Wireless capsule endoscopy (91110) is considered medically necessary for obscure digestive tract bleeding, the site of which has not previously been identified by upper gastrointestinal endoscopy, colonoscopy, push enteroscopy, nuclear imaging, or radiological procedures.

This test is indicated for the following diagnosis for those patients who have undergone complete gastrointestinal studies:

• Occult gastrointestinal bleeding (562.02, 562.03, 569.86, 578.1, 578.9, 792.1)
• Initial diagnosis of suspected Crohn’s disease (555.0)
• Angiodysplasias of the gastrointestinal tract (569.85)

Claims reporting conditions other than those referenced above should be denied as not medically necessary and, therefore, not covered. A participating, preferred, or network provider cannot bill the member for the denied service.

Wireless capsule endoscopy is limited to those patients who have undergone complete gastrointestinal studies (i.e., barium enema, stool specimen, upper gastrointestinal endoscopy, and colonoscopy), and such studies fail to reveal a source of bleeding. Medical record documentation must indicate that the member has continuing GI blood loss and anemia secondary to the bleeding.

Description

Wireless capsule endoscopy is an ingestible telemetric gastrointestinal capsule imaging system that is used for visualization of the small bowel mucosa. It is used in the detection of abnormalities of the small bowel, which are not accessible via standard upper gastrointestinal endoscopy and colonoscopy. A small capsule (approximately 11x30mm) 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 in real time. The capsule passes naturally from the body with the stool. Since it is disposable, it is not recovered.

NOTE:

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.

PRN References

02/2003, Wireless Capsule Endoscopy 08/2004, Wireless Capsule Endoscopy eligible for suspected Crohn’s disease

Capsule Endoscopy, Clinical Update, American Society for Gastrointestinal Endoscopy, Volume 10, No. 2, 10/2002

Capsule Endoscopy in the Evaluation of Patients with Suspected Small Intestinal Bleeding: Results of a Pilot Study, Gastrointestinal Endoscopy, Volume 56, No. 3, 09/2002

Wireless Capsule Diagnostic Endoscopy for Recurrent Small Bowel Bleeding, New England Journal of Medicine, Volume 344, No. 3, 1/2001

National Blue Cross Blue Shield Association Medical Policy 6.01.33, Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, 04/2003