MEDICAL POLICY

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DESCRIPTION
SCOPE
BENEFIT APPLICATION
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APPENDIX
HISTORY

Upper Gastrointestinal (UGI) Endoscopy for Adults

Number 2.01.533*

Effective Date May 12, 2015

Revision Date(s) 05/12/15; 12/22/14; 10/13/14; 08/11/14; 10/01/13

Replaces 11.01.504

*Medicare has a policy.

Policy

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Upper Gastrointestinal Endoscopy (UGI) may be considered medically necessary for patients 19 years of age and older, for the following indications when criteria are met:

Malignant Indications

Upper Gastrointestinal Endoscopy (UGI) may be considered medically necessary for any of the following indications:

  • Dysplasia
  • Esophageal cancer
  • Familial adenomatous polyposis
  • Gastric cancer
  • History of Lynch Syndrome (HNPCC or hereditary nonpolyposis colorectal cancer)
  • Head/neck cancer
  • In situations where clinical features are highly suspicious for UGI malignancy (e.g. epigastric mass found on x-ray, abnormal Barium study, and others)
  • Metaplastic columnar or glandular epithelium
  • Patients with prior adenomatous gastric polyps or sessile polyps (rare)
  • Strong family history of gastrointestinal cancer
  • Tylosis

Non-malignant Indications

Upper Gastrointestinal (UGI) Endoscopy may be considered medically necessary for any of the following indications when criteria are met:

Alarm Symptoms

Evaluation of any of the following alarm symptoms that may be associated with reflux symptoms or dyspepsia (heartburn):

  • Anemia or gastrointestinal bleeding (see GI Bleed section below)
  • Epigastric mass (found on examination)
  • Persistent vomiting of unknown cause, including vomiting blood
  • Swallowing that is difficult (dysphagia)
  • Unintentional weight loss of 3 kg (approx. 6.6 lbs.) or more since symptoms started

Follow-up of Known Conditions

Evaluation of any of the following indications that may be associated with reflux symptoms or dyspepsia:

  • Anorexia of unknown cause
  • Chest pain that is unusual, and that persists after heart disease is ruled out (See Rationale)
  • Erosive esophagitis
  • Esophageal varices, with or without bleeding
  • History of gastric surgery
  • NSAID use is stopped yet symptoms continue
  • Swallowing that is difficult (dysphagia)
  • Swallowing that is painful (odynophagia)

Gastrointestinal (GI) Bleeding Symptoms

Evaluation of GI Bleeding when 1 or more of the following are present:

  • Blood in stools when a colonoscopy is negative or inconclusive
  • Chronic GI bleeding
  • History of long term use of anticoagulation therapy
  • History of long term use of NSAIDs for arthritis
  • Iron deficiency anemia
  • Persistent blood tinged vomitus

Gastroesophageal Reflux (GERD) Symptoms

Evaluation of GERD symptoms that are present for at least 3 months and persist after 4-weeks of treatment with daily proton pump inhibitor therapy.

Upper Gastrointestinal (UGI) Tract Symptoms

Evaluation of UGI symptoms (dyspepsia/heartburn) that are present for at least 3 months, and persist after 4- weeks of medical management including treatment with daily proton pump inhibitor therapy.

Other Upper Gastrointestinal (UGI) Indications

UGI endoscopy may be considered medically necessary for any of the following indications:

  • Achalasia
  • Barrett’s esophagus (BE) surveillance based on the pathology:
  • High-grade dysplasia: repeat EGD every 3 months after initial biopsy for 1 year, then annually
  • Low grade dysplasia: repeat EGD twice within 12 months after initial biopsy, then annually if pathology unchanged
  • No dysplasia: repeat EGD one time within 12 months after initial biopsy; then every 3 years if pathology unchanged
  • Celiac disease (Duodenal disease) and ALL of the following:
  • GI symptoms are consistent with chronic malabsorption and
  • Serology tests are positive for celiac disease and
  • Conservative medical management was tried and failed to relieve symptoms (e.g. gluten-free diet)
  • Cirrhosis upon initial diagnosis, one UGI endoscopy to screen for esophageal varices
  • Crohn disease that involves the esophagus, stomach or duodenum
  • Gastric, peptic, esophageal ulcer confirmation when:
  • Conservative medical management was tried and failed to relieve symptoms (e.g. cessation of NSAIDs, trial of appropriate medication) or
  • Conservative medical management is contraindicated
  • Ingestion of a caustic agent
  • Ingested foreign body, known or suspected
  • Male patient, aged 50 years or older with 5 years or more of GERD symptoms with development of NEW UGI symptoms and 1 or more of the following:
  • Elevated body mass index (BMI)
  • Excess abdominal fat (intra-abdominal fat distribution)
  • Hiatal hernia
  • Night-time symptoms of reflux
  • Tobacco use
  • Patients scheduled for a gastric bypass surgery
  • Patients scheduled for organ transplantation
  • Pernicious anemia symptoms (when other testing is inconclusive)
  • UGI tract stricture or obstruction

Documentation in the medical record must support the medical necessity for the procedure. (See Policy Guidelines)

UGI endoscopy is considered not medically necessary for any of the following:

  • Evaluation of UGI symptoms that are chronic, non-progressive, atypical for known organic disease, and is considered functional in origin (infrequent exceptions exist when a one-time endoscopic examination may be done to rule out organic disease, in cases where symptoms are unresponsive to therapy)
  • Evaluation of uncomplicated heartburn that responds to conservative medical management
  • Evaluation of UGI conditions/diagnoses when the endoscopy results will not alter management
  • Evaluation of X-ray findings showing any of the following:
  • Deformed duodenal bulb that is asymptomatic or has responded to ulcer therapy
  • Duodenal bulb ulcer that is uncomplicated and has responded to therapy
  • Sliding hiatal hernia that is asymptomatic or uncomplicated
  • Routine screening of the upper gastrointestinal (UGI) tract in the absence of a clinical indication

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

Note: See Policy Guidelines for Documentation information and Definition of Terms

Related Policies

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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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Contraindications to Upper GI Endoscopy

Absolute contraindications to endoscopy from the Merck Manual (1) include:

  • Acute myocardial infarction (unless active, life-threatening hemorrhage is present)
  • Fulminant colitis
  • Perforated viscus (e.g., esophagus, stomach, intestine)
  • Peritonitis
  • Severe cardiac decompensation
  • Shock

Relative contraindications to endoscopy from the Merck Manual (1) include:

  • Cardiac arrhythmias
  • Coma (unless the patient is intubated)
  • Poor patient cooperation
  • Recent myocardial ischemia

Definition of Terms

  • Achalasia: An esophageal motility disorder involving the smooth muscle of the esophagus and the lower esophageal sphincter (LES)
  • Barrett esophagus: The replacement of the normal squamous epithelium of the esophagus that is damaged by gastroesophageal reflux disease with metaplastic columnar or glandular epithelium that is predisposed to esophageal adenocarcinoma
  • Crohn's or Crohn disease: Also known as Crohn syndrome and regional enteritis, this is a type of inflammatory bowel disease (IBD) that may affect any part of the gastrointestinal tract from mouth to anus
  • Celiac disease (also known as celiac sprue or gluten-sensitive enteropathy): An autoimmune digestive disorder. When foods with gluten are eaten the body’s reaction causes damage to the intestinal lining.
  • Cirrhosis: Scarring of the liver because of injury or long-term disease. The most common causes in the U.S. are chronic alcoholism and hepatitis. A small number of people with cirrhosis get liver cancer. (See esophageal varices)
  • Dyspepsia: A chronic or recurrent pain or discomfort centered in the upper abdomen; patients with predominant or frequent (more than once a week) heartburn or acid regurgitation (see GERD)
  • Dysphagia: Difficulty or inability to swallow
  • Esophageal varices: Abnormally enlarged veins in the lower part of the esophagus, usually formed in the presence of a clot or when scar tissue in the liver obstructs blood flow
  • Gastrointestinal: A broad term relating to the organs and muscles of the digestive system (e.g. esophagus, stomach, small/large intestine)
  • GERD: The acronym for gastroesophageal reflux disease, a digestive disorder affecting the lower esophageal sphincter (LES); (see Dyspepsia)
  • Odynophagia: The sensation of burning, squeezing pain when swallowing
  • Pernicious anemia: A vitamin B12 deficiency which reduces the body’s ability to make healthy red blood cells. (Symptoms include but are not limited to anemia, extreme fatigue, pallor, red tongue, shortness of breath, tingling/numbness/coldness of hands and feet)
  • Medical Management: Includes non-invasive interventions such as acid suppressive medications, nutritional counseling for dietary changes, weight loss counseling, environmental changes (e.g., elevating the head of bed) and others
  • Tylosis: A rare autosomal dominant syndrome that causes thickened skin on the palms of the hands and soles of the feet, associated with increased risk of esophageal squamous cell carcinoma
  • Varices: See esophageal varices above

Documentation

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 patient’s symptoms and duration
  • Prior treatment trial, failure, or contraindication to proton pump inhibitors or other conservative medical management such as NSAID cessation (if applicable)
  • Reports of previous diagnostic and/or ancillary testing
  • Lifestyle modification(s) that was tried and failed (e.g. diet change, weight loss, elevating head of bed, etc.)

Coding

Specific CPT codes for the UGI procedures are in the 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 using an endoscope, that is a flexible tube-like instrument containing light transmitting glass fibers that return a magnified image directly or by video.

The instrument is inserted through the mouth for a visual inspection of the esophagus, stomach and first part of the small intestine (upper duodenum).

Primarily a diagnostic tool the 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 can be performed using an endoscope such as removal of polyps, papilla and removal of stones from the bile duct.

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. This medical policy does not apply to Medicare Advantage.

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, 7)

Non-cardiac Chest Pain (NCCP)

NCCP describes pain in the chest area that is similar to heart muscle pain (also called angina) in patients who do not have heart disease confirmed by a cardiac work-up. NCCP occurs in men and women of all ages as well as children. Because of the anatomy of the chest cavity with the heart and esophagus resting near each other, pain from either organ may be similar, which makes it hard to differentiate the pain source. Patients, who continue to have chest pain after a cardiac work up fails to provide evidence of heart disease, may need a GI work up. The American College of Gastroenterology makes a strong recommendation stating that “a cardiac cause should be excluded in patients with chest pain before the commencement of a gastrointestinal evaluation”. (4)

Medicare National Coverage

The coverage statement is that “Endoscopic procedures are covered when reasonable and necessary for the individual patient”. (5,6)

Practice Guidelines and Position Statements

American College of Physicians (ACP)

In December of 2012 the American College of Physicians (ACP) published clinical guidelines for upper endoscopy. (7) 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:

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

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.

American College of Gastroenterology (ACG)

The American College of Gastroenterology (ACG) developed guidelines (8) for the diagnosis and management of GERD. The relevant guideline information follows:

Establishing the diagnosis of Gastroesophageal reflux disease (GERD) from the ACG

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

American Society for Gastrointestinal Endoscopy (ASGE)

In 2012, the ASGE (9) published updated SOP recommendations for esophagogastroduodenoscopy (EGD) with specific indications statements as follows:

Esophagogastroduodenoscopy is generally indicated for evaluating:

  1. Upper abdominal symptoms that persist despite an appropriate trial of therapy.
  2. Upper abdominal symptoms associated with other symptoms or signs suggesting structural disease (e.g., anorexia and weight loss) or new-onset symptoms in patients older than 50 years of age.
  3. Dysphagia or odynophagia.
  4. Esophageal reflux symptoms that persist or recur despite appropriate therapy.
  5. Persistent vomiting of unknown cause.
  6. diseases in which the presence of upper GI pathology might modify other planned management. Examples include patients who have a history of ulcer or GI bleeding who are scheduled for organ transplantation, long-term anti-coagulation, or non-steroidal anti-inflammatory drug therapy for arthritis, and those with cancer of the head and neck.
  7. adenomatous polyposis syndromes.
  8. confirmation and specific histological diagnosis of radiologically demonstrated lesions:
  1. Suspected neoplastic lesion
  2. Gastric or esophageal ulcer
  3. Upper tract stricture or obstruction
  1. bleeding:
  1. In patients with active or recent bleeding
  2. For presumed chronic blood loss and for iron deficiency anemia when the clinical situation suggests an upper GI source or when colonoscopy does not provide an explanation
  1. sampling of tissue or fluid is indicated.
  2. patients with suspected portal hypertension to document or treat esophageal varices.
  3. assess acute injury after caustic ingestion.
  4. assess diarrhea in patient suspected of having small-bowel disease (e.g. celiac disease)
  5. of bleeding lesions such as ulcers, tumors, vascular abnormalities (e.g., electrocoagulation, heater probe, laser photocoagulation, or injection therapy).
  6. of foreign bodies.
  7. of selected lesions.
  8. of feeding or drainage tubes (peroral, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy).
  9. and stenting of stenotic lesions (e.g., with transendoscopic balloon dilators or dilation systems using guide wires).
  10. of achalasia (e.g., botulinum toxin, balloon dilation).
  11. treatment of stenosing neoplasms (e.g., laser, multi-polar electrocoagulation, stent placement).
  12. therapy of intestinal metaplasia.
  13. evaluation of anatomic reconstructions typical of modern foregut surgery (e.g., evaluation of anastomotic leak and patency, fundoplication formation, pouch configuration during bariatric surgery).
  14. of operative complications (e.g., dilation of anastomotic strictures, stenting of anastomotic disruption, fistula, or leak in selected circumstances).

Esophagogastroduodenoscopy is generally not indicated for evaluating:

  1. Symptoms that are considered functional in origin (there are exceptions in which an endoscopic examination may be done once to rule out organic disease, especially if symptoms are unresponsive to therapy or symptoms recur that are different in nature from the original symptoms).
  2. Metastatic adenocarcinoma of unknown primary site when the results will not alter management.
  3. Radiographical findings of:
  1. Asymptomatic or uncomplicated sliding hiatal hernia
  2. Uncomplicated duodenal ulcer that has responded to therapy
  3. Deformed duodenal bulb when symptoms are absent or respond adequately to ulcer therapy

Sequential or periodic EGD may be indicated for:

  1. Surveillance for malignancy in patients with pre-malignant conditions (e.g. Barrett's esophagus, polyposis syndromes, gastric adenomas, tylosis or previous caustic ingestion).

Sequential or periodic EGD is generally not indicated for:

  1. Surveillance for malignancy in patients with gastric atrophy, pernicious anemia, or fundic gland or hyperplastic polyps, gastric intestinal metaplasia, or prior gastric operations for benign disease.
  2. Surveillance of healed benign disease such as esophagitis or gastric or duodenal ulcer.

American Association for the Study of Liver Diseases (AASLD)

In 2007 the AASLD published the following recommendations (10) for Prevention and Management of Gastroesophageal Varices and Variceal Hemorrhage in Cirrhosis:

  1. Screening esophagogastroduodenoscopy (EGD) for the diagnosis of esophageal and gastric varices is recommended when the diagnosis of cirrhosis is made (Class IIa, Level C).
  2. On EGD, esophageal varices should be graded as small or large (>5 mm) with the latter classification encompassing medium-sized varices when 3 grades are used (small, medium, large). The presence or absence of red signs (red wale marks or red spots) on varices should be noted (Class IIa, Level C).
  3. In patients with cirrhosis who do not have varices, nonselective beta-blockers cannot be recommended to prevent their development (Class III, Level B).
  4. In patients who have compensated cirrhosis and no varices on the initial EGD, it should be repeated in 3 years (Class I, Level C). If there is evidence of hepatic decompensation, EGD should be done at that time and repeated annually (Class I, Level C).
  5. In patients with cirrhosis and small varices that have not bled but have criteria for increased risk of hemorrhage (Child B/C or presence of red wale marks on varices), nonselective beta-blockers should be used for the prevention of first variceal hemorrhage (Class IIa, Level C).
  6. In patients with cirrhosis and small varices that have not bled and have no criteria for increased risk of bleeding, beta-blockers can be used, although their long-term benefit has not been established (Class III, Level B).
  7. In patients with small varices that have not bled and who are not receiving beta-blockers, EGD should be repeated in 2 years (Class I, Level C). If there is evidence of hepatic decompensation, EGD should be done at that time and repeated annually (Class I, Level C). In patients with small varices who receive beta-blockers, a follow-up EGD is not necessary.
  8. In patients with medium/large varices that have not bled but have a high risk of hemorrhage (Child B/C or variceal red wale markings on endoscopy), nonselective beta-blockers (propranolol or nadolol) or EVL may be recommended for the prevention of first variceal hemorrhage (Class I, Level A).
  9. In patients with medium/large varices that have not bled and are not at the highest risk of hemorrhage (Child A patients and no red signs), nonselective beta-blockers (propranolol, nadolol) are preferred and EVL should be considered in patients with contraindications or intolerance or non-compliance to beta-blockers (Class I, Level A).
  10. If a patient is placed on a nonselective beta-blocker, it should be adjusted to the maximal tolerated dose; follow-up surveillance EGD is unnecessary. If a patient is treated with EVL, it should be repeated every 1-2 weeks until obliteration with the first surveillance EGD performed 1-3 months after obliteration and then every 6-12 months to check for variceal recurrence (Class I, Level C).
  11. Nitrates (either alone or in combination with beta-blockers), shunt therapy, or sclerotherapy should not be used in the primary prophylaxis of variceal hemorrhage (Class III, Level A).
  12. Acute GI hemorrhage in a patient with cirrhosis is an emergency that requires prompt attention with intravascular volume support and blood transfusions, being careful to maintain a hemoglobin of 8g/dL (Class I, Level B).
  13. Short-term (maximum 7 days) antibiotic prophylaxis should be instituted in any patient with cirrhosis and GI hemorrhage (Class I, Level A). Oral norfloxacin (400 mg BID) or intravenous ciprofloxacin (in patients in whom oral administration is not possible) is the recommended antibiotic (Class I, Level A). In patients with advanced cirrhosis intravenous ceftriaxone (1 g/day) may be preferable particularly in centers with a high prevalence of quinolone-resistant organisms (Class I, Level B).
  14. Pharmacological therapy (somatostatin or its analogues octreotide and vapreotide; terlipressin) should be initiated as soon as variceal hemorrhage is suspected and continued for 3-5 days after diagnosis is confirmed (Class I, Level A).
  15. EGD, performed within 12 hours, should be used to make the diagnosis and to treat variceal hemorrhage, either with EVL or sclerotherapy (Class I, Level A).
  16. TIPS is indicated in patients in whom hemorrhage from esophageal varices cannot be controlled or in whom bleeding recurs despite combined pharmacological and endoscopic therapy (Class I, Level C).
  17. Balloon tamponade should be used as a temporizing measure (maximum 24 hours) in patients with uncontrollable bleeding for whom a more definitive therapy (e.g., TIPS or endoscopic therapy) is planned (Class I, Level B).
  18. In patients who bleed from gastric fundal varices, endoscopic variceal obturation using tissue adhesives such as cyanoacrylate is preferred, where available. Otherwise, EVL is an option (Class I, Level B).
  19. A TIPS should be considered in patients in whom hemorrhage from fundal varices cannot be controlled or in whom bleeding recurs despite combined pharmacological and endoscopic therapy (Class I, Level B).
  20. Patients with cirrhosis who survive an episode of active variceal hemorrhage should receive therapy to prevent recurrence of variceal hemorrhage (secondary prophylaxis) (Class I, Level A).
  21. Combination of nonselective beta-blockers plus EVL is the best option for secondary prophylaxis of variceal hemorrhage (Class I, Level A).
  22. The nonselective beta-blocker should be adjusted to the maximal tolerated dose. EVL should be repeated every 1-2 weeks until obliteration with the first surveillance EGD performed 1-3 months after obliteration and then every 6-12 months to check for variceal recurrence (Class I, Level C).
  23. TIPS should be considered in patients who are Child A or B who experience recurrent variceal hemorrhage despite combination pharmacological and endoscopic therapy. In centers where the expertise is available, surgical shunt can be considered in Child A patients (Class I, Level A).
  24. Patients who are otherwise transplant candidates should be referred to a transplant center for evaluation (Class I, Level C).

References

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  1. Chan WW ed. Endoscopy. The Merck Manual Online. Merck Research Laboratories; revised February 2013. Available at: http://www.merck.com/mmpe/sec02/ch009/ch009c.html. Accessed April, 2015.
  2. 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. PMID 23419381. Available at URL address: http://gi.org/guideline/diagnosis-and-managemen-of-gastroesophageal-reflux-disease/. Accessed April, 2015.
  3. Choosing Wisely® Campaign. American Gastroenterological Association: Five things physician and patients should question. The ABIM Foundation 2012. Available at: http://www.choosingwisely.org/wp-content/uploads/2013/01/5things_12_factsheet_AGA.pdf. Accessed April, 2015.
  4. Achem SR. American College of Gastroenterology. Non-cardiac chest pain. Patient education and resource center updated July 2013 [online]. Available online at URL address: http://patients.gi.org/topics/non-cardiac-chest-pain/. Accessed April, 2015.
  5. 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&. Accessed April, 2015.
  6. 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&. Accessed April, 2015.
  7. 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. PMID 23208168. Available at URL address: http://annals.org/article.aspx?articleid=1470281. Accessed April, 2015
  8. 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. PMID 15184824. Available at URL address: http://gi.org/guideline/diagnosis-and-managemen-of-gastroesophageal-reflux-disease/. Accessed April, 2015.
  9. ASGE Standards of Practice Committee, Early DS, Ben-Menachem T, et al. Appropriate use of GI endoscopy. Specific indications statements from the SOP committee. Gastrointest Endosc 2012; 75(6):1127-1131. PMID 22624807. Available online at: http://www.asge.org/clinicalpractice/clinical-practice.aspx?id=352. Accessed April, 2015.
  10. Garcia-Tsao G, Sanyal AJ, Grace ND, et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 2007 Sep, 46(3):922-938. AASLD practice guidelines. PMID 17879356. Available at http://www.aasld.org/publications/practice-guidelines-0. Accessed April, 2015.
  11. Cerulli MA. Upper gastrointestinal bleeding. eMedicine Medicine Topic 3565.eMedicine.com; updated May 2014. Available at: http://www.emedicine.com/med/topic3565.htm. Accessed April, 2015.
  12. Liu, R., Kriz, H., Thielke, A., Vandegriff, S., & King, V. (2012). Upper Endoscopy for Gastroesophageal Reflux Disease (GERD) and Upper Gastrointestinal (GI) Symptoms. Portland, OR: Center for Evidence-based Policy, Oregon Health and Science University. Available at: http://www.hca.wa.gov/hta/documents/upper_endoscopy_final_published_041812.pdf. Accessed April, 2015.
  13. American Society for Gastrointestinal Endoscopy, Hwang JH, Shergill AK, et al. The role of endoscopy in the management of variceal hemorrhage. Gastrointest Endosc 2014 Aug; 80(2): 221-227. PMID 25034836. Available online at: http://www.asge.org/clinicalpractice/clinical-practice.aspx?id=352. Accessed April, 2015.

Coding

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Codes

Number

Description

CPT

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

 

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

 

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)

 

43257

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

 

43266

Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)

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

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).

08/11/14

Annual Review. Changed the title to Upper Gastrointestingal (UGI) Endoscopy for Adults, for ease of finding the document. Policy extensively re-written. Policy statements reorganized but intent is unchanged. Revised “adult” to patients of 19 years old and older. Policy updated with literature search through June, 2014. Reference to using MCG as a tool to guide determinations is removed. References 6-10 added; others renumbered/removed. New CPT codes 43233, 43253, 43254, 43266, 43270 added for 2014. Policy statements changed as noted.

10/13/14

Interim Update. Removed Policy statement under UGI Tract Symptoms header that states “interferes with activities of daily living on 3 or more days a week”. Extensive editorial changes to consolidate and simplify criteria in the policy statements. Clarification for non-cardiac chest pain (NCCP) added to the rationale section. Reference 5 added; others renumbered. Policy statements revised, intent is unchanged.

12/22/14

Interim Update. Policy reclassified, renumbered from 11.01.504 to 2.01.533 and moved from UM section to Medicine section. Reference 1 removed; others renumbered and broken hyperlinks repaired. Policy statements unchanged.

05/12/15

Annual Review. Policy updated with literature search through April, 2015. Added esophageal varices with or without bleeding to the Follow Up of Known Conditions list. Added new cirrhosis diagnosis to the Other Indications list. Cirrhosis added to Definition of Terms. Added AASLD recommendations to Practice Guidelines and Position Statements section. References 10,13 added; others renumbered. Policy statements changed as noted. Remove informational CPT codes: 43233-34, 43237, 43240-41, 43243-43256; 43258-59; 43270; remove ICD-9 diagnosis codes, as they do not affect policy adjudication.

06/02/15

Update Related Policies. Remove 2.01.81 as it was archived.


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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