Friday, April 1, 2011

Capsule endoscopy not medically necessary denial

Capsule Endoscopy Other indications:

1. When the diagnosis of Crohn's disease is suspected but not diagnosed.

2. When the diagnosis of Crohn's disease is known but it is necessary to determine whether there is involvement of the small bowel as well.

3. When a diagnosis of colitis of an indeterminate type, affecting the colon, is known and a more specific diagnosis is sought by evaluating possible small bowel involvement.

4. As a primary procedure in the evaluation of suspected, but undiagnosed, small bowel neoplasm, regional enteritis, or malabsorption syndrome.

Capsule Endoscopy is payable when all of the following criteria are met:

1. Patients are receiving services using FDA approved devices.

2. The service is performed by physicians trained in endoscopy or in an independent diagnostic testing facility under the general supervision of a physician trained in endoscopy procedures.

Capsule Endoscopy is not considered medically necessary, and is not covered, for:

1. The confirmation of lesion pathology, or the management of conditions diagnosed by prior endoscopy (including push enteroscopy), colonoscopy or radiological procedures.

2. Patients with hematemesis.

3. The management, as opposed to the diagnosis, of Crohn's Disease, other inflammatory conditions, neoplasms and malabsorbtion syndromes of the small intestine.

 Capsule endoscopy of the esophagus has been used by some practitioners for patients with suspected
gastroesophageal reflux disease, Barrett's Esophagus, or esophageal varices. However, mere visualization will not diagnose Barrett's Esophagus (i.e., a biopsy is needed), and there is no need, nor is it standard, to monitor treatment of GERD, varices, etc. by this method (i.e., patients with symptoms will need upper endoscopy to determine severity of disease and potential complications). Since the findings will not alter the treatment plan, these will be denied as not medically necessary.

Patency Capsule testing is not covered. It is used to verify adequate patency of the gastrointestinal tract prior to administration of the PillCam video capsule in patients with known or suspected strictures. There are insufficient studies available to support coverage.

The ASGE Technology Status Evaluation Report Wireless Capsule Endoscopy lists, "Patients with known or suspected gastrointestinal (GI) obstruction, strictures, or fistulas based on the clinical picture or preprocedure testing" under contraindications for the small bowel capsule.

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