Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon

Policy ID: G-41-033

Section: Miscellaneous

Effective Date: July 01, 2018

Revised Date: September 20, 2022

Revision Effective Date: October 01, 2022

Last Reviewed: September 28, 2022

Applies To: Commercial and Medicaid Expansion

Description

Wireless capsule endoscopy (WCE) is an ingestible telemetric gastrointestinal capsule imaging system that is used for visualization of the small bowel mucosa. It is used in the detection of abnormalities of the small bowel, which are not accessible via standard upper gastrointestinal endoscopy and colonoscopy.

Criteria

Coverage is subject to the specific terms of the member’s benefit plan.

Use of an U.S. FDA approved WCE may be considered medically necessary for ANY of the following indications:

Suspected small bowel bleeding; or
Initial diagnosis in individuals with suspected Crohn's disease; or
In individuals with an established diagnosis of Crohn's disease, when there are unexpected change(s) in the course of disease or response to treatment, suggesting the initial diagnosis may be incorrect and reexamination may be indicated; or
For surveillance of the small bowel in individuals with hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome.
For evaluation of individuals with suspected undefined enteropathies to help direct/guide device assisted enteroscopy; or
- Individuals with enteropathies who are unable to undergo esophagogastroduodenoscopy (EGD) with biopsy; or
For re-evaluation of individuals with celiac disease who remain symptomatic despite treatment and there is no suspected or confirmed gastro-intestinal (GI) obstruction, stricture, or fistulae; or
For screening or surveillance of esophageal varices in cirrhotic individuals with significantly compromised liver function (i.e., Child-Pugh score of Class B or greater) or other situations where a standard upper endoscopy with sedation or anesthesia is contraindicated; or
For evaluation of known or suspected small bowel tumors; or
Persistent or unexplained iron deficiency anemia suspected to be due to GI bleeding.

WCE is considered experimental/investigational for the following indication, this is not an all inclusive list:

Evaluation of other GI diseases and conditions not presenting with GI bleeding, including but not limited to:
- Use in evaluating the stomach; or
- Duodenal lymphocytosis; or
- Lynch syndrome (risk for hereditary nonpolyposis colorectal cancer); or
- Portal hypertensive enteropathy or gastropathy; or
- Unexplained chronic abdominal pain; or
- Use for evaluating intussusception; or
- Use for follow-up of individuals with known small bowel disease other than Crohn’s disease; or
Evaluation of the colon, including but not limited to, detection of colonic polyps or colon cancer; or
Initial evaluation of individuals with acute upper GI bleeding; or
Use for evaluating diseases involving the esophagus other than esophageal varices; or
Use in confirming pathology identified by other diagnostic means.
Evaluation of individuals with evidence of lower GI bleeding and major risks for colonoscopy or moderate sedation; or
Evaluation of individuals following incomplete colonoscopy; or
Evaluation of the esophagus, in individuals with gastroesophageal reflux or Barrett’s esophagus.

WCE 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.

The patency capsule, including use to evaluate patency of the GI tract before WCE 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

91110

91111

91113

0651T

91299

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes 91110 and 91111

C17.0

C17.1

C17.2

C17.3

C17.8

C17.9

C78.4

C7A.010

C7A.011

C7A.012

C7A.019

D13.2

D13.30

D13.39

D37.2

D3A.010

D3A.011

D3A.012

D3A.019

D50.0

D50.1

D50.8

D50.9

I85.00

I85.01

I85.10

I85.11

K20.0

K22.0

K22.10

K22.11

K22.4

K22.5

K22.6

K22.81

K22.82

K22.89

K22.9

K23

K31.A0

K31.A11

K31.A12

K31.A13

K31.A14

K31.A15

K31.A19

K31.A21

K31.A22

K31.A29

K50.00

K50.011

K50.012

K50.013

K50.014

K50.018

K50.019

K50.10

K50.111

K50.112

K50.113

K50.114

K50.118

K50.119

K50.80

K50.811

K50.812

K50.813

K50.814

K50.818

K50.819

K50.90

K50.911

K50.912

K50.913

K50.914

K50.918

K50.919

K51.00

K51.011

K51.012

K51.013

K51.014

K51.018

K51.019

K51.20

K51.211

K51.212

K51.213

K51.214

K51.218

K51.219

K51.30

K51.311

K51.312

K51.313

K51.314

K51.318

K51.319

K51.80

K51.811

K51.812

K51.813

K51.814

K51.818

K51.819

K51.90

K51.911

K51.912

K51.913

K51.914

K51.918

K51.919

K52.3

K58.0

K58.1

K58.2

K58.8

K58.9

K90.0

K92.0

K92.1

K92.2

Q85.81

Q85.82

Q85.83

Q85.59

Q85.9

Z84.89

Professional Statements and Societal Positions Guidelines

The American College of Gastroenterology (ACG) – 2013

The ACG (2013) issued guidelines on the diagnosis and management of celiac disease. The guidelines recommended that capsule endoscopy (CE) not be used for initial diagnosis, except for individuals with positive celiac-specific serology who are unwilling or unable to undergo upper endoscopy with biopsy.

CE should be considered for the evaluation of small bowel mucosa in individuals with complicated Crohn disease.

The ACG (2018) updated its guidelines on the management of CD in adults. It makes two recommendations specific to video capsule endoscopy:

“Video capsule endoscopy (VCE) is a useful adjunct in the diagnosis of individuals with small bowel Crohn’s disease in individuals in whom there is a high index of suspicion of disease.”
“Individuals with obstructive symptoms should have small bowel imaging and/or patency capsule evaluation before VCE to decrease risk of capsule retention.”

These recommendations are based on multiple studies. Capsule endoscopy was found to be “superior to small bowel barium studies, computed tomography enterography (CTE) and ileocolonoscopy in individuals with suspected CD, with incremental yield of diagnosis of 32%, 47%, and 22%, respectively….Capsule endoscopy has a high negative predictive value of 96%.”

“However, some studies have questioned the specificity of capsule endoscopy findings for CD, and to date there is no consensus as to exactly which capsule endoscopy findings constitute a diagnosis of CD.”

The ACG (2015) issued guidelines on the diagnosis and management of small bowel bleeding (including using “small bowel bleeding” to replace “obscure GI [gastrointestinal] bleeding,” which should be reserved for individuals in whom a source of bleeding cannot be identified anywhere in the GI tract).

ND Committee Review

Internal Medical Policy Committee 11-14-2019 Coding update

Update- no changes in criteria, and
Reformat diagnosis codes, and
Remove duplicate diagnosis codes.

Internal Medical Policy Committee 3-16-2020 Revision

Removed the indications (Angiodysplasias of the gastrointestinal tract; To investigate anemia with concomitant iron deficiency, suspected to be of small bowel origin, after appropriate evaluation (at a minimum lower and upper endoscopy) has excluded a source of anemia from the upper GI tract and colon)

Internal Medical Policy Committee 9-21-2020 Coding update

Added Diagnosis Codes C17.0; C17.1; C17.2; C17.3; C17.8; C17.9; C78.4; C7A.010; C7A.011; C7A.012; C7A.019; D37.2; D3A.010; D3A.011; D3A.012; D3A.019; D50.0

Internal Medical Policy Committee 1-19-2021 Coding update

Removed Diagnosis Codes D12.6, G89.29, K52.22, R10.0, R10.10, R10.11, R10.12, R10.13, R10.30, R10.31, R10.32, R10.33 and
Added D50.1, D50.8, D50.9 and K52.3, and
Added Procedure code 91299

Internal Medical Policy Committee 7-22-2021 Coding update

Added Procedure code 0651T

Internal Medical Policy Committee 9-21-2021 Coding update-

Removed Diagnosis code K22.8;
Added Diagnosis codes: K22.81, K22.82, K22.89, K31.A0; K31.A11; K31.A12; K31.A13, K3.A14, K31.A15, K31.A19, K31.A21, K31.A22, K31.A29

Internal Medical Policy Committee 11-23-2021 Coding update-Effective January 01, 2022

Added Diagnosis codes: I85.00; I85.01; I85.10; I85.11, and
Added Procedure code 91113, and
Removed Diagnosis codes: K21.9; K22.2; K22.3; K22.70; K22.710; K22.711; K22.719, and
Removed Procedure code: 0355T

Internal Medical Policy Committee 9-28-2022 Coding update - Effective October 01, 2022

Removed Diagnosis codes Q85.8 and
Added Diagnosis codes Q85.81; Q85.82; Q85.83 and Q85.89

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: G-41-032

Section: Miscellaneous

Effective Date: July 01, 2018

Revised Date: December 02, 2021

Revision Effective Date: January 01, 2022

Last Reviewed: November 23, 2021

Archived Date: September 30, 2022

Applies To: Commercial and Medicaid Expansion

Description

Criteria

Coverage is subject to the specific terms of the member’s benefit plan.

Use of an U.S. FDA approved WCE may be considered medically necessary for ANY of the following indications:

Suspected small bowel bleeding; or
Initial diagnosis in individuals with suspected Crohn's disease; or
In individuals with an established diagnosis of Crohn's disease, when there are unexpected change(s) in the course of disease or response to treatment, suggesting the initial diagnosis may be incorrect and reexamination may be indicated; or
For surveillance of the small bowel in individuals with hereditary GI polyposis syndromes, including familial adenomatous polyposis and Peutz-Jeghers syndrome.
For evaluation of individuals with suspected undefined enteropathies to help direct/guide device assisted enteroscopy; or
- Individuals with enteropathies who are unable to undergo esophagogastroduodenoscopy (EGD) with biopsy; or
For re-evaluation of individuals with celiac disease who remain symptomatic despite treatment and there is no suspected or confirmed gastro-intestinal (GI) obstruction, stricture, or fistulae; or
For screening or surveillance of esophageal varices in cirrhotic individuals with significantly compromised liver function (i.e., Child-Pugh score of Class B or greater) or other situations where a standard upper endoscopy with sedation or anesthesia is contraindicated; or
For evaluation of known or suspected small bowel tumors; or
Persistent or unexplained iron deficiency anemia suspected to be due to GI bleeding.

WCE is considered experimental/investigational for the following indication, this is not an all inclusive list:

Evaluation of other GI diseases and conditions not presenting with GI bleeding, including but not limited to:
- Use in evaluating the stomach; or
- Duodenal lymphocytosis; or
- Lynch syndrome (risk for hereditary nonpolyposis colorectal cancer); or
- Portal hypertensive enteropathy or gastropathy; or
- Unexplained chronic abdominal pain; or
- Use for evaluating intussusception; or
- Use for follow-up of individuals with known small bowel disease other than Crohn’s disease; or
Evaluation of the colon, including but not limited to, detection of colonic polyps or colon cancer; or
Initial evaluation of individuals with acute upper GI bleeding; or
Use for evaluating diseases involving the esophagus other than esophageal varices; or
Use in confirming pathology identified by other diagnostic means.
Evaluation of individuals with evidence of lower GI bleeding and major risks for colonoscopy or moderate sedation; or
Evaluation of individuals following incomplete colonoscopy; or
Evaluation of the esophagus, in individuals with gastroesophageal reflux or Barrett’s esophagus.

Procedure Codes

91110

91111

91113

0651T

91299

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes 91110 and 91111

C17.0

C17.1

C17.2

C17.3

C17.8

C17.9

C78.4

C7A.010

C7A.011

C7A.012

C7A.019

D13.2

D13.30

D13.39

D37.2

D3A.010

D3A.011

D3A.012

D3A.019

D50.0

D50.1

D50.8

D50.9

I85.00

I85.01

I85.10

I85.11

K20.0

K22.0

K22.10

K22.11

K22.4

K22.5

K22.6

K22.81

K22.82

K22.89

K22.9

K23

K31.A0

K31.A11

K31.A12

K31.A13

K31.A14

K31.A15

K31.A19

K31.A21

K31.A22

K31.A29

K50.00

K50.011

K50.012

K50.013

K50.014

K50.018

K50.019

K50.10

K50.111

K50.112

K50.113

K50.114

K50.118

K50.119

K50.80

K50.811

K50.812

K50.813

K50.814

K50.818

K50.819

K50.90

K50.911

K50.912

K50.913

K50.914

K50.918

K50.919

K51.00

K51.011

K51.012

K51.013

K51.014

K51.018

K51.019

K51.20

K51.211

K51.212

K51.213

K51.214

K51.218

K51.219

K51.30

K51.311

K51.312

K51.313

K51.314

K51.318

K51.319

K51.80

K51.811

K51.812

K51.813

K51.814

K51.818

K51.819

K51.90

K51.911

K51.912

K51.913

K51.914

K51.918

K51.919

K52.3

K58.0

K58.1

K58.2

K58.8

K58.9

K90.0

K92.0

K92.1

K92.2

Q85.8

Q85.9

Z84.89

Professional Statements and Societal Positions Guidelines

The American College of Gastroenterology (ACG) – 2013

CE should be considered for the evaluation of small bowel mucosa in individuals with complicated Crohn disease.

The ACG (2018) updated its guidelines on the management of CD in adults. It makes two recommendations specific to video capsule endoscopy:

“Video capsule endoscopy (VCE) is a useful adjunct in the diagnosis of individuals with small bowel Crohn’s disease in individuals in whom there is a high index of suspicion of disease.”
“Individuals with obstructive symptoms should have small bowel imaging and/or patency capsule evaluation before VCE to decrease risk of capsule retention.”

ND Committee Review

Internal Medical Policy Committee 11-14-2019 Update, no changes in criteria. Reformat diagnosis codes. Remove duplicate diagnosis codes.

Internal Medical Policy Committee 3-16-2020 Removed the indications (Angiodysplasias of the gastrointestinal tract; To investigate anemia with concomitant iron deficiency, suspected to be of small bowel origin, after appropriate evaluation (at a minimum lower and upper endoscopy) has excluded a source of anemia from the upper GI tract and colon)

Internal Medical Policy Committee 9-21-2020 Added Diagnosis Codes C17.0; C17.1; C17.2; C17.3; C17.8; C17.9; C78.4; C7A.010; C7A.011; C7A.012; C7A.019; D37.2; D3A.010; D3A.011; D3A.012; D3A.019; D50.0

Internal Medical Policy Committee 1-19-2021 Removed Diagnosis Codes D12.6, G89.29, K52.22, R10.0, R10.10, R10.11, R10.12, R10.13, R10.30, R10.31, R10.32, R10.33 and Added D50.1, D50.8, D50.9 and K52.3. Added Procedure code 91299

Internal Medical Policy Committee 7-22-2021 Added: Procedure code 0651T

Internal Medical Policy Committee 9-21-2021 Coding update- Removed Diagnosis code K22.8; Added Diagnosis codes: K22.81, K22.82, K22.89, K31.A0; K31.A11; K31.A12; K31.A13, K3.A14, K31.A15, K31.A19, K31.A21, K31.A22, K31.A29

Internal Medical Policy Committee 11-23-2021 Coding update-Effective January 01, 2022

Added Diagnosis codes: I85.00; I85.01; I85.10; I85.11 and Procedure code 91113;
Removed Diagnosis codes: K21.9; K22.2; K22.3; K22.70; K22.710; K22.711; K22.719 and Procedure code: 0355T

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