MEDICAL POLICY

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APPENDIX
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Adult Upper Gastrointestinal Endoscopy

Number 11.01.504*

Effective Date October 1, 2013

Revision Date(s) N/A

Replaces N/A

*Medicare has a policy.

Policy

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Upper Gastrointestinal Endoscopy (UGI) may be considered medically necessary for patients 18 years and older, when applicable MCG™ (formerly Milliman Care Guidelines®) criteria and specified modifications found in this policy are met. (See Policy Guidelines for modifications to MCG™ criteria.)

UGI is considered not medically necessary for individuals without a documented clinical indication that meets the medical necessity criteria for the procedure.

UGI is considered not medically necessary for routine screening of the upper gastrointestinal tract.

Related Policies

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2.01.20

Esophageal pH Monitoring

2.01.80

Endoscopic Radiofrequency Ablation or Cryoablation for Barrett’s Esophagus

2.01.81

Ingestible pH and Pressure Capsule

2.01.87

Confocal Laser Endomicroscopy

5.01.605

Medical Necessity Criteria for Pharmacy Edits

6.01.33

Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus and Colon

7.02.500

Monitored Anesthesia Care (MAC)

Policy Guidelines

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MCG™ (formerly Milliman Care Guidelines®) is used as a tool to guide medical necessity determinations and utilization management decisions, per licensed agreement, for diagnostic upper gastrointestinal endoscopy. The related MCG™ ORG is Esophagogastroduodenoscopy (EGD), UGI Endoscopy ACG: A-0203 (1).

Modifications to MCG™

The following are criteria modifications to the MCG™:

  • Dyspepsia, as indicated by 1 or more of the following:
  • Failure of medical therapy (e.g. poor response to H2-receptor antagonists, proton pump inhibitors)
  • Added criteria: Trial and failure of daily treatment with proton pump inhibitor for 4 weeks
  • Persistence for 3 months or longer
  • Added criteria: In spite of trial of daily treatment with proton pump inhibitor for 4 weeks
  • Strong family history of cancer
  • Added criteria: Strong family history of gastrointestinal cancer
  • Use of NSAIDS
  • Added criteria: NSAID use is stopped yet GI symptoms continue for 4 weeks
  • Vomiting
  • Added criteria: Vomiting is persistent and/or recurrent
  • Weight loss of more than 3 kg since symptoms began
  • Added criteria: Unintentional weight loss of more than 3 kg since symptoms began
  • Gastroesophageal reflux disease symptoms and 1 or more of the following:
  • Failure of medical therapy (e.g. poor response to empiric twice daily proton pump inhibitor for 4-8 weeks)
  • Added criteria: Trial and failure of daily treatment with proton pump inhibitor for 4 weeks
  • Male 50 years old or greater with 5 years or more of gastroesophageal reflux disease symptoms and 1 or more of the following:
  • Added criteria: Male 50 years old or greater with 5 years or more of gastroesophageal reflux disease symptoms with development of NEW upper GI symptoms and 1 or more of the following:
  • Weight loss of more than 3 kg since symptoms began
  • Added criteria: Unintentional weight loss of more than 3 kg since symptoms began
  • Weight loss, unexplained
  • Added criteria: Unintentional weight loss of more than 3 kg since symptoms began

NOTE: The MCG™ manuals are proprietary and cannot be published and/or distributed. However, on an individual member basis, Premera can share a copy of the specific criteria used to make a utilization management decision. If you would like a copy of these criteria, you may request a copy by calling the Customer Service number on the member’s health plan card.

The plan reserves the right to review and modify MCG™ or Customized Guidelines at any time.

Administrative Guidelines

Medical records may be requested to review the services for medical necessity. Documentation in the medical record must clearly support the medical necessity of the UGI services and include the following information:

  • the individual’s symptoms and duration
  • prior treatment trial, failure, or contraindication
  • reports of previous diagnostic and/or ancillary testing
  • lifestyle modification tried and failed

Coding

There are specific CPT codes for the UGI procedures. (See Coding section)

Place of service

Upper Gastrointestinal Endoscopy is a diagnostic or therapeutic procedure that is performed in an ambulatory surgery center, or an inpatient or outpatient hospital setting.

Description

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Upper gastrointestinal (UGI) endoscopy also known as esophagogastroduodenoscopy (EGD) and gastroscopy is a procedure that examines the upper gastrointestinal tract. A long flexible tube-like instrument is inserted into the body through the mouth permitting visual inspection of the esophagus, stomach and first part of the small intestine (upper duodenum). Primarily a diagnostic tool the fiber-optic endoscope is used to search for cause(s) of severe heartburn (dyspepsia), difficulty swallowing (dysphagia), gastroesophageal reflux disease (GERD), persistent vomiting, and frank GI bleeding. Certain therapeutic procedures such as removal of polyps, endoscopic papillotomy to and to remove stones from the bile duct can also be performed using an endoscope. UGI endoscopy is usually performed under light sedation using an intravenous medication.

Scope

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Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply.

Benefit Application

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N/A

Rationale

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In the absence of a clear cancer diagnosis, professional societies indicate that conservative medical management of gastrointestinal symptoms should be the first intervention before an invasive diagnostic test such as an upper gastrointestinal endoscopy. (2,3)

Practice Guidelines and Position Statements

In December of 2012 the American College of Physicians (ACP) published clinical guidelines for upper endoscopy. (2) The best practice recommendations from the professional organization follow.

Best Practice Advice 1: Upper endoscopy is indicated in men and women with heartburn and alarm symptoms:

  • Dysphagia
  • Bleeding
  • Anemia
  • Weight loss
  • Recurrent vomiting

Best Practice Advice 2: Upper endoscopy is indicated in men and women with:

  • Typical gastroesophageal reflux disease (GERD) symptoms that persist despite a therapeutic trial of 4 to 8 weeks of twice-daily proton-pump inhibitor therapy.
  • Severe erosive esophagitis after a 2-month course of proton-pump inhibitor therapy to assess healing and rule out Barrett esophagus. Recurrent endoscopy after this follow-up examination is not indicated in the absence of Barrett esophagus.
  • History of esophageal stricture that have recurrent symptoms of dysphagia.

Best Practice Advice 3: Upper endoscopy may be indicated:

  • In men older than 50 years with chronic GERD symptoms (symptoms for more than 5 years) and additional risk factors (nocturnal reflux symptoms, hiatal hernia, elevated body mass index, tobacco use, and intra-abdominal distribution of fat) to detect esophageal adenocarcinoma and Barrett esophagus.
  • For surveillance evaluation in men and women with a history of Barrett esophagus. In men and women with Barrett esophagus and no dysplasia, surveillance examinations should occur at intervals no more frequently than 3 to 5 years. More frequent intervals are indicated in patients with Barrett esophagus and dysplasia.

The American College of Gastroenterology (ACG) developed guidelines (3) for the diagnosis and management of GERD. The relevant guidelines information follows:

Establishing the diagnosis of Gastroesophageal reflux disease (GERD)

Recommendations

The diagnosis of GERD is made using some combination of symptom presentation, objective testing with endoscopy, ambulatory reflux monitoring, and response to antisecretory therapy.

  1. A presumptive diagnosis of GERD can be established in the setting of typical symptoms of heartburn and regurgitation. Empiric medical therapy with a PPI is recommended in this setting. (Strong recommendation, moderate level of evidence).
  2. Patients with non-cardiac chest pain suspected due to GERD should have diagnostic evaluation before institution of therapy. (Conditional recommendation, moderate level of evidence) A cardiac cause should be excluded in patients with chest pain before the commencement of a gastrointestinal evaluation (Strong recommendation, low level of evidence)
  3. Barium radiographs should not be performed to diagnose GERD (Strong recommendation, high level of evidence)
  4. Upper endoscopy is not required in the presence of typical GERD symptoms. Endoscopy is recommended in the presence of alarm symptoms and for screening of patients at high risk for complications. Repeat endoscopy is not indicated in patients without Barrett’s esophagus in the absence of new symptoms. (Strong recommendation, moderate level of evidence)
  5. Routine biopsies from the distal esophagus are not recommended specifically to diagnose GERD. (Strong recommendation, moderate level of evidence)
  6. Esophageal manometry is recommended for preoperative evaluation, but has no role in the diagnosis of GERD. (Strong recommendation, low level of evidence)
  7. Ambulatory esophageal reflux monitoring is indicated before consideration of endoscopic or surgical therapy in patients with NERD, as part of the evaluation of patients refractory to PPI therapy, and in situations when the diagnosis of GERD is in question. (Strong recommendation, low level evidence). Ambulatory reflux monitoring is the only test that can assess reflux symptom association (Strong recommendation, low level of evidence).
  8. Ambulatory reflux monitoring is not required in the presence of short or long-segment Barrett’s esophagus to establish a diagnosis of GERD. (Strong recommendation, moderate level of evidence).
  9. Screening for Helicobacter pylori infection is not recommended in GERD. Eradication of H. pylori infection is not routinely required as part of antireflux therapy (Strong recommendation, low level of evidence)

Diagnostic testing for GERD and utility of tests

Diagnostic test

Indication

Highest level of evidence

Recommendation

PPI trial

Classic symptoms, no warning signs

Meta-analysis

Negative trial does not rule out GERD

Barium swallow

Not for GERD diagnosis. Use of evaluation of dysphagia.

Case-control

Do not use unless evaluating for complication (stricture, ring)

Endoscopy

Alarm symptoms, screening of high-risk patients, chest pain

Randomized control trial

Consider early for elderly, those at risk for Barrett’s, noncardiac chest pain, patients unresponsive to PPI

Esophageal

biopsy

Exclude non-GERD causes for symptoms

Case – Control

Not indicated for diagnosis of GERD

Esophageal

manometry

Preoperative evaluation for

surgery

Observational

Not recommended for GERD diagnosis. Rule out achalasia /scleroderma-like esophagus preop

Ambulatory

reflux

monitoring

Preoperatively for non-erosive disease. Refractory GERD symptoms,

GERD diagnosis in question

Observational

Correlate symptoms with reflux, document abnormal acid exposure or

reflux frequency

GERD=gastroesophageal reflux disease; PPI=proton pump inhibitor

References

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  1. MCG™ – 17th Edition (formerly Milliman Care Guidelines®): Esophagogastroduodenoscopy (EGD), UGI Endoscopy ACG: A-0203 (AC). Available online at: http://cgi.careguidelines.com/login-careweb.htm. Last accessed on May 17, 2013.
  2. Shaheen NJ, Weinberg DS, et al. Upper Endoscopy for Gastroesophageal Reflux Disease: Best Practice Advice from the Clinical Guidelines Committee of the American College of Physicians. Annals of Internal Medicine. Vol 157, number 11, pgs. 806-816. Available at URL address: http://annals.org/article.aspx?articleid=1470281. Last accessed May 17, 2013.
  3. Katz PO, Gerson LB, Vila MF. Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. The American College of Gastroenterology. Am J Gastroenterol 2013; 108:308 – 328. Available at URL address: http://gi.org/guideline/diagnosis-and-managemen-of-gastroesophageal-reflux-disease/. Last accessed May 17, 2013.
  4. Medicare National Coverage Determination, Endoscopy (100.2). Available at URL address: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=81&ncdver=1&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=Washington&KeyWord=Endoscopy&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAAAAAAA%3d%3d&. Last accessed May 17, 2013.
  5. Medicare National Coverage Determination, Capsule Endoscopy (L30141). Updated 12/19/12. Available at URL address: http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=30141&ContrId=268&ver=24&ContrVer=1&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=Washington&KeyWord=Endoscopy&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAAAAAAA%3d%3d&. Last accessed May 17, 2013.

Coding

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Codes

Number

Description

CPT

43234

Upper gastrointestinal endoscopy, simple primary examination (e.g., with small diameter flexible endoscope) (separate procedure)

 

43235

Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)

 

43236

… with directed submucosal injection(s) any substance

 

43237

with endoscopic ultrasound examination limited to the esophagus

 

43238

with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), esophagus (includes endoscopic ultrasound examination limited to the esophagus)

 

43239

…with biopsy, single or multiple

 

43240

with transmural drainage of pseudocyst

 

43241

with transendoscopic intraluminal tube or catheter placement

 

43242

…with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum and/or jejunum as appropriate)

 

43243

…with injection sclerosis of esophageal and/or gastric varices

 

43244

…with band ligation of esophageal and/or gastric varices

 

43245

…with dilation of gastric outlet for obstruction (e.g., balloon, guide wire, bougie)

 

43246

…with directed placement of percutaneous gastrostomy tube

 

43247

…with removal of foreign body

 

43248

…with insertion of guide wire followed by dilation of esophagus over guide wire

 

43249

…with balloon dilation of esophagus (less than 30 mm diameter)

 

43250

with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery

 

43251

with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

 

43255

…with control of bleeding, any method

 

43256

…with transendoscopic stent placement (includes predilation) (deleted effective 12/31/13)

 

43257

with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease

 

43258

…with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique (deleted effective 12/31/13)

 

43259

…with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum and/or jejunum as appropriate

ICD-9 Procedure

45.13

Other endoscopy of small intestine

 

45.14

Closed endoscopic biopsy of small intestine

 

45.16

Esophagogastroduodenoscopy (EGD) with closed biopsy

ICD-9 Diagnosis

   
 

211.1

Benign Neoplasm Of Stomach

 

211.3

Benign Neoplasm Of Colon

 

211.4

Benign Neoplasm Of Rectum and Anal canal

 

280.9

Iron deficiency anemia, unspecified

 

285.9

Anemia, unspecified

 

456.1

Esophageal Varices Without Mention Of Bleeding

 

530.10

Esophagitis, Unspecified

 

530.11

Reflux Esophagitis

 

530.13

Eosinophilic esophagitis

 

530.19

Other Esophagitis

 

530.20

Ulcer Of Esophagus Without Bleeding

 

530.3

Stricture And Stenosis Of Esophagus

 

530.81

Esophageal Reflux

 

530.85

Barrett’s Esophagus

 

530.89

Other Diseases Of Esophagus

 

530.9

Unspecified Disorder Of Stomach And Duodenum

 

531.90

Gastric Ulcer, Unspecified As Acute Or Chronic, Without Mention Of Hemorrhage, perforation, or obstruction

 

535.00

Acute Gastritis (Without Mention Of Hemorrhage)

 

535.10

Atrophic Gastritis (Without Mention Of Hemorrhage)

 

535.40

Other Specified Gastritis (Without Mention Of Hemorrhage)

 

535.50

Unspecified Gastritis And Gastroduodenitis (Without Mention Of Hemorrhage)

 

535.60

Duodenitis (Without Mention Of Hemorrhage)

 

536.8

Dyspepsia And Other Specified Disorders Of Function Of Stomach

 

537.89

Gastroduodenal Dis Nec

 

537.9

Unspecified Disorder Of Stomach And Duodenum

 

553.3

Diaphragmatic Hernia Without Mention Of Obstruction Or Gangrene

 

558.9

Other And Unspecified Noninfectious Gastroenteritis And Colitis

 

562.10

Diverticulosis Of Colon (Without Mention Of Hemorrhage)

 

569.3

Hemorrhage Of Rectum And Anus

 

578.0

Hematemesis

 

578.1

Blood In Stool

 

578.9

Hemorrhage Of Gastrointestinal Tract, Unspecified

 

579.0

Celiac Disease

 

786.50

Unspecified chest pain

 

787.01

Nausea With Vomiting

 

787.02

Nausea Alone

 

787.1

Heartburn

 

787.20

Dysphagia, Unspecified Difficulty In Swallowing Nos

 

787.21

Dysphagia, Oral Phase

 

787.22

Dysphagia, Oropharyngeal Phase

 

787.23

Dysphagia, Pharyngeal Phase

 

787.24

Dysphagia, Pharyngoesophageal Phase

 

787.29

Other Dysphagia Cervical Dysphagia Neurogenic Dysphagia

 

787.91

Diarrhea

 

787.99

Other Symptoms Involving Digestive System

 

789.00

Abdominal Pain, Unspecified Site

 

789.01

Abdominal Pain, Right Upper Quadrant

 

789.02

Abdominal Pain, Left Upper Quadrant

 

789.06

Abdominal Pain, Epigastric

 

789.07

Abdominal Pain, Generalized

 

789.09

Abdominal Pain, Other Specified Site

 

792.1

Nonspecific Abnormal Findings In Stool Contents

 

793.4

Nonspecific Abnormal Findings On Radiological And Other Examination Of Gastrointestinal tract

 

V12.72

Personal History Of Colonic Polyps

 

V16.0

Family History Of Malignant Neoplasm Of Gastrointestinal Tract

 

V49.83

Awaiting organ transplant status [history of ulcer or GI bleeding and scheduled for organ transplantation]

 

V76.51

Special Screening For Malignant Neoplasms - Colon

HCPCS

   

ICD-10-CM (effective 10/1/14)

   

ICD-10-PCS (effective 10/1/14)

   

Type of Service

Inpatient

Outpatient

 

Place of Service

ASC

Hospital

 

Appendix

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N/A

History

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Date

Reason

06/10/13

New policy. Add to Utilization Management section. Policy approved with 90-day hold for provider notification. The policy effective date is October 01, 2013.

08/15/13

Update Related Policies. Remove 2.01.520 and add 2.01.20.

09/05/13

Coding update. CPT code 43252 removed from policy as it pertains to another policy (2.01.87).


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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