Payer / Policy Name Link to Policy Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy) Medicare Part B Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsy Capsule Endoscopy Celiac disease Suspected Crohn's disease Suspected small intestinal bleeding Premera BCBS Obscure GI bleed OGIB: Prior inconclusive upper AND lower gastrointestinal endoscopic studies Suspected Crohn's disease https://www.premera.com/stellent/groups/public/documents/medicalpolicy/cmi_003621.htm Cigna Obscure GI bleed Capsule Endoscopy Suspected Crohn's disease Suspected small bowel tumor Celiac disease Humana Obscure GI bleed Unlisted Capsule Endoscopy Suspected Crohn's or Celiac disease Polyposis syndromes Suspected small intestinal tumors United Healthcare GI blood loss and/or iron-deficiency anemia Suspected or known Crohn's disease Celiac disease Suspected small bowel tumor Celiac disease: Prior serology or GI endoscopy are not diagnostic Small bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor April 2012 https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en- US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Policies%20and%20Protocols/Medical%20Policies/Medical%20Policies/Wireless_Capsule_Endoscopy.pdf Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization. Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood. "The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof. OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleeding Crohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT http://apps.humana.com/tad/tad_new/Search.aspx?searchtype=beginswith&docbegin=C GI blood loss and/or iron deficiency anemia:Upper endoscopy and colonoscopy are negative for source of bleeding 152.0, 152.1, 152.2, 152.3, 152.8, 152.9, 209.00, 209.01, 209.02, 209.03, 211.2, 235.2, 280.0, 280.9, 555.0, 555.1, 555.2, 555.9, 558.1, 558.2, 558.3, 558.9, 562.02, 562.03, 569.85, 759.6, 578.0, 578.1, 578.9, 579.0, 792.1, V84.09 Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location or extent of pathology, and treatment decisions would be affected by the results of the test Lynch syndrome or inherited polyposis syndromes such as familial adenomatous polyposis and Peutz- Jeghers syndrome http://www.aetna.com/cpb/medical/data/500_599/0588.html All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive 152.0-152.9, 211.2, 235.2, 280.0, 280.8, 280.9, 281.9, 285.9, 555.0-555.9, 558.9, 578.1-578.9, 579.0 http://www.cigna.com/assets/docs/health-care-professionals/coverage_positions/mm_0008_coveragepositioncriteria_wireless_capsule_endoscopy.pdf Wireless Capsule Endoscopy as a Diagnostic Technique in the Disorders of the Small Bowel, Esophagus and Colon Hereditary GI polyposis syndromes including familial adenomatous polyposis and Peutz-Jeghers syndrome Crohn's: Without evidence of disease on conventional diagnostics tests such as SBFT and upper and lower endoscopy 211.2, 555.0, 555.1, 555.2, 555.9, 578.0, 578.1. 578.9, 759.6 209.00-209.03, 209.40-209.43, 211.2, 280.0, 280.9, 285.1, 288.8, 555.0-555.9, 558.1- 558.9, 578.0-578.9, 579.0, 759.6, 780.60, 780.61, 783.21, 787.91, 789.00-789.09, 790.1 Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopy Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source ALASKA Capsule Endoscopy Payer Guidelines - CPT 91110 MAC: Noridian Administrative Services No published LCD for capsule endoscopy. Claims will be manually reviewed.
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ALASKA Capsule Endoscopy Payer Guidelines - … Capsule Endoscopy Payer Guidelines - CPT 91110 MAC: Noridian Administrative Services No published LCD for capsule endoscopy. Claims
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Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Premera BCBS Obscure GI bleed OGIB: Prior inconclusive upper AND lower gastrointestinal endoscopic studiesSuspected Crohn's disease
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
ALASKA
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: Noridian Administrative Services
No published LCD for capsule endoscopy. Claims will be manually reviewed.
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Obscure GI bleedCrohn's diseaseSuspected small intestinal tumors
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS AL Recurrent, obscure GI bleed UnlistedSuspected Crohn's diseaseKnown Crohn's disease
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopy
Lynch syndrome or inherited polyposis syndromes such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Crohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
OGIB: Documented GI blood loss and anemia secondary to bleeding. Site not previously identified by upper GI endoscopy, colonoscopy, push enteroscopy or radiological procedureCrohn's: Suspected but undiagnosed Crohn's or when necessary to determine whether there is small bowel involvement** It is expected that this test will be performed only once during any episode of illness
Medicine: Wireless Capsule Imaging
Suspected or refractory malabsorptive syndromes (eg, Celiac disease)
Crohn's: Without evidence of disease on conventional diagnostic tests such as upper GI, EGD, or colonoscopy
Wireless Capsule Endoscopy
Hereditary GI polyposis syndromes including familial adenomatous polyposis and Peutz-Jeghers syndrome
Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Crohn's: Without evidence of disease on conventional diagnostic tests such as SBFT, and/or upper and lower endoscopyOGIB: Not found on upper and lower GI endoscopic studies, although bleeding has been noted in the stool by direct observation or immunohistochemical testing
Iron deficiency anemia: Not diagnosed by upper and lower GI endoscopy, and bleeding has not been detected by direct observation from the colon or rectum, or by immunohistochemical testing, and yet the cause is of suspected small bowel originGI polyposis syndromes: Surveillance is allowed no more frequently than annually in patients in whom polyps are detected in the small bowel distal to the first portion of the duodenum, and no more frequently than biennially in patients in whom polyps are not detected
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
ARKANSAS
Capsule Endoscopy Payer Guidelines - CPT 91110
Carrier: Pinnacle Business Solutions, Inc.
OGIB: Not previously identified by upper GI endoscopy, colonoscopy, push endoscopy or other radiologic procedure
OGIB: Iron deficiency anemia, postive fecal occult blood test, or visible bleeding with no source found on original endoscopy, hematocrit < 34, failure of previous diagnostics to diagnose source of GI bleeding and GI bleeding is thought to be in the small intestine
Small Bowel Neoplasm: Diagnosis not previously confirmed by upper GI, colonoscopy, push enteroscopy, nuclear imaging or radiological procedures. Patient must be symptomatic for neoplasm (e.g. GI bleeding)
OGIB: Bleeding of unknown origin that persists or recurs after a negative initial upperand lower endoscopy (may be visible or occult)Crohn's: Negative upper and lower endoscopy and documentation of ANY of the following: abdominal pain, persistent; bleeding; diarrhea; negative stool cultures; weight loss
Endoscopy by Video Capsule Hereditary GI polyposis syndromes including familial
adenomatous polyposis and Peutz-Jeghers syndrome
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
No published LCD for capsule endoscopy. Claims will be manually reviewed.
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy
are negative for source of bleeding
152.0, 152.1, 152.2, 152.3,
152.8, 152.9, 209.00, 209.01,
209.02, 209.03, 211.2, 235.2,
280.0, 280.9, 555.0, 555.1,
555.2, 555.9, 558.1, 558.2,
558.3, 558.9, 562.02, 562.03,
569.85, 759.6, 578.0, 578.1,
578.9, 579.0, 792.1, V84.09
Wireless Capsule
Endoscopy
152.0-152.9, 211.2, 235.2,
280.0, 280.8, 280.9, 281.9,
285.9, 555.0-555.9, 558.9,
578.1-578.9, 579.0
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule
to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more
intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and
comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report
and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses,
claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Wireless Capsule
Endoscopy for
Esophageal and Small
Bowel Imaging and the
Patency Capsule
OGIB: Upper and lower endoscopy excluded a source of bleeding in the upper GI
tract or colon
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no
suspected or confirmed GI obstruction, stricture, or fistulae
OGIB: Iron deficiency anemia, postive fecal occult blood test, or visible bleeding
with no source found on original endoscopy, hematocrit < 34, failure of previous
diagnostics to diagnose source of GI bleeding and GI bleeding is thought to be in
the small intestine
Small Bowel Neoplasm: Diagnosis not previously confirmed by upper GI,
colonoscopy, push enteroscopy, nuclear imaging or radiological procedures. Patient
must be symptomatic for neoplasm (e.g. GI bleeding)
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Occult GI bleedingCeliac diseaseSuspected or known Crohn's diseaseColitis
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Anthem BCBS Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease with prior negative biopsy)Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Wireless Capsule Endoscopy
OGIB: Source of bleeding not previously identified by upper GI and colonoscopy and any of the following: push enteroscopy, nuclear imaging or radiological procedures; medical record must indicate if anemia is present
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulaeCrohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Anthem BCBS Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopy
Wireless Capsule Endoscopy for
Esophageal and Small Bowel Imaging and the
Patency Capsule
Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease with prior negative biopsy)
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulae
Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel
Crohn's: Imaging studies and/or upper or lower GI endoscopic examination fail to reveal the location or extent of the pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
OGIB: After appropriate evalution (at minimum upper and lower endoscopy) has excluded a source of bleeding in the upper GI tract or colon
Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
GI blood loss/Iron-deficiency anemia: Other diagnostic methods (upper endoscopy and colonoscopy) failed to identify source of bleeding
Crohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS DE Angiodysplasias of the GI tract
Suspected Crohn's diseaseOccult GI bleedingPeutz-Jeghers syndrome Suspected or refractory malabsorptive syndromesSuspected small bowel tumors
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location or extent of pathology, and treatment decisions would be affected by the results of the test
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Wireless Capsule Endoscopy (Enteral
Camera)
Hereditary GI polyposis syndromes including familial polyposis
All diagnoses: Conventional endoscopic and diagnostic imaging evaluations (e.g. upper GI endoscopy, colonoscopy, push enteroscopy, nuclear imaging, or radiological procedure) are inconclusive
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Lynch syndrome or inherited polyposis syndromes such as familial adenomatous polyposis and Peutz-Jeghers syndrome
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
DELAWARE
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: Novitas Solutions Inc.
No published LCD for capsule endoscopy. Claims will be manually reviewed.
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Wireless Capsule Endoscopy (Enteral
Camera)Hereditary GI polyposis syndromes including familial adenomatous polyposis and Peutz-Jeghers syndrome
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
DISTRICT OF COLUMBIA
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: Novitas Solutions Inc.
No published LCD for capsule endoscopy. Claims will be manually reviewed.
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsy
Capsule Endoscopy Celiac disease
Suspected Crohn's disease
Suspected small intestinal bleeding
BCBS FL Suspected Crohn's disease
Obscure GI bleed
OGIB: Prior inconclusive upper and lower GI endoscopic studies
Cigna Obscure GI bleed
Capsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumor
Celiac disease
Humana Obscure GI bleed Unlisted
Capsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromes
Suspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemia
Suspected or known Crohn's disease
Celiac disease
Suspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnostic
Small bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
March 2012
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more
intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and
comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report
and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses,
claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Hereditary GI polyposis syndromes, including familial
adenomatous polyposis and Peutz-Jeghers
syndromehttp://mcgs.bcbsfl.com/
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule
to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower
endoscopy) are inconclusive
MAC: First Coast Service
Options
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify
source of bleeding
Crohn's or Celiac disease: No evidence of disease found via standard diagnostic
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Obscure GI bleedCrohn's diseaseSuspected small intestinal tumors
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS GA Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
OGIB: Documented GI blood loss and anemia secondary to bleeding. Site not previously identified by upper GI endoscopy, colonoscopy, push enteroscopy or radiological procedureCrohn's: Suspected but undiagnosed Crohn's or when necessary to determine whether there is small bowel involvement
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulaeCrohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease with prior negative biopsy)Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
IOWA
Capsule Endoscopy Payer Guidelines - CPT 91110
OGIB: Anemic patient when site of bleeding is not previously identified by upper GI, colonoscopy, push endoscopy or other radiologic procedure, and EGD endoscopy and colonoscopy have been performed during same episode of illness; documented GI bleeding and anemia secondary to blood loss
MAC: Wisconsin Physicians Service Continued GI blood loss and anemia secondary to
bleeding
Angiodysplasias: EGD and colonoscopy performed during same episode of illness
Blood Loss: EGD and colonoscopy have been performed during same episode of illnessCrohn's: Documented suspicion of diagnosis or procedure was necessary to determine small bowel involvement** Medical records must document the need for the test, contain reports of previous diagnostic procedures prior to capsule endoscopy but during the same episode of illness
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Lynch syndrome or inherited polyposis syndromes such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Crohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
IDAHO
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: Noridian Administrative Services
No published LCD for capsule endoscopy. Claims will be manually reviewed.
United Healthcare GI blood loss and/or iron-deficiency anemia
Suspected or known Crohn's disease
Celiac disease
Suspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnostic
Small bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
March 2012
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower
endoscopy) are inconclusive
Capsule Endoscopy
OGIB: Cause undetected by standard diagnostic methods and evidenced by iron-
deficiency anemia not attributable to other etiology
OGIB: Anemic patient when site of bleeding is not previously identified by upper GI,
colonoscopy, push endoscopy or other radiologic procedure, and EGD endoscopy
and colonoscopy have been performed during same episode of illness; documented
GI bleeding and anemia secondary to blood loss
Crohn's: Documented suspicion of diagnosis or procedure was necessary to
determine small bowel involvement
Blood Loss: EGD and colonoscopy have been performed during same episode of
illness
Angiodysplasias: EGD and colonoscopy performed during same episode of illness
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule
to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more
intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and
comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report
and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses,
claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Carrier: Wisconsin
Physicians Service
152.0, 152.1, 152.2, 152.3,
152.8, 152.9, 209.00, 209.01,
209.02, 209.03, 211.2, 235.2,
280.0, 280.9, 555.0, 555.1,
555.2, 555.9, 558.1, 558.2,
558.3, 558.9, 562.02, 562.03,
569.85, 759.6, 578.0, 578.1,
578.9, 579.0, 792.1, V84.09
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy
are negative for source of bleeding
Crohn's: Negative for evidence of disease on conventional diagnostic tests, such
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Anthem BCBS Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease with prior negative biopsy)
Crohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulae
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Carrier: National Government Services
No published LCD for capsule endoscopy. Claims will be manually reviewed.
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Occult GI bleedingSuspected angiodysplasias
Capsule EndoscopySuspected or known Crohn's diseaseColitisSuspected small bowel neoplasm
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS KS Suspected Crohn's diseaseObscure GI bleeding
OGIB: Prior inconclusive upper and lower GI endoscopic studies
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostics tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
MAC: Wisconsin Physicians Service Continued GI blood loss and anemia secondary to
bleeding
OGIB: Anemic patient when site of bleeding is not previously identified by upper GI, colonoscopy, push endoscopy or other radiologic procedure, and EGD endoscopy and colonoscopy have been performed during same episode of illness; documented GI bleeding and anemia secondary to blood loss
Angiodysplasias: EGD and colonoscopy performed during same episode of illness
Blood Loss: EGD and colonoscopy have been performed during same episode of illnessCrohn's: Documented suspicion of diagnosis or procedure was necessary to determine small bowel involvement** Medical records must document the need for the test, contain reports of previous diagnostic procedures prior to capsule endoscopy but during the same episode of illness
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B GI bleedingSmall bowel neoplasmCrohn's disease
Endoscopy by Capsule
Evaluation prior to surgery
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Anthem BCBS Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
Bluegrass Family Health Obscure GI bleedCrohn's diseaseSuspected small bowel tumor
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopy
Other conditions: Suspected to originate in the small intestinal mucosa. Prior negative or non-diagnostic evaluations of the stomach, duodenum/small intestine, and colon by flexible endoscopy, and complementary radiologic procedures and/or microbiologic studies must be documented
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulaeCrohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
KENTUCKY
Capsule Endoscopy Payer Guidelines - CPT 91110
GI bleed: Site of bleeding not previously identified by any of the following: upper GI endoscopy, colonoscopy, push enteroscopy, nuclear imaging, or radiological procedures. Documented continuing GI blood loss or anemia secondary to bleeding or iron deficiency anemia
Surgery: Coverage limited to patients who are contemplated for surgical resection of the small bowel to control recurrent bleeding or protein loss is reasonable
Other conditions (malabsorption syndrome, chronic diarrhea, or protein-losing enteropathy) Small bowel neoplasm: Diagnosis not previously confirmed by other studies (e.g.,
upper GI endoscopy, colonoscopy, push enteroscopy, nuclear imaging, or radiological procedures). Patient must be symptomatic for neoplasm (e.g., GI bleeding) or have a documented polyposis syndrome associated with small bowel neoplasia or there is other history suggesting presence of small bowel neoplasia and other diagnostic testing to assess these symptoms (i.e., upper GI endoscopy and/or colonoscopy) must have been performedCrohn's: Condition not been previously confirmed or when a diagnosis of colitis of an indeterminate type affecting the colon is known, and a more specific diagnosis is sought by evaluating for small bowel involvement
Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
Crohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
No published LCD for capsule endoscopy. Claims will be manually reviewed.
MASSACHUSETTS
Capsule Endoscopy Payer Guidelines - CPT 91110
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Neoplasm: Upper GI endoscopy, colonoscopy, push enteroscopy, nuclear imaging or radiological procedures have failed to identify a tumorCrohn's: Complete lower GI studies have failed to reveal the source of the patient's symptoms
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part BMAC: NHIC, Corp
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Anthem BCBS Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
No published LCD for capsule endoscopy. Claims will be manually reviewed.
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulaeCrohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease with prior negative biopsy)
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Occult GI bleedSuspected angiodysplasias of the GI tractAnemia secondary to bleeding
Capsule Endoscopy Crohn's diseaseColitis
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS MI Suspected Crohn's disease UnlistedObscure GI bleed
Angiodysplasia of intestine with hemorrhage
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
Priority Health Occult GI bleedCapsule Endoscopy Crohn's disease
Known Crohn's: When necessary to determine small bowel involvement
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
March 2012
Suspected small bowel neoplasm, regional enteritis, or malabsorption syndrome
OGIB: Site of bleeding not previously identified by upper GI endoscopy, colonoscopy, push endoscopy or other radiologic procedure, and EGD endoscopy and colonoscopy were performed during same episode of illness in anemic patientAngiodysplasias: EGD endoscopy and colonoscopy have been performed during same episode of illnessAnemia: Documented continuing GI blood loss, anemia secondary to bleeding, and EGD and colonoscopy were performed during same episode of illness
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Colitis: colitis of an indeterminate type, affecting the colon, is known and a more specific diagnosis is sought by evaluating possible small bowel involvement
OGIB: Documented continuing GI blood loss and anemia secondary to bleeding. Siteof bleeding not identified by upper GI endoscopy, colonoscopy within the same episode of illness
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleedingWireless Capsule
Endoscopy
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
Crohns: Suspected Crohn's disease or when diagnosis is known but it is necessary to determine whether there is involvement of the small bowel
Lynch syndrome or inherited polyposis syndromes such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location or extent of pathology, and treatment decisions would be affected by the results of the test
Surveillance of small bowel in patients with hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome
Crohn's: No evidence of disease on conventional diagnostic tests such as SBFT and upper and lower endoscopyOGIB: Suspected to be of small bowel origin, as evidenced by prior inconclusive upper and lower GI endoscopic studies
Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Suspected Crohn's: Upper GI endoscopy, colonoscopy and either push enteroscopy or small bowel radiologic study within the same period of illness which failed to reveal a focus of disease
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Occult GI bleedingSuspected angiodysplasias
Capsule EndoscopySuspected or known Crohn's diseaseColitisSuspected small bowel neoplasm
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS MN Obscure GI bleed OGIB: Evaluation by upper and lower endoscopies has been inconclusive UnlistedSuspected Crohn's disease Crohn's: Conventional diagnostic tests have been inconclusive
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
Continued GI blood loss and anemia secondary to bleeding
Angiodysplasias: EGD and colonoscopy performed during same episode of illness
Blood Loss: EGD and colonoscopy have been performed during same episode of illness
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
Wireless Capsule Endoscopy Hereditary GI polyposis syndromes including familial
adenomatous polyposis and Peutz-Jeghers syndrome
MINNESOTA
Capsule Endoscopy Payer Guidelines - CPT 91110
OGIB: Anemic patient when site of bleeding is not previously identified by upper GI, colonoscopy, push endoscopy or other radiologic procedure, and EGD endoscopy and colonoscopy have been performed during same episode of illness; documented GI bleeding and anemia secondary to blood loss
Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Crohn's: Documented suspicion of diagnosis or procedure was necessary to determine small bowel involvement** Medical records must document the need for the test, contain reports of previous diagnostic procedures prior to capsule endoscopy but during the same episode of illness
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopy
Payer / Policy Name Link to
Policy Coverage Pre-requisites Covered ICD-9 CodesMedicare Part B Occult GI bleeding
Suspected angiodysplasias
Capsule EndoscopySuspected or known Crohn's diseaseColitisSuspected small bowel neoplasm
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Anthem BCBS Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
** Medical records must document the need for the test, contain reports of previous diagnostic procedures prior to capsule endoscopy but during the same episode of illness
OGIB: Anemic patient when site of bleeding is not previously identified by upper GI, colonoscopy, push endoscopy or other radiologic procedure, and EGD endoscopy and colonoscopy have been performed during same episode of illness; documented GI bleeding and anemia secondary to blood loss
Angiodysplasias: EGD and colonoscopy performed during same episode of illness
Crohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulae
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Blood Loss: EGD and colonoscopy have been performed during same episode of illnessCrohn's: Documented suspicion of diagnosis or procedure was necessary to determine small bowel involvement
Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease with prior negative biopsy)
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Obscure GI bleedCrohn's diseaseSuspected small intestinal tumors
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS MS Suspected Crohn's diseaseObscure GI bleeding
OGIB: Prior inconclusive upper and lower gastrointestinal endoscopic studies
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Suspected or refractory malabsorptive syndromes (eg, Celiac disease)
OGIB: Documented GI blood loss and anemia secondary to bleeding. Site not previously identified by upper GI endoscopy, colonoscopy, push enteroscopy or radiological procedureCrohn's: Suspected but undiagnosed Crohn's or when necessary to determine whether there is small bowel involvement** It is expected that this test will be performed only once during any episode of illness
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS MT Suspected Crohn's disease UnlistedObscure GI bleeding
OGIB: Prior inconclusive upper and lower GI endoscopic studies
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
March 2012
OGIB: Significant GI bleed demonstrated by acute drop in hemoglobin/hematocrit, unexplained recurrent or persistent iron deficiency anemia, persistently positive fecal occult blood test or visible bleeding with no bleeding source found at original endoscopy. Failure of upper and lower GI endoscopy to diagnose source of bleeding
Hereditary GI polyposis syndromes including familial adenomatous polyposis and Peutz-Jeghers syndrome
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleeding
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopy
OGIB: Anemia secondary to suspected occult blood loss, the origin of which is suspected to be in the small intestinal mucosa, based on documented negative or non-diagnostic prior evaluation of the stomach, duodenum (EGD) and colon (colonoscopy) by conventional instrumental endoscopy
Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
Crohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
Hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome or Lynch syndrome
OGIB: Prior inconclusive upper and lower GI endoscopic studies must be documented
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
OGIB: Must have recurrent or persistent iron-deficiency anemia; positive fecal occult blood test; or visible bleeding with no bleeding source found at original endoscopy
Crohn's: Without evidence of disease on conventional diagnostic tests such as SBFT, and upper and lower endoscopy
Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Crohn's: Documented suspicion of diagnosis or procedure was necessary to determine small bowel involvement** Medical records must document the need for the test, contain reports of previous diagnostic procedures prior to capsule endoscopy but during the same episode of illness
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopy
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
MAC: Wisconsin Physicians Service Continued GI blood loss and anemia secondary to
bleeding
OGIB: Anemic patient when site of bleeding is not previously identified by upper GI, colonoscopy, push endoscopy or other radiologic procedure, and EGD endoscopy and colonoscopy have been performed during same episode of illness; documented GI bleeding and anemia secondary to blood loss
Angiodysplasias: EGD and colonoscopy performed during same episode of illness
Blood Loss: EGD and colonoscopy have been performed during same episode of illness
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part BMAC: NHIC, Corp
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Anthem BCBS Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
Harvard Pilgrim Obscure GI bleed UnlistedSuspected or known Crohn's diseaseIron deficiency anemia
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
NEW HAMPSHIRE
Capsule Endoscopy Payer Guidelines - CPT 91110
OGIB: After appropriate evaluation (at minimum upper and lower endoscopy) has excluded a source of bleeding in the upper GI tract or colon
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulaeCrohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease with prior negative biopsy)Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopic examination fail to
reveal the location or extent of the pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
No published LCD for capsule endoscopy. Claims will be manually reviewed.
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
Hereditary GI polyposis syndromes including familial adenomatous polyposis and Peutz-Jeghers syndrome
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
NEW JERSEY
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: Novitas Solutions Inc.
Wireless Capsule Endoscopy as a
Diagnostic Technique in Disorders of the Small
Bowel and Colon
Crohn's: Without evidence of disease on conventional diagnostic tests such as SBFT and upper and lower endoscopy
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopy
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Occult GI bleedingCeliac diseaseSuspected or known Crohn's diseaseColitis
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS NM Suspected Crohn's disease 211.2, 555.0-555.9, 759.6Obscure GI bleed
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Wireless Capsule Endoscopy (WCE)
Hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome
OGIB: Cause has been undetected by standard diagnostic methods (i.e. colonoscopy and upper gastric endoscopy), AND that is evidenced by recurrent or persistent iron deficiency anemia, positive fecal occult blood test, or visible bleeding
MAC: Trailblazer Health Enterprises, LLCWireless Capsule
Endoscopy
OGIB: Source of bleeding not previously identified by upper GI and colonoscopy and any of the following: push enteroscopy, nuclear imaging or radiological procedures; medical record must indicate if anemia is present
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part BMAC: Palmetto GBA
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Anthem BCBS Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease with prior negative biopsy)Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulaeCrohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
NEVADA
Capsule Endoscopy Payer Guidelines - CPT 91110
No published LCD for capsule endoscopy. Claims will be manually reviewed.
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Oxford Health Plans GI blood loss and/or iron-deficiency anemia
Suspected or known Crohn's disease
Celiac disease
Suspected small bowel tumor
Celiac Disease: Prior serology or GI endoscopy are not diagnostic
Small Bowel Tumor: Imaging studies or GI endoscopy failed to confirm tumorhttps://www.oxhp.com/secure/policy/wireless_capsule_endoscopy_212.html
March 2012
Capsule Endoscopy
(Camera Pill)
152.0, 152.1, 152.2, 152.3,
152.8, 152.9, 209.00, 209.01,
209.02, 209.03, 211.2, 235.2,
280.0, 280.9, 555.0, 555.1,
555.2, 555.9, 558.1, 558.2,
558.3, 558.9, 562.02, 562.03,
569.85, 578.0, 578.1, 578.9,
579.0, 759.6, 792.1, V84.09
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule
to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Crohn's: Prior radiological study to exclude stricture, which did not demonstrate the
presence of Crohn's disease. Abdominal pain, occult or overt GI bleeding, diarrhea
and weight loss must all be present
Small Bowel Neoplasm: Diagnosis not previously confirmed by other studies.
Abdominal pain, occult or overt GI bleeding, diarrhea and weight loss must all be
present; or documented associated polyposis syndrome; or other history suggesting
the presence of small bowel neoplasia and have undergone prior diagnostic testing
to assess these symptoms
Evaluation of malabsorptions syndrome or protein-
losing enteropathy of obscure origin
Malabsorptions Syndrome: Diarrhea with greasy voluminous foul smelling stool,
and weight loss despite adequate food intake or anorexia, flatulence and abdominal
distention
Lymphangiectasia: For surgical resection of the small bowel to control recurrent
bleeding or protein loss is reasonable
OGIB: After appropriate evaluation (at minimum upper and lower endoscopy) has
excluded a source of bleeding in the upper GI tract or colon
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more
intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and
comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report
and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses,
claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
No published LCD for capsule endoscopy. Claims will be manually reviewed.
Wireless Capsule
Endoscopy
Wireless Capsule
Endoscopy for the
Examination of the GI
Tract
Wireless Capsule
Endoscopy for
Esophageal and Small
Bowel Imaging and the
Patency Capsule
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no
suspected or confirmed GI obstruction, stricture, or fistulae
Lynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-
Jeghers syndrome
GI blood loss/Iron-deficiency anemia: Other diagnostic methods (upper
endoscopy and colonoscopy) failed to identify source of bleeding
Crohn's: Imaging studies and/or upper or lower GI endoscopic examination fail to
reveal the location or extent of the pathology, and treatment decisions would be
affected by the results of the test
OGIB: Documented presence of GI bleeding and negative upper and lower
endoscopies performed during current episode of illness
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B GI bleedingSmall bowel neoplasmCrohn's disease
Endoscopy by Capsule
Evaluation prior to surgery
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Anthem BCBS Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Medical Mutual of Ohio Suspected occult blood loss UnlistedIron deficiency anemiaSmall bowel neoplasm or regional enteritis (Crohn's)Refractory undiagnosed malabsorptive syndromes
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
March 2012
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease)All diagnoses: At least one of the following clinical conditions present: Malignant neoplasm of small intestine, including duodenum; Secondary malignant neoplasm of small intestine, including duodenum; Malignant carcinoid tumor of small intestine, unspecific portion; Malignant carcinoid tumor of the duodenum; Malignant carcinoid tumor of the jejunum; Malignant carcinoid tumor of the ileum; Benign carcinoid tumor of the small intestine, unspecified portion; Benign carcinoid tumor of the duodenum; Benign carcinoid tumor of the jejunum; Benign carcinoid tumor of the ileum; Benign neoplasm of duodenum, jejunum, and ileum; Benign neoplasm of colon; Carcinoma in situ of other and unspecified parts of intestine; Neoplasm of uncertain behavior of stomach, intestines, and rectum; Iron deficiency anemias secondary to blood loss (chronic); Iron deficiency anemia, unspecified; Acute posthemorrhagic anemia; Other lymphedema; Regional enteritis of large intestine; Other specified disorders of stomach and duodenum; Regional enteritis of small intestine; Regional enteritis of small intestine with largeintestine; Vascular insufficiency of intestine; Gastroenteritis and colitis due to radiation; Toxic gastroenteritis and colitis; Other and unspecified noninfectious gastroenteritis and colitis; Intussusception; Unspecified intestinal obstruction; Diverticula of small intestine; Irritable bowel syndrome; Other specified disorders of intestine; GI hemorrhage; Other specified intestinal malabsorption; Unspecified intestinal malabsorption; Other hamartoses, not elsewhere classified; Diarrhea; Abdominal pain; Nonspecific abnormal findings in stool contents; Nonspecific abnormal findings in radiological and other examinations of GI tract
Other conditions (malabsorption syndrome, chronic diarrhea, or protein-losing enteropathy)
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
GI bleed: Site of bleeding not previously identified by any of the following: upper GI endoscopy, colonoscopy, push enteroscopy, nuclear imaging, or radiological procedures. Documented continuing GI blood loss or anemia secondary to bleeding or iron deficiency anemia
Small bowel neoplasm: Diagnosis not previously confirmed by other studies (e.g., upper GI endoscopy, colonoscopy, push enteroscopy, nuclear imaging, or radiological procedures). Patient must be symptomatic for neoplasm (e.g., GI bleeding) or have a documented polyposis syndrome associated with small bowel neoplasia or there is other history suggesting presence of small bowel neoplasia and other diagnostic testing to assess these symptoms (i.e., upper GI endoscopy and/or colonoscopy) must have been performed.Crohn's: Condition not been previously confirmed or when a diagnosis of colitis of an indeterminate type affecting the colon is known, and a more specific diagnosis is sought by evaluating for small bowel involvementOther conditions: Suspected to originate in the small intestinal mucosa. Prior negative or non-diagnostic evaluations of the stomach, duodenum/small intestine, and colon by flexible endoscopy, and complementary radiologic procedures and/or microbiologic studies must be documented.
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulaeCrohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease with prior negative biopsy)Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location or
extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Surgery: Coverage limited to patients who are contemplated for surgical resection of the small bowel to control recurrent bleeding or protein loss is reasonable
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
Blood loss: GI blood loss or anemia where small bowel is suspected bleeding source and investigation of the stomach, duodenum and colon were unremarkable or non-diagnostic by EGD or colonoscopyIron deficiency anemia: Unexplained by other factors (e.g., menstrual history, blood donation history)Small bowel neoplasm/Crohn's: Primary evaluation demonstrates signs and symptoms
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Occult GI bleedingCeliac diseaseSuspected or known Crohn's diseaseColitis
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS OK Suspected Crohn's disease 211.2, 555.0-555.9, 759.6Obscure GI bleed
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
OGIB: Source of bleeding not previously identified by upper GI and colonoscopy and any of the following: push enteroscopy, nuclear imaging or radiological procedures; medical record must indicate if anemia is present
Crohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome
Crohn's: Without evidence of disease on conventional diagnostic tests, such as endoscopy and SBFT
OGIB: Cause has been undetected by standard diagnostic methods (i.e. colonoscopy and upper gastric endoscopy), AND that is evidenced by recurrent or persistent iron deficiency anemia, positive fecal occult blood test, or visible bleeding
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleeding
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
OREGON
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: Noridian Administrative Services
No published LCD for capsule endoscopy. Claims will be manually reviewed.
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
United Healthcare GI blood loss and/or iron-deficiency anemia
Suspected or known Crohn's disease
Celiac disease
Suspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnostic
Small bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
March 2012
Suspected or refractory malabsorptive syndromes
(Celiac disease)
All diagnoses: Inconclusive conventional endoscopy and diagnostic imaging
evaluations (upper GI endoscopy, colonoscopy, push enteroscopy, nuclear imaging,
or radiological procedure)
Independence Blue
Cross Wireless Capsule
Endoscopy (WCE) using
the Given® Diagnostic
Imaging and PillCam™
Capsule Systems
Small bowel neoplasm: Diagnosis previously unconfirmed by upper GI endoscopy,
push enteroscopy, nuclear imaging or radiological procedures. Must be symptomatic
for neoplasm (GI bleeding), documented hereditary polyposis syndrome associated
with small bowel neoplasia, or have other history suggesting presence of small
bowel neoplasia. Other diagnostic testing to assess these symptoms (upper GI
endoscopy and/or colonoscopy) have have been performed
Other conditions (Suspected or refractory
malabsorption syndromes (eg, Celiac disease),
chronic diarrhea, or protein-losing enteropathy)
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule
to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more
intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and
comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report
and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses,
claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower
endoscopy) are inconclusive
152.0-152.9, 211.2, 235.2,
280.0, 280.8, 280.9, 281.9,
285.9, 555.0-555.9, 558.9,
578.1-578.9, 579.0
Wireless Capsule
Endoscopy
152.0-152.9, 209.00-209.03,
211.2, 211.3, 280.0, 280.9,
285.1, 555.0-555.9, 562.02,
562.03, 569.85, 569.86, 578.0-
578.9, 579.0-579.9, 759.6,
792.1
Hereditary GI polyposis syndromes including familial
polyposis
Crohn's: Suspected but unconfirmed, without evidence of disease on conventional
diagnostic test, such as SBFT and upper and lower endoscopy
Surgery: Limited to individuals who are being considered for surgical resection of
the small bowel to control recurrent bleeding or protein loss is appropriate
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
PUERTO RICO
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: First Coast Service Options
Wireless Capsule Endoscopy
Continuous blood loss and anemia secondary to obscure bleeding of the small bowel
Blood Loss: Colonoscopy, endoscopy or radiographic exams failed to reveal a source of bleeding, or interaoperative enteroscopy is being consideredCrohn's: No evidence provided by conventional diagnostic tests such as small bowel follow-through (SBFT) and upper and lower endoscopy** Documented reason why patient is not a candidate for conventional endoscopy. There must be specific co-morbidities and complicating medical conditions that lead the performing provider of the conventional endoscopy to believe that the risk/benefit ratio of a conventional endoscopy was not maintained. Medical record must also support how capsule endoscopy would contribute to the patient’s care
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleeding
Crohn's: Without evidence of disease on conventional diagnostic tests, including upper and lower endoscopy (EGD, colonoscopy), and small-bowel evaluation such as upper GI with SBFT or MR enterography or CT enterography
Crohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
OGIB: Upper endoscopy and colonoscopy, or push endoscopy or other radiologic procedures, and EGD endoscopy and colonoscopy have been performed during the same episode of illnessAngiodysplasia: EGD endoscopy and colonoscopy have been performed during the same episode of illness
RHODE ISLAND
Capsule Endoscopy Payer Guidelines - CPT 91110
No published LCD for capsule endoscopy. Claims will be manually reviewed.
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Obscure GI bleedMAC: Palmetto GBA Small bowel neoplasm or Regional enteritis
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS SC Suspected Crohn's disease UnlistedObscure GI bleed
OGIB: Prior inconclusive upper and lower gastrointestinal endoscopic studies
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location or extent of pathology, and treatment decisions would be affected by the results of the test
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
Wireless Capsule Endoscopy
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Lynch syndrome or inherited polyposis syndromes such as familial adenomatous polyposis and Peutz-Jeghers syndrome
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome
SOUTH CAROLINA
Capsule Endoscopy Payer Guidelines - CPT 91110
OGIB: Anemia secondary to suspected occult blood loss, the origin of which is suspected to be in the small intestinal mucosa, based on documented negative or non-diagnostic prior evaluation of the stomach, duodenum (EGD) and colon (colonoscopy) by conventional instrumental endoscopy
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
SOUTH DAKOTA
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: Noridian Administrative Services
No published LCD for capsule endoscopy. Claims will be manually reviewed.
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Obscure GI bleedCrohn's diseaseSuspected small intestinal tumors
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS TN Obscure GI bleed UnlistedSuspected Crohn's disease
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
OGIB: Positive fecal occult blood tests, visible bleeding, or recurrent or persistent iron-deficient anemia despite treatment AND inconclusive results from two or more standard accepted diagnostic tests Crohn's: Inconclusive results from two or more standard accepted diagnostic tests
Administrators Suspected or refractory malabsorptive syndromes (eg, Celiac disease)
OGIB: Documented GI blood loss and anemia secondary to bleeding. Site not previously identified by upper GI endoscopy, colonoscopy, push enteroscopy or radiological procedureCrohn's: Suspected but undiagnosed Crohn's or when necessary to determine whether there is small bowel involvement** It is expected that this test will be performed only once during any episode of illness
Medicine:Wireless Capsule Endoscopy
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Wireless Capsule Endoscopy Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location
or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
United Healthcare GI blood loss and/or iron-deficiency anemia
Suspected or known Crohn's disease
Celiac disease
Suspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnostic
Small bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
March 2012
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule
to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more
intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and
comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report
and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses,
claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
152.0, 152.1, 152.2, 152.3,
152.8, 152.9, 209.00, 209.01,
209.02, 209.03, 211.2, 235.2,
280.0, 280.9, 555.0, 555.1,
555.2, 555.9, 558.1, 558.2,
558.3, 558.9, 562.02, 562.03,
569.85, 759.6, 578.0, 578.1,
578.9, 579.0, 792.1, V84.09
TEXAS
Capsule Endoscopy Payer Guidelines - CPT 91110
Wireless Capsule
Endoscopy (WCE)
209.00-209.03, 209.40-
209.43, 211.2, 280.0, 280.9,
285.1, 288.8, 555.0-555.9,
558.1-558.9, 578.0-578.9,
579.0, 759.6, 780.60, 780.61,
783.21, 787.91, 789.00-
789.09, 790.1
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever,
elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without
evidence of disease on conventional diagnostic tests, including SBFT, abdominal
CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a
bleeding source
Crohn's or Celiac disease: No evidence of disease found via standard diagnostic
tests such as SBFT
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy
are negative for source of bleeding
MAC: Trailblazer Health
Enterprises, LLC
OGIB: Source of bleeding not previously identified by upper GI and colonoscopy
and any of the following: push enteroscopy, nuclear imaging or radiological
procedures; medical record must indicate if anemia is present
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Obscure GI bleedSmall bowel neoplasm or regional enteritis
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Anthem BCBS Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulaeCrohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopy
OGIB: Anemia secondary to suspected occult blood loss, the origin of which is suspected to be in the small intestinal mucosa, based on documented negative or non-diagnostic prior evaluation of the stomach, duodenum (EGD) and colon (colonoscopy) by conventional instrumental endoscopy
Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease with prior negative biopsy)
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
Crohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleeding
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Crohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
Lynch syndrome or inherited polyposis syndromes such as familial adenomatous polyposis and Peutz-Jeghers syndrome
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Occult GI bleedingSuspected angiodysplasias
Capsule EndoscopySuspected or known Crohn's diseaseColitisSuspected small bowel neoplasm
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Anthem BCBS Obscure GI bleedCrohn's diseaseDiagnostic re-evaluation of Crohn's diseaseSuspected small intestinal tumorsLynch syndrome or polyposis syndromesRefractory undiagnosed malabsorptive syndromesIron deficiency anemia Lynch or Polyposis Syndromes: Patient must be age 35 or greater
OGIB: Anemic patient when site of bleeding is not previously identified by upper GI, colonoscopy, push endoscopy or other radiologic procedure, and EGD endoscopy and colonoscopy have been performed during same episode of illness; documented GI bleeding and anemia secondary to blood loss
Angiodysplasias: EGD and colonoscopy performed during same episode of illness
Blood Loss: EGD and colonoscopy have been performed during same episode of illnessCrohn's: Documented suspicion of diagnosis or procedure was necessary to determine small bowel involvement
Carrier: Wisconsin Physicians Service Continued GI blood loss and anemia secondary to
** Medical records must document the need for the test, contain reports of previous diagnostic procedures prior to capsule endoscopy but during the same episode of illness
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopy
Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Malabsorptive Syndromes: Prior history of negative small bowel biopsy (e.g. suspected celiac disease with prior negative biopsy)Iron Deficiency Anemia: Upper and lower endoscopy, GU assessment with urinalysis and examination of abdomen and pelvis has excluded a source of anemia from the GU region, upper GI tract and colon
All diagnoses: Standard endoscopic and imaging evaluations (i.e., upper and lower endoscopy) are inconclusive
Crohn's: SBFT and upper and lower endoscopy are non-diagnostic AND there is no suspected or confirmed GI obstruction, stricture, or fistulaeCrohn's re-evaluation: Symptomatic after appropriate treatment has occurred and there is no suspected or confirmed GI obstruction, stricture or fistulae
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Obscure GI bleedSmall bowel neoplasm or regional enteritis
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
Highmark BCBS Angiodysplasias of the GI tract
Suspected Crohn's diseaseOccult GI bleedPeutz-Jeghers syndrome
Celiac Disease: Negative biopsy
Suspected small bowel turmors
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
All diagnoses: Inconclusive conventional endoscopy and diagnostic imaging evaluations (upper GI endoscopy, colonoscopy, push enteroscopy, nuclear imaging, or radiological procedure)OGIB: Iron deficiency anemia or acute posthemorrhagic anemia, the site of which has not been previously identified; positive fecal occult blood test or visible bleeding with no bleeding source found at original endoscopy
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopy
OGIB: Anemia secondary to suspected occult blood loss, the origin of which is suspected to be in the small intestinal mucosa, based on documented negative or non-diagnostic prior evaluation of the stomach, duodenum (EGD) and colon (colonoscopy) by conventional instrumental endoscopy
Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS WY Suspected Crohn's diseaseObscure GI bleeding
OGIB: Prior inconclusive upper and lower GI endoscopic studies
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
WYOMING
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: Noridian Administrative Services
No published LCD for capsule endoscopy. Claims will be manually reviewed.
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part BMAC: Palmetto GBA
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
HMSACigna Obscure GI bleed
Capsule Endoscopy Suspected Crohn's diseaseSuspected small bowel tumorCeliac disease
Humana Obscure GI bleed UnlistedCapsule Endoscopy Suspected Crohn's or Celiac disease
Polyposis syndromesSuspected small intestinal tumors
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Payer / Policy Name Link to Policy
Policy Coverage Pre-requisites Covered ICD-9 Codes (listed in policy)
Medicare Part B Occult GI bleedSuspected Angiodysplasias of the GI tractKnown Crohn's disease
Capsule Endoscopy
Aetna Locoregional carcinoid tumors of the small bowel Celiac Disease: Positive serology and negative biopsyCapsule Endoscopy Celiac disease
Suspected Crohn's diseaseSuspected small intestinal bleeding
BCBS LA Suspected Crohn's diseaseObscure GI bleed
OGIB: Prior inconclusive upper and lower GI endoscopic studies
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopyPeutz-Jeghers syndrome and other polyposis
syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and lower GI endoscopies within the last 12 months that have failed to identify a bleeding source
Hereditary gastrointestinal polyposis syndromes, including familiar adenomatous polyposis and Peutz-Jeghers
Crohn's: Without evidence of disease on conventional diagnostic tests such as SBFT, and upper and lower endoscopy
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
OGIB: Push enteroscopy, small bowel series and/or enteroclysis failed to identify source of bleedingCrohn's or Celiac disease: No evidence of disease found via standard diagnostic tests such as SBFT
211.2, 555.0-556.9, 578.0-578.9, 759.6
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
Cigna Obscure GI bleedCapsule Endoscopy Suspected Crohn's disease
Suspected small bowel tumorCeliac disease
HealthNet Obscure GI bleedSmall bowel neoplasmSuspected Crohn's
Crohn's: Patient has diarrhea, GI bleeding, abdominal pain, weight loss, negativestool cultures and negative upper and lower endoscopy
United Healthcare GI blood loss and/or iron-deficiency anemiaSuspected or known Crohn's diseaseCeliac diseaseSuspected small bowel tumor
Celiac disease: Prior serology or GI endoscopy are not diagnosticSmall bowel tumor: Imaging studies or GI endoscopy fail to confirm a tumor
April 2012
"The information presented here is for illustrative purposes only and does not constitute reimbursement or legal advice. The medical coverage policy summary information provided by Olympus America Inc. and/or its direct or indirect (through one or more intermediaries) parent companies, affiliates, or subsidiaries (collectively, the "Olympus Group") is gathered from third party sources and is subject to change without notice. Medical coverage policy may vary widely by insurer so you should understand and comply with any specific rules that may be set by the patient's insurer. You must also understand and comply with Medicare's complex rules. It is the provider’s sole responsibility to determine medical necessity and to in turn identify which CPT codes to report and to submit accurate claims. You should always consult with your local payers regarding reimbursement matters. Under no circumstances shall the Olympus Group or its employees, consultants, agents or representatives be liable for costs, expenses, losses, claims, liabilities or other damages (whether direct, indirect, special, incidental, consequential or otherwise) that may arise from or be incurred in connection with this information or any use thereof.
OGIB: Iron deficiency anemia, postive fecal occult blood test, or visible bleeding with no source found on original endoscopy, hematocrit < 34, failure of previous diagnostics to diagnose source of GI bleeding and GI bleeding is thought to be in the small intestineSmall Bowel Neoplasm: Diagnosis not previously confirmed by upper GI, colonoscopy, push enteroscopy, nuclear imaging or radiological procedures. Patient must be symptomatic for neoplasm (e.g. GI bleeding)
Prior authorization requirements can vary by plan. Please contact the payer to verify if your patient’s plan requires prior authorization.
Use of the Endo Capsule is limited to that which is approved by the FDA and outlined in the labeled Indications for Use of the product, and as such, not all coverage may be applicable. The labeled Indications for Use of the Endo Capsule is for the Endo Capsule to be used for visualization of the small intestine mucosa, and its Red Color Detection Function is intended to mark frames of the video suspected of containing blood.
GI blood loss and/or iron deficiency anemia: Upper endoscopy and colonoscopy are negative for source of bleeding
Crohn's: Imaging studies and/or upper or lower GI endoscopy fail to reveal location or extent of pathology, and treatment decisions would be affected by the results of the testLynch syndrome or inherited polyposis syndromes
such as familial adenomatous polyposis and Peutz-Jeghers syndrome
Crohn's: Abdominal pain or diarrhea plus one or more signs of inflammation (fever, elevated WBC count, elevated erythrocyte sedimentation rate, or bleeding) without evidence of disease on conventional diagnostic tests, including SBFT, abdominal CT scan/CT enterography and upper and lower endoscopy
WASHINGTON
Capsule Endoscopy Payer Guidelines - CPT 91110
MAC: Noridian Administrative Services
No published LCD for capsule endoscopy. Claims will be manually reviewed.
Peutz-Jeghers syndrome and other polyposis syndromes affecting the small bowel Intestinal Bleeding: Positive fecal occult blood test or visible bleeding, upper and
lower GI endoscopies within the last 12 months that have failed to identify a bleeding source