Wireless Capsule Endoscopy of Small Intestine

Wireless capsule endoscopy of the small intestine (91110) is considered medically necessary for the following indications when conventional endoscopic and diagnostic imaging evaluations (e.g., upper gastrointestinal endoscopy, colonoscopy, push enteroscopy, nuclear imaging, or radiological procedure) are inconclusive:

• Angiodysplasias of the gastrointestinal tract
• Hereditary gastrointestinal polyposis syndromes including familial polyposis
• Initial diagnosis of suspected Crohn’s disease
• Occult gastrointestinal bleeding (e.g., iron-deficiency anemia, acute posthemorrhagic anemia) the site of which has not previously been identified
• Peutz-Jeghers syndrome
• Suspected or refractory malabsorptive syndromes (e.g., celiac disease in individuals with a negative biopsy)
• Suspected small bowel tumors

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 unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost.  The member must agree in writing to assume financial responsibility, in advance of receiving the service.  The signed agreement should be maintained in the provider's records.

Wireless capsule endoscopy is limited to those patients who have undergone complete gastrointestinal studies (i.e., stool specimen, upper gastrointestinal endoscopy, and colonoscopy or barium enema), and such studies are inconclusive.  Results of the gastrointestinal evaluations, performed prior to wireless capsule endoscopy, including all endoscopic and radiologic studies, must be kept in the medical record documentation and be available upon request.

Wireless Capsule Endoscopy of the Esophagus

Wireless capsule endoscopy of the esophagus (91111) 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.

Date Last Reviewed - 03/2010

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 PillCam^TM 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.

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.

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

12/2006, Coverage for Wireless Capsule Endoscopy Expanded

10/2010, Criteria for Wireless Capsule Endoscopy of the Small Bowel Revised

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, Esophagus, and Colon, 08/2009

The Accuracy of PillCam ESO Capsule Endoscopy Versus Conventional Upper Endoscopy for the Diagnosis of Esophageal Varices: A Prospective Three-Center Pilot Study, Endoscopy, Volume 38, Number 1, 2006

Esophageal Capsule Endoscopy Versus Esophagogastroduodenoscopy for Evaluating Portal Hypertension: A Perspective Comparative Study of Performance and Tolerance, Endoscopy, Volume 38, Number 1, 2006.

ASGE Technology Status Evaluation Report: Wireless Capsule Endoscopy, Gastrointestinal Endoscopy, Volume 63, Number 4, 04/2006

Blinded Comparison of Esophageal Capsule Endoscopy Versus Conventional Endoscopy for a Diagnosis of Barrett's Esophagus in Patients with Chronic Gastroesophageal Reflux, Gastrointestinal Endoscopy, Volume 65, Number 4, 04/2007

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Tomizawa Y, Wang KK. Changes in screening, prognosis and therapy for esophageal adenocarcinoma in Barrett's esophagus. Curr Opin Gastroenterol. 2009 Jul; 25(4): 358-65

Kav T. Five years' experience with capsule endoscopy in a single center. World J Gastroenterol. 2009 Apr; 15(16): 1934-4

Maiden L. A blinded pilot comparison of capsule endoscopy and small bowel histology in unresponsive celiac disease. Dig Dis Sci. 2009 Jun; 54(6): 1280-3

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Ladas SD., et al. European Society of Gastrointestinal Endoscopy (ESGE): Recommendations (2009) on clinical use of video capsule endoscopy to investigate small-bowel, esophageal and colonic disease. Endoscopy. 2010 Mar; 42(3): 220-7