Highmark Medical Policy Bulletin
Section: Miscellaneous
Number: G-41
Topic: Wireless Capsule Endoscopy
Effective Date: September 18, 2006
Issued Date: September 18, 2006
Date Last Reviewed: 04/2006

General Policy Guidelines

Indications and Limitations of Coverage

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.

Wireless capsule endoscopy of the esophagus (91110) is considered experimental/investigational.  Clinical data are inadequate to permit scientific conclusions regarding the clinical role of esophageal capsule endoscopy.  A participating, preferred, or network provider can bill the member for the denied service.

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.

In November 2004, the Given® Diagnostic System with the PillCamTM ESO Capsule received FDA clearance for the visualization of esophageal mucosa.

In the esophagus, the capsule camera has been proposed as a screening technique for Barrett's esophagus associated with gastroesophageal reflux disease (GERD).  Evaluation of the esophagus requires limited transit time, and it is estimated that the test takes 20 minutes to perform.  Alternative techniques include upper endoscopy.


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.

Procedure Codes

91110     

Traditional (UCR/Fee Schedule) Guidelines

Refer to General Policy Guidelines

FEP Guidelines

This medical policy may not apply to FEP.  Medical policy is not an authorization, certification, explanation of benefits or a contract.  Benefits are determined by the Federal Employee Program.

Comprehensive / Wraparound / PPO / Major Medical Guidelines

Refer to General Policy Guidelines

Any reference in this bulletin to non-billable services by a network provider may not be applicable to Major Medical.

Managed Care (HMO/POS) Guidelines

Refer to General Policy Guidelines

Publications

PRN References

02/2003, Wireless Capsule Endoscopy

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

08/2006, Wireless Capsule Endoscopy of the Esophagus Not Covered

References

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 and Esophagus, 03/2006

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Glossary




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.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.