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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. Cave MD PhD, David R. “Wireless video capsule endoscopy.” Clinical Perspectives in Gastroenterology July/Aug 2003; 203-7.
  2. Costamagna, Guido; Saumil K Shah; Maria Elena Riccioni; et al. “A prospective trial comparing small bowel radiographs and video capsule endoscopy for suspected small bowel disease.” Gastroenterology Oct 2002 123:4.
  3. Eil, C; S Remke; A. May; et al. “The first prospective controlled trial comparing wireless capsule endoscopy with push enteroscopy in chronic gastrointestinal bleeding.” Endoscopy 2002:34(9); 685-689.
  4. Eliakim, Rami; Doron Foscher; Alain Suissa; et al. “Wireless capsule video endoscopy is a superior diagnostic tool in comparison to barium follow-through and computerized tomography in patients with suspected Crohn’s disease.” European Journal of Gastroenterology and Hepatology 2003: 15(4);363-367.
  5. Fireman, A; E Mahajna; E Broide; et al. “Diagnosing small bowel Crohn’s disease with wireless capsule endoscopy.” Gut 2003;52:390-392.
  6. Giardiello, F. M., Allen, J. I., Axilbund, J. E., Boland, R., Burke, C. A., Burt, R. W., et al. (2014). Guidelines on Genetic Evaluation and Management of Lynch Syndrome: A Consensus Statement by the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol, 109:1159-1179.
  7. Goldfarb GA, Neil I; Amy Phillips, PharmD; Mitchell Conn, MD; et al. “Economic and health outcomes of capsule endoscopy: opportunities for improved management of the diagnostic process for obscure gastrointestinal bleeding.” Disease Management 5(3) 2002: 123-133.
  8. Haanstra, J. F., Al-Toma, A., Dekker, E., Vanhoutvin, S. A. L. W., Nagengast, F. M., Mathus-Vliegen, E. M., et al. (2014). Prevalence of small-bowel neoplasia in Lynch syndrome assessed by video capsule endoscopy. Gut, 64: 1578-1583.
  9. Hayes, Inc. (2011). Capsule Endoscopy for the Diagnosis of Small Bowel Crohn’s Disease. Philadelphia, PA: Hayes, Inc.
  10. Hayes, Inc. (2016). Capsule Endoscopy of the Small Bowel in Adults with Familial Adenomatous Polyposis (FAP). Philadelphia, PA: Hayes, Inc.
  11. Iaquinto G, Fornasarig M, Quaia M, Giardullo N, D'Onofrio V, Iaquinto S, et al. Capsule endoscopy is useful and safe for small-bowel surveillance in familial adenomatous polyposis. Gastrointest Endosc. 2008;67(1):61.
  12. Koornstra, J. J. (2012) Small bowel endoscopy in familial adenomatous polyposis and Lynch syndrome. Best Practice & Research Clinical Gastroenterology, 26: 359–368
  13. National Institute for Health and Clinical Excellence (2004). Guideline: Wireless capsule endoscopy for investigation of the small bowel (IPG101). Manchester, England: National Institute for Health and Care Excellence (NICE).
  14. Shergill, A. K., Lightdale, J. R., Bruining, D. H., Acosta, R. D., Chandrasekhara V., Chathadi, K. V., et al. (2015). The role of endoscopy in inflammatory bowel disease. Gastrointestinal Endoscopy, 81(5), 1101-1121. Copyright © 2015 American Society for Gastrointestinal Endoscopy.
  15. 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. Am J Gastroenterol, 110(2): 223–263.

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Policy activity

  • 08/13/2002 - Date of origin
  • 10/01/2016 - Effective date
Review date
  • 09/2016
Revision date
  • 09/28/2016

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