Monday, February 28, 2011

bcbs policy of capsule endoscopy - CPT 76499, DX 578.0, 578.1 & 578.9

BCBS POLICY

Wireless Capsule Endoscopy may be considered medically necessary for the following indications:

•    Initial diagnosis in patients with suspected Crohn's disease without evidence of disease on conventional diagnostic tests such as small-bowel follow-through (SBFT) and upper and lower endoscopy

•    Obscure gastrointestinal (GI) bleeding suspected of being of small bowel origin, as evidenced by prior inconclusive upper and lower gastrointestinal endoscopic studies

•    For surveillance of the small bowel in patients with hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome

Other indications of wireless capsule endoscopy are considered investigational, including but not limited to:

•    Evaluation of the extent of involvement of known Crohn’s disease
•    Evaluation of the esophagus, in patients with gastroesophageal reflux (GERD) or other esophageal pathologies
•    Evaluation of other gastrointestinal diseases not presenting with GI bleeding including, but not limited to, celiac sprue, irritable bowel syndrome, small bowel neoplasm
•    Evaluation of the colon including, but not limited to, detection of colonic polyps or colon cancer.
The patency capsule is considered investigational, including use to evaluate patency of the gastrointestinal tract before wireless capsule endoscopy.

POLICY EXCEPTIONS
None

POLICY GUIDELINES
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Obscure GI bleeding is defined as "recurrent or persistent iron-deficiency anemia, positive fecal occult blood test, or visible bleeding with no bleeding source found at original endoscopy." (Van Gossum 2001)
In 2004, a CPT code 91110 was introduced, which specifically describes the use of the capsule camera as follows:

91110: Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus through ileum, with physician interpretation and report.

Effective in 2007, there is a CPT code specific to capsule endoscopy of the esophagus alone:
91111: Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus with physician interpretation and report.

POLICY HISTORY


5/16/2002: Approved by Medical Policy Advisory Committee (MPAC), Code Reference section 'Non-Covered Codes' completed, CPT code 76499 (There are no specific CPT codes for this procedure), ICD-9 diagnosis code 578.0, 578.1, 578.9

3/20/2003: Reviewed by MPAC, investigational status changed to medically necessary, Sources and Code Reference sections updated, HCPCS G0262 added

2/13/2004: Code Reference section updated, ICD-9 diagnosis code 280.0 added

3/25/2004: Reviewed by MPAC, expanded Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel to medically necessary for the initial diagnosis in patients with suspected Crohn's disease without evidence of disease on conventional diagnostic tests such as small-bowel follow-through (SBFT), and upper and lower endoscopy, Wireless capsule endoscopy remains investigational as a technique to evaluate other gastrointestinal diseases not presenting with gastrointestinal bleeding, including, but not limited to celiac sprue, irritable bowel syndrome, small bowel neoplasm or intestinal polyposis syndrome. Description revised to be consistent with BCBSA policy # 6.01.33, Sources updated

5/18/2004: Code Reference section updated, "There are no specific CPT codes for this procedure" deleted, CPT code 91110 added, CPT code 76499 deleted 12-31-2003 statement added, ICD-9 procedure code 88.90 added, ICD-9 diagnosis codes 555.0, 555.1, 555.2, 555.9 added

9/1/2006: Policy revised. Revisions approved by Medical Policy Advisory Committee (MPAC) 7/27/2006. HCPC G0262 deleted from covered table

1/4/2007: Code reference section updated per the 2007 CPT/HCPCS revisions

5/15/2007: Policy reviewed. Added medically necessary indication for surveillance of the small bowel in patients with hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome. Investigational indications clarified. CPT code 91111 moved to non-covered. ICD-9 code 211.2 added to covered table. Policy name changed to "Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel and Esophagus." Previously named "Wireless Capsule Endoscopy in Obscure Digestive Tract Bleeding"

7/19/2007: Reviewed and approved by MPAC

7/14/2008: Policy statement added that the patency capsule system is considered investigational

9/15/2008: Code reference section updated per the annual ICD-9 updates effective 10-1-2008

8/19/2009: Policy statement updated to include the following indication as investigational: evaluation of the colon including, but not limited to, detection of colonic polyps or colon cancer as investigational. ICD-9 diagnosis codes  280.8, 280.9 and 759.6 added to covered table.

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