Colon Capsule Endoscopy (CCE)

Jurisdiction: J6 MAC Part B. States: Illinois, Minnesota, Wisconsin. Type: Active LCD

Diagnostic and/or surveillance* (performed for signs/symptoms of disease) colon capsule colonoscopy (CCE) is medically necessary for the detection of colon polyps when EITHER of the following criteria are met: Secondary procedure after an incomplete diagnostic optical colonoscopy (OC) with adequate preparation, and a complete evaluation of the colon was not technically possible (1,2) when EITHER of the following criteria are met Detection or surveillance of colon polyp(s) OR Diagnostic procedure when ANY of the following criteria are met (3): Fecal Occult Blood Test (FOBT) positive (guaiac or immunochemical) OR Multitarget Stool DNA (sDNA) Test positive OR Blood-based biomarker colorectal cancer screening test positive OR Other evidence of lower GI bleed in hemodynamically stable patients Primary procedure in patients with major risks for OC or moderate sedation as indicated from an evaluation of the patient by a board certified or board eligible gastroenterologist, a surgeon trained in endoscopy, or a physician with equivalent endoscopic training when EITHER of the following criteria are met: Surveillance of colon polyp(s) in previously diagnosed patients OR Diagnostic procedure when ANY of the following criteria are met (3): Fecal Occult Blood Test (FOBT) positive (guaiac or immunochemical) OR Multitarget Stool DNA (sDNA) Test positive OR Blood-based biomarker colorectal cancer screening test positive OR Other evidence of lower GI bleed in hemodynamically stable patients Exclusion Criteria (NONE of the below are allowed) Known or suspected gastrointestinal obstruction, stricture, or fistula Cardiac pacemaker or another implanted electro-medical device if the CCE device is contraindicated due to emission of a radiofrequency or other interfering signal Swallowing disorder Known contraindication or allergy to any medication or preparation agent used before or during the procedure May not be done in conjunction with CT Colonography (CTC) CCE is not a Medicare Benefit for colorectal cancer screening, regardless of family history or other risk factors for the development of colonic disease * Cancer Diagnostic strategies refer to the measures taken to investigate persons with symptoms suspicious for malignancy or as a result of positive screening tests. Cancer Surveillance refers to the interval utilization of diagnostic strategies in people with previously detected cancerous or pre-cancerous lesions. Cancer Screening strategies refer to those measures taken to diagnose cancerous and pre-cancerous lesions in asymptomatic people with no previous history of such.