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Coverage criteria policies

Capsule endoscopy

These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Wireless Capsule Endoscopy does not require prior authorization.

Coverage

Wireless capsule endoscopy is covered per the indications listed below.

Indications that are covered

FDA approved wireless capsule endoscopy (WCE) for imaging of the small bowel will be covered for members when:

  1. Wireless capsule endoscopy is performed by physicians trained in endoscopy or in an independent diagnostic testing facility under the general supervision of a physician trained in endoscopy procedures; and
  2. Standard endoscopic and imaging evaluations have been completed and results were inconclusive; and
  3. The member has one of the following conditions:
    1. An obscure source of gastrointestinal (GI) bleeding; or
    2. Suspected Crohn’s disease; or
    3. Known Crohn’s disease when member remains symptomatic after treatment; and there is no suspected or confirmed GI obstruction, stricture, fistulae or swallowing disorder; or
    4. Suspected small-bowel tumor; or
    5. Diagnosis of Peutz-Jeghers syndrome (PJS). Screening for small bowel cancer is covered for members with PJS beginning at age eight years and every three years thereafter if indicated.

Indications that are not covered

  1. Wireless capsule endoscopy is not covered when there is suspected or confirmed GI obstruction, stricture, fistulae or swallowing disorder.
  2. Wireless capsule endoscopy is not considered medically necessary for the screening or management of any other conditions because there is conflicting and insufficient evidence to determine the safety and efficacy or its effect on health care outcomes, including but not limited to:
    1. Lynch syndrome, familial adenomatous polyposis (FAP) syndrome, or other genetic gastrointestinal syndromes at risk for tumors
    2. Other polyposis syndromes, other inflammatory conditions, neoplasms and malabsorption syndromes of the small intestine, hematemesis, or chronic abdominal pain

Definitions

Wireless capsule endoscopy - A diagnostic test that involves the patient swallowing a disposable imaging capsule. The capsule contains video imaging, self-illumination, and image transmission modules as well as a battery supply that lasts for up to 8 hours. The indwelling camera takes images at a rate of 2 frames per second and uses wireless radio-transmission to send the images to a receiving recorder device that the patient wears around the waist. The current proposed use of this technology is with patients who have digestive tract bleeding for which other testing hasn't found a cause.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes

Description

91110

Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus through
ileum, with interpretation and report

91111

Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus with
interpretation and report

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee: Gurudu, S. R., Bruining, D. H., Acosta, R. D., Eloubeidi, M. A., Faulx, A. L., Khashab, M. A., … DeWitt, J. M. (2017). The role of endoscopy in the management of suspected small-bowel bleeding. Gastrointestinal Endoscopy, 85(1), 22-31. doi: http://dx.doi.org/10.1016/j.gie.2016.06.013
  2. Cave, D. Wireless video capsule endoscopy. In: UpToDate, Saltzman, J. R. (Ed), UpToDate, Waltham, MA. (Accessed on June 8, 2018.)
  3. Cusack, J. C. Diagnosis and staging of small bowel neoplasms. In: UpToDate, Goldberg, R. M. (Ed), UpToDate, Waltham, MA. (Accessed on June 13, 2018.)
  4. Giardiello, F. M., Allen, J. I., Axilbund, J. E., Boland, C. R., Burke, C. A., Burt, R. W., …. Rex, D. K. (2014). Guidelines on genetic evaluation and management of lynch syndrome: a consensus statement by the U.S. Multi-Society Task Force on Colorectal Cancer. The American Journal of Gastroenterology, 109, 1159-1179. doi: 10.1038/ajg.2014.186
  5. Haanstra, J. F., Al-Toma, A., Dekker, E., Vanhoutvin, S. A. L. W., Nagengast, F. M., Mathus-Vliegen, E. M., …. Koornstra, J. J. (2015). Prevalence of small-bowel neoplasia in Lynch syndrome assessed by video capsule endoscopy. Gut, 64, 1578-1583. doi:10.1136/gutjnl-2014-307348
  6. Haanstra, J. F., Al-Toma, A., Dekkerj, E., Vanhoutvin, S. A. L. W., Nagengast, F. M., Mathus-Vliegen, E. M., … Koornstra, J. J. (2017). Incidence of small bowel neoplasia in Lynch syndrome assessed by video capsule endoscopy. Endoscopy International Open, 05, E622–E626. doi: 10.1055/s-0043-111723
  7. Hayes, Inc. Hayes Medical Technology Directory Report. Capsule Endoscopy for the Diagnosis of Small Bowel Crohn’s Disease. Lansdale, PA: Hayes, Inc.; March, 2017. Reviewed March, 2018.
  8. Iaquinto, G., Fornasarig, M., Quaia, M., Giardullo, N., D'Onofrio, V., Iaquinto, S., … Cannizzaro, R. (2008). Capsule endoscopy is useful and safe for small-bowel surveillance in familial adenomatous polyposis. Gastrointestinal Endoscopy, 67(1), 61-67. doi:10.1016/j.gie.2007.07.048
  9. Koornstra, J. J. (2012). Small bowel endoscopy in familial adenomatous polyposis and Lynch syndrome. Best Practice & Research Clinical Gastroenterology, 26, 359–368. doi:10.1016/j.bpg.2012.01.022
  10. National Institute for Clinical Excellence. (2004). Wireless capsule endoscopy for investigation of the small bowel. NICE guideline (IPG101).
  11. Pasha, S. F., Leighton, J. A., Das, A., Harrison, M. E., Decker, G. A., Fleischer, D. E., & Sharma, V. K. (2008). Double-balloon enteroscopy and capsule endoscopy have comparable diagnostic yield in small-bowel disease: A meta-analysis. Clinical Gastroenterology and Hepatology, 6, 671–676. doi:10.1016/j.cgh.2008.01.005’\
  12. Pennazio, M., Spada, C., Eliakim, R., Keuchel, M., May, A., Mulder, C. J., … Gralnek, I. M. (2015). Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy, 47(4), 352-76. doi: 10.1055/s-0034-1391855
  13. Shergill, A. K., Lightdale, J. R., Bruining, D. H., Acosta, R. D., Chandrasekhara V., Chathadi, K. V., … DeWitt, J. M. (2015). The role of endoscopy in inflammatory bowel disease. Gastrointestinal Endoscopy, 81(5), 1101-1121.
  14. Syngal, S., Brand, R. E., Church, J. M., Giardiello, F. M., Hampel, H. L., & Burt, R. W. (2015). ACG clinical guideline: Genetic testing and management of hereditary gastrointestinal cancer syndromes. The American Journal of Gastroenterology, 110(2), 223–263. doi:10.1038/ajg.2014.435
  15. Xue, M., Chen, X., Shi, L., Si, J., Wang, L, & Chen, S. (2015). Small-bowel capsule endoscopy in patients with unexplained chronic abdominal pain: A systematic review. Gastrointestinal Endoscopy, 81(1), 186-193. http://dx.doi.org/10.1016/j.gie.2014.04.062

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Policy activity

  • 08/13/2002 - Date of origin
  • 05/01/2018 - Effective date
Review date
  • 05/2018
Revision date
  • 09/28/2016

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