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)
All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date; or
All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.
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
