Cryotherapy for the treatment of BE is considered medically necessary as a second line treatment for individuals who do not fully respond to RFA or if there is a clinical contraindication to using RFA.
Cryotherapy 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.
Gastric Antral Vascular Ectasia (GAVE)
RFA is considered medically necessary in individuals with GAVE that are difficult to control with recurrent bleeds despite treatment with Argon Plasma Coagulation (APC)/frequent hospitalizations requiring transfusions.
RFA for the treatment of GAVE 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.
Procedure Codes
