, or the presence of a polyposis syndrome associated with small bowel neoplasia or other history suggesting the presence of small bowel neoplasia is not covered.Endoscopy by capsule of the esophagus is not covered in patients with a current history of dysphagia suggestive of esophageal stricture. Other Comments:For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC to process their claims.Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC.For dates of service prior to April 1, 2010, FQHC services should be reported with bill type 73X. For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services.Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes. Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A

Abstract: Endooscopy by capsule is carried out by a wireless video capsule that is swallowed and ultimately passed from the rectum. Two capsules are available, one designed for the small bowel and one for the esophagus. This LCD outlines coverage guidelines for conditions involving the small bowel where small bowel capsule use may be helpful for diagnosis. This LCD also defines coverage for the esophageal capsule in a subgroup of patients with hepatic cirrhosis to identify medium-large esophageal varices. Indications: The indications below were derived in part from The American Society for Gastrointestinal Endoscopy (ASGE) Technology Status Evaluation Report:Wireless Capsule Endoscopy Endoscopy by Capsule of the Esophagus The esophageal capsule is a wireless diagnostic video capsule specifically designed for visualization of the esophagus. The device acquires video images via camera ports at both ends as it travels through the esophagus. No sedation is required for the procedure. There is a high mortality associated with bleeding from esophageal varices. Treatment with beta blockers or variceal ligation is generally accepted to reduce the incidence of first bleeding in patients with medium to large varices. Consequently triage of cirrhotics into those with medium-large varices or none-small varices is reasonable to determine who should be treated. Capsule endoscopy of the esophagus is an alternative to conventional endoscopy in cirrhotic patients who are anticipated to tolerate adequate doses of beta-blockers (see documentation requirements). Cirrhotic patients unlikely to tolerate beta-blockers should be examined with conventional endoscopy so that variceal ligation may be performed if indicated. Since variceal size estimates should be comparable to estimates made by conventional endoscopy the capsule endoscopist should use a previously validated algorithm to estimate variceal size. The recommended algorithm to estimate variceal size by capsule endoscopy was developed from the initial pilot data (Eisen et al. Endoscopy 2006) and subsequently used and validated (compared to conventional endoscopy) in a multi-center international trial (De Franchis et al. presented at Digestive Disease Week 2007). In this algorithm a varix is considered small if the diameter is greater than zero and less than 1/4 of the video circumference for the frame that shows its largest diameter. It is considered medium/large if this measurement is greater than or equal to 1/4 of the circumference. Evaluation for esophageal varices is reasonable in patients with cirrhosis and portal hypertension and no prior variceal bleeding. Cirrhosis and portal hypertension is defined for this policy as a Child's class B or C stage or a class A with a low platelet count ( 13 mm), or evidence of collateral circulation on ultrasound (see Grace ND et al). For those patients diagnosed with medium to large varices subsequent capsule endoscopy would not be reasonable. However, coverage for conventional flexible endoscopy would be available when reasonable and necessary. The American Society for Gastrointestinal Endoscopy suggests repeat evaluation in 3-year intervals for those without varices and in 1 to 2 years for those with small varices. Endoscopy by Capsule of the Small Intestine It may be an adjunctive tool used in the detection of abnormalities of the small bowel, which is not accessible to standard upper endoscopy and colonoscopy. A small capsule is swallowed and moves through the GI tract propelled by peristalsis, transmitting video pictures. The video images are transmitted to sensors taped to the body and stored on a portable recorder. The strength of the signal is used to calculate the position of the capsule as it passes through the GI tract. Video images are stored on a portable recorder and later downloaded to a computer, from which they may be viewed. The capsule passes naturally from the body with the stool, and since it is disposable, it is not recovered. Gastrointestinal Bleeding The test is indicated for the diagnosis of occult gastrointestinal bleeding, the site of which has not been identified previously by any of the following: upper gastrointestinal endoscopy, colonoscopy, push enteroscopy, nuclear imaging, or radiological procedures. The test is especially helpful in the diagnosis of angiodysplasias of the gastrointestinal tract. Endoscopy by capsule is limited to those patients who have generally undergone both upper GI endoscopy and colonoscopy, and when these tests have failed to reveal a source of bleeding. In rare situations where hemotemesis occurs repeatedly and upper GI endoscopy is repeatedly negative capsule endoscopy may be indicated. Small Bowel Neoplasm The test is indicated for the detection of neoplasms of the small bowel, when the diagnosis has not been previously confirmed by other studies (e.g., upper gastrointestinal endoscopy, colonoscopy, push enteroscopy, nuclear imaging, or radiological procedures). The patient must be symptomatic for a neoplasm (e.g., GI bleeding) or have a documented polyposis syndrome that is associated with small bowel neoplasia or there is other history suggesting the 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. Endoscopy by capsule may be indicated for the detection of small bowel neoplasm in those patients with documented intussusception of the small bowel, without established etiology. In such instances the requirement for prior examination by upper and lower endoscopies may be waived. Crohn's Disease Endoscopy by capsule is indicated for the diagnosis of Crohn's disease when the condition has not been previously confirmed or gastrointestinal capsule imaging is indicated when a diagnosis of colitis of an indeterminate type affecting the colon is known, and a more specific diagnosis is sought by evaluating for possible small bowel involvement. Endoscopy by capsule is reasonable in those patients in whom there is strong clinical suspicion of Crohn's disease (with abdominal pain, weight loss, diarrhea, anorexia, bleeding and biochemical indicators of inflammation) and in whom, in the physician's judgment, there is no intestinal stricture. In these patients with a strong clinical suspicion of Crohn's disease, negative colonoscopy is a prerequisite to the performance of the capsule endoscopy. Other Conditions Evaluation of malabsorption syndrome, chronic diarrhea, or protein-losing enteropathy of obscure origin is reasonable when it is suspected to originate in the small intestinal mucosa. Appropriate prior negative or non-diagnostic evaluations of the esophagus, stomach, duodenum/small intestine, and colon by flexible endoscopy, and complementary radiologic procedures and/or microbiologic studies must be documented. Evaluation Prior to Surgery Evaluation of extent of small bowel involvement with arteriovenous malformations or lymphangiectasia for patients who are contemplated for surgical resection of the small bowel to control recurrent bleeding or protein loss is reasonable. Limitations: Endoscopy by Capsule of the Esophagus Medicare contractor local coverage determinations (LCDs) generally cover esophagoscopy in patients with Gastroesophageal Reflux Disease (GERD) symptoms that persist despite appropriate therapy. The American College of Gastroenterology (ACGE) states in regard to empirical therapy for GERD: "Further diagnostic testing should be considered if the patient does not respond to therapy, when there are alarm symptoms suggesting complicated disease (dysphagia, odynophagia, bleeding, weight loss, or anemia) and when patients have a sufficient duration of symptoms to put them at risk for Barrett's esophagus." The American Society for Gastrointestinal Endoscopy states "When there are clinical clues that suggest that reflux may be severe or that other diseases may be present, endoscopy is the diagnostic procedure of choice." The reported frequency of Barrett's esophagus in those with reflux symptoms ranges from 5% to 15%, and these patients without significant inflammatory changes undergo biopsy at the time of endoscopy. Indications for endoscopy in GERD assume that endoscopy has the potential to obtain tissue samples and to examine the stomach and duodenum. Since the capsule does not have these capabilities, the above recommendations cannot be carried over to the capsule. Until a clear description of the population who would benefit from endoscopy by capsule (patients who do not need evaluation of the stomach and duodenum and who do not need initial biopsies) becomes available, endoscopy by capsule is not covered for GERD evaluation. Patency Capsule Testing Patency Capsule Testing will also not be covered. Sufficient peer-reviewed literature supporting its use is not currently available. On occasion Patency Capsule has been reported to cause obstruction requiring urgent intervention. The ASGE Technology Status Evaluation Report Wireless Capsule Endoscopy lists, "Patients with known or suspected gastrointestinal (GI) obstruction, strictures, or fistulas based on the clinical picture or preprocedure testing" under contraindications for the small bowel capsule. Endoscopy by Capsule of the Small Intestine When representing chronic stable symptoms, these conditions rarely represent reasonable indications for endoscopy by capsule. When these diagnostic codes are used, the codes must be applicable and the rationale for capsule endoscopy must be carefully documented in the medical record. The ingestion of the capsule is part of the test and an evaluation & management (E&M) service may not be billed for this purpose. Endoscopy by capsule of the small intestine is not covered in the following situations: Colorectal cancer screening When carried out by FDA non-approved devices Confirmation of lesions or pathology normally within the reach of upper or lower endoscopy (lesions proximal to the ligament of Treitz or distal to the ileum) or for the confirmation of lesions or pathology discovered by prior endoscopy (including push enteroscopy), colonoscopy, or radiology When performed by physicians not trained in endoscopy or for independent diagnostic testing facilities, which are not under the general supervision of a physician trained in endoscopy procedures. Endoscopy by capsule performed to diagnose obscure gastrointestinal bleeding, is only covered if it is documented that the beneficiary had continuing GI blood loss or anemia secondary to bleeding or iron deficiency anemia. Endoscopy by capsule is not generally reimbursable when used for management of patients with a confirmed diagnosis of Crohn's disease. Onset of new symptoms suggestive of Crohn's disease at an undiagnosed small bowel region may make endoscopy by capsule reasonable. Endoscopy by capsule for the detection of small bowel malignancies, in the absence of obscure gastrointestinal bleeding, or symptoms suggesting Crohn's disease, or the presence of a polyposis syndrome associated with small bowel neoplasia or other history suggesting the presence of small bowel neoplasia is not covered. Endoscopy by capsule of the esophagus is not covered in patients with a current history of dysphagia suggestive of esophageal stricture. Other Comments: For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC to process their claims. Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC. For dates of service prior to April 1, 2010, FQHC services should be reported with bill type 73X. For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services. Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.