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| Medical Policy: | M-77-002 |
| Topic: | Upper Gastrointestinal Endoscopy/Esophagoscopy |
| Section: | Diagnostic Medical |
| Effective Date: | September 25, 2017 |
| Issue Date: | September 25, 2017 |
| Last Reviewed: | August 2017 |
Esophagogastroduodenoscopy (EGD)/upper endoscopy is performed to view mucosal surfaces of the esophagus, stomach, and proximal duodenum for screening, diagnostic and therapeutic purposes. |
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
| Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
High Risk Screening EGD
EGD/upper endoscopy may be considered medically necessary for high risk screening for ANY of the following conditions:
- Individuals with chronic gastroesophageal reflux disease (GERD) at high risk for Barrett's esophagus (BE). (Note: After a negative screening EGD, further screening EGD is not indicated); or
- Individuals with cirrhosis and/or portal hypertension but no prior variceal hemorrhage, especially those with platelet counts less than 140,000/mm3; or
- Individuals with a family history of esophageal or gastric cancer; or
- Individuals with familial adenomatous polyposis (FAP) syndrome; or
- Individuals being considered for bariatric surgery in which the presence of upper gastrointestinal (GI) pathological conditions might modify planned management.
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All other indications for high risk screening EGD are considered experimental/investigational and, therefore, non-covered. The safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature. |
Diagnostic EGD
Diagnostic EGD may be considered medically necessary for ANY of the following conditions:
- Upper abdominal symptoms (e.g., pain, heartburn, non-cardia chest pain etc.) that persist despite an appropriate trial of therapy (e.g., acid suppression with proton-pump inhibitors (PPI); or
- Upper abdominal symptoms associated with symptoms and/or signs suggesting serious organic disease (e.g., prolonged anorexia and weight loss) or in individuals greater than 45 years of age; or
- Dysphagia (difficulty or discomfort in swallowing), chronic dyspeptic symptoms, or odynophagia (painful swallowing); or
- Esophageal reflux symptoms that are persistent or recurrent despite appropriate therapy; or
- Esophageal masses and for directing biopsies for diagnosing esophageal cancer; or
- Individuals with signs or symptoms of loco-regional recurrence after resection of esophageal cancer; or
- Persistent vomiting of unknown origin; or
- Other diseases in which the presence of upper gastrointestinal (GI) pathological conditions might modify other planned management (e.g., individuals who have a history of GI bleeding who are scheduled for organ transplantation, long-term anticoagulation, chronic non-steroidal therapy for arthritis; Barrett's esophagus or long-term non-steroidal anti-inflammatory drug therapy for arthritis, and those with cancer of the head and neck); or
- Confirmation and specific histological diagnosis of radiologically (X-ray) demonstrated lesions:
- Gastric or esophageal ulcer; or
- Suspected neoplastic lesion; or
- Evidence of upper GI tract stricture or obstruction; or
- Presence of GI bleeding:
- For individuals with active or recent bleeding; or
- For presumed chronic blood loss and for iron deficiency anemia when the clinical situation suggests an upper GI source or when colonoscopy results are negative; or
- When sampling of duodenal or jejunal tissue or fluid is indicated in patients with chronic unexplained diarrhea; or
- To access acute injury after caustic agent ingestion; or
- Dyspepsia when ANY of the following is present:
- Chronic GI bleeding; or
- Epigastric mass; or
- Iron deficiency anemia; or
- Persistent nausea or vomiting; or
- Progressive difficulty swallowing; or
- Progressive unintentional weight loss; suspicious barium meal (upper GI series)
- Individuals with a positive tissue transglutaminase (TTG); or
- Individuals with symptomatic pernicious anemia (e.g., anemia, fatigue, pallor, red tongue, shortness of breath, as well as tingling and numbness in the hands and feet) to identify prevalent lesions (e.g., carcinoid tumors, gastric cancer).
All other indications for diagnostic EGD are considered experimental/investigational and, therefore, non-covered. The safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.
Therapeutic EGD
Therapeutic EGD may be considered medically necessary for ANY of the following conditions:
- Treatment of bleeding from lesions such as ulcers, tumors, and vascular abnormalities (e.g., electrocoagulation, heater probe, laser photocoagulation or injection therapy); or
- Sclerotherapy for bleeding from esophageal or proximal gastric varices or banding of varices; or
- Removal of foreign bodies; or
- Removal of selected polypoid lesions; or
- Placement of feeding or drainage tubes (oral, peroral, trans-nasal, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy); or
- Dilation of stenotic lesions (e.g., with trans-endoscopic balloon dilators or dilation systems using guide wires); or
- Management of achalasia by means of botulinum toxin, balloon dilation; or
- Palliative treatment for stenosis lesions for neoplastic or non-neoplastic strictures (e.g., laser, bipolar electrocoagulation, stent placement); or
- Endoscopic mucosal resection for suspicious lesions of the upper layer.
All other indications for therapeutic EGD are considered experimental/investigational and, therefore, non-covered. The safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.
Sequential or Periodic EGD
Sequential or periodic EGD may be considered medically necessary for ANY of the following conditions:
- To assess for healing or Barrett’s in patients with severe erosive esophagitis or ulcer after a two (2) month course of PPI therapy; or
- Follow-up of individuals with BE without dysplasia. For individuals with established BE of any length and with no dysplasia, after two (2) consecutive examinations within one (1) year, an acceptable interval for additional surveillance is every three (3) to five (5) years; or
- Follow-up of individuals with BE and low-grade dysplasia (LGD) at six (6) months. If LGD is confirmed, then surveillance at 12 months and yearly thereafter as long as dysplasia persists. If three (3) sequential biopsies show no dysplasia, then acceptable interval for surveillance is every three (3) to five (5) years; or
- Follow-up of individuals with BE and high-grade dysplasia every three (3) to six (6) months for at least one (1) year. After one (1) year of no cancer detection, the interval of surveillance may be lengthened if there are no dysplastic changes on two (2) subsequent endoscopies performed at three (3) to six (6) month intervals; or
- Follow up of individuals with dysplastic BE after ablative therapy every three (3) to six (6) months for one (1) year; or
- Follow-up of esophageal, gastric or stomal ulcers to demonstrate healing in patients with continued symptoms despite adequate medical therapy trial in two (2) to four (4) months; or
- Follow-up in individuals with prior adenomatous gastric polyps in one (1) year after resection six (6) months after resection of sessile and dysplastic polyps and in high risk patients every one (1) to three (3) years; or
- Follow-up of individuals after treatment of esophageal varices every one (1) to three (3) months till varices adequately treated; or
- Follow-up of individuals with a severe caustic esophageal injury every one (1) to three (3) years beginning 15 to 20 years after the injury; or
- Follow-up of individuals with tylosis every one (1) to three (3) years beginning at 30 years of age; or
- Follow-up of recurrence of adenomatous polyps in synchronous and metachronous sites at three (3) to five (5) year intervals; or
- Follow-up of individuals with familial adenomatous polyposis (FAP) starting around the time of colectomy or after age of 25 years, surveillance every six (6) months to four (4) years depending on Speigelman classification of duodenal adenomas; or
- Follow-up of individuals with hereditary non-polyposis colorectal cancer (Lynch syndrome) every three (3) to five (5) years; or
- Follow-up of individuals after endoscopic mucosal resection every three (3) to six (6) months until completion of resection; or
- Follow-up of gastric intestinal metaplasia every one (1) to three (3) years.
All other indications for sequential or periodic EGD are considered experimental/investigational and, therefore, non-covered. The safety and/or effectiveness cannot be established by review of the available published peer-reviewed literature.
Refer to medical policy HMK S-4 Endoscopic Procedures and Related Services for additional information. Refer to medical policy HMK S-145 Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD) for additional information. Refer to medical policy HMKS-204 Radiofrequency Ablation of the Esophagus, Nonvariceal Gastrointestinal Bleeding and Anemia for additional information. Refer to medical policy S-233 Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease for additional information. |
| Place of Service: Inpatient/Outpatient |
Experimental/Investigational (E/I) services are not covered regardless of place of service.
Upper gastrointestinal endoscopy is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
| The policy position applies to all commercial lines of business |
| Denial Statements |
Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
| Links |
- Link to Provider Resource Center for the Medical Policy Update
02/2017 New Coverage Position for Upper Gastrointestinal Endoscopy
 |
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
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