Highmark Commercial Medical Policy - Pennsylvania
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:

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. 

Procedure Codes
43180, 43191, 43192, 43193, 43194, 43195, 43196, 43197, 43198, 43200, 43201, 43202, 43204, 43205, 43206, 43211, 43212, 43213, 43214, 43215, 43216, 43217, 43220, 43226, 43227, 43229, 43233, 43235, 43236, 43237, 43239, 43241, 43242, 43243, 43244, 43245, 43246, 43247, 43248, 43249, 43250, 43251, 43252, 43254, 43255, 43259, 43266, 43270


Diagnostic EGD

Diagnostic EGD may be considered medically necessary for ANY of the following conditions:

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.

Procedure Codes
43180, 43191, 43192, 43193, 43194, 43195, 43196, 43197, 43198, 43200, 43201, 43202, 43204, 43205, 43206, 43211, 43212, 43213, 43214, 43215, 43216, 43217, 43220, 43226, 43227, 43233, 43235, 43236, 43237, 43239, 43241, 43243, 43244, 43245, 43246, 43247, 43248, 43249, 43250, 43251, 43252, 43254, 43255, 43266


Therapeutic EGD

Therapeutic EGD may be considered medically necessary for ANY of the following conditions:

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.

Procedure Codes
43180, 43191, 43192, 43193, 43194, 43195, 43196, 43197, 43198, 43200, 43201, 43202, 43204, 43205, 43206, 43211, 43212, 43213, 43214, 43215, 43216, 43217, 43220, 43226, 43227, 43229, 43233, 43235, 43236, 43239, 43241, 43243, 43244, 43245, 43246, 43247, 43248, 43249, 43250, 43251, 43252, 43254, 43255, 43266, 43270


Sequential or Periodic EGD

Sequential or periodic EGD may be considered medically necessary for ANY of the following conditions:

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.

Procedure Codes
43180, 43191, 43192, 43193, 43194, 43195, 43196, 43197, 43198, 43200, 43201, 43202, 43204, 43205, 43206, 43211, 43212, 43213, 43214, 43215, 43216, 43217, 43220, 43226, 43227, 43229, 43233, 43235, 43236, 43239, 43241, 43243, 43244, 43245, 43246, 43247, 43248, 43249, 43250, 43251, 43252, 43254, 43255, 43266, 43270


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.

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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.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer: If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

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