Endoscopic stricturotomy is considered medically necessary when the following criteria are met:
- The stricture(s) are seven (7) cm or less in length; and
- The IBD physician or IBD surgeon determines that the procedure is indicated/required; or
- The stricture is refractory to endoscopic balloon dilation.
Endoscopic stricturotomy should only be performed in appropriately selected individuals, by physicians who are adequately trained and experienced in the specific techniques utilized during the endoscopic stricturotomy procedure.
Endoscopic stricturotomy not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.