Tuesday, March 29, 2011

LCD for capsule Endoscopy

Local Coverage Determination (LCD) for Capsule Endoscopy (L30141)

LCD Information

Document Information

LCD ID Number - L30141

LCD Title - Capsule Endoscopy

Contractor's Determination Number - GI-009

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Original Determination Effective Date
For services performed on or after 12/16/2009

Original Determination Ending Date

Revision Effective Date
For services performed on or after 02/21/2011

Revision Ending Date

CMS National Coverage Policy
Title XVIII of the Social Security Act section 1862(a)(1)(A). This section excludes coverage and payment for items and services that are not considered reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the function of a malformed body member.

Indications and Limitations of Coverage and/or Medical Necessity
Capsule endoscopy is a noninvasive diagnostic imaging device for use in viewing the gastrointestinal tract, especially the small bowel, which is not accessible to standard upper endoscopy and colonoscopy. A small capsule (approximately 11x30mm) 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 and documented. The capsule passes naturally from the body with the stool, and since it is disposable, is not recovered.

Indications:

I. Occult gastrointestinal bleeding

This test is indicated for the diagnosis of occult gastrointestinal bleeding in the anemic patient when:
1. The site of bleeding has not previously been identified by upper gastrointestinal endoscopy, colonoscopy, push endoscopy or other radiologic procedure, and EGD endoscopy and colonoscopy have been performed during the same episode of illness.

2. The diagnosis of angiodysplasias of the GI tract is suspected, and EGD endoscopy and colonoscopy have been performed during the same episode of illness.

3. Patients have documented continuing GI blood loss and anemia secondary to bleeding, and EGD endoscopy and colonoscopy have been performed during the same episode of illness.

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