Sunday, December 26, 2010

Description of Service/Assessment/Background Information for Capsule Endoscopy:

Endoscopy by Capsule of the Small Intestine

PillCam SB is an ingestible telemetric gastrointestinal capsule imaging system that is used for visualization of the small bowel mucosa. It is an adjunctive tool used in the detection of abnormalities of the small bowel, which is not accessible to standard upper endoscopy and colonoscopy. A small capsule is swallowed and moves through the GI tract propelled by peristalsis, transmitting video pictures. The video images are transmitted to sensors taped to the body and stored on a portable recorder. The strength of the signal is used to calculate the position of the capsule as it passes through the GI tract. Video images are stored on a portable recorder and later downloaded to a computer, from which they may be viewed. The capsule passes naturally from the body with the stool, and since it is disposable, it is not recovered.

Endoscopy by Capsule of the Esophagus

PillCam ESO is a wireless diagnostic video capsule specifically designed for visualization of the esophagus. The device acquires video images via camera ports at both ends as it travels through the esophagus. No sedation is required for the procedure.

Policy and Rationale:

Oxford will cover Wireless Capsule Endoscopy subject to the clinical criteria outlined in Treatment/Application Guidelines.

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