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

Section: Miscellaneous
Effective Date: July 01, 2018
Revised Date: November 14, 2019
Last Reviewed: November 14, 2019

Description

Wireless capsule endoscopy 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.

Wireless Capsule Endoscopy of Small Intestine

Wireless capsule endoscopy (WCE) of the small intestine may be considered medically necessary for ages 2 yr. and older for the following indications when conventional endoscopic and diagnostic imaging evaluations (e.g., upper gastrointestinal endoscopy, colonoscopy, push enteroscopy, nuclear imaging, or radiological procedure) are inconclusive:

  • Angiodysplasias of the gastrointestinal tract; or
  • Suspected small bowel tumors in individuals with hereditary gastrointestinal polyposis syndromes including familial polyposis, Peutz-Jeghers syndrome, and Lynch syndrome; or
  • Initial diagnosis of suspected Crohn’s disease without evidence of disease on conventional diagnostic tests such as small-bowel follow-through (SBFT) and upper and lower endoscopy; or
  • In individuals with an established diagnosis of Crohn disease, when there are unexpected change(s) in the course of disease or response to treatment, suggesting the initial diagnosis may be incorrect and re-examination may be indicated; or
  • Occult gastrointestinal bleeding suspected of being of small bowel origin, as evidenced by prior inconclusive upper and lower gastrointestinal endoscopic studies performed in the past 12 months of the current episode of illness; or
  • For evaluation of individuals with celiac disease with a positive serology and a negative biopsy; 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
  • 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.

Results of the gastrointestinal evaluations, performed prior to wireless capsule endoscopy, including all endoscopic and radiologic studies, must be kept in the medical record documentation and be available upon request.

Procedure Codes

91110 91111

WCE are considered experimental and investigational for all other indications including but not limited to the following because of insufficient evidence of efficacy and safety; therefore considered non-covered:

  • Repeat use to verify the effectiveness of surgery; or 
  • Use as a screening test (other than esophageal varices); or 
  • Use as an initial evaluation of acute gastrointestinal bleeding; or 
  • Use for colorectal cancer screening; or 
  • Use for detecting gastric varices; or 
  • Use for evaluating intussusception; or 
  • Use for evaluating the colon, including but not limited to: 
    • Detection of colonic polyps; or
    • Colon cancer.
  • Use for evaluating diseases involving the esophagus other than esophageal varices; or
  • Use for follow-up of persons with known small bowel disease other than Crohn’s disease; or
  • Use for staging portal hypertensive gastropathy; or
  • Use in confirming pathology identified by other diagnostic means; or
  • Use in evaluating the stomach; or
  • Use in investigating duodenal lymphocytosis, small bowel neoplasm, or suspected irritable bowel syndrome; or
  • Use of a patency capsule; or
  • Evaluation of other gastrointestinal diseases and conditions not presenting with GI bleeding, including but not limited to: 
    • Celiac sprue; or 
    • Irritable bowel syndrome; or 
    • Lynch syndrome; or 
    • Portal; or 
    • Hypertensive enteropathy; or 
    • Small bowel neoplasm; or 
    • Unexplained chronic abdominal pain.
  • Evaluation of the extent of involvement of known Crohn disease or ulcerative colitis.

Procedure Codes

0355T 91111

Diagnosis Codes

C17.0 C17.1 C17.2 C17.3 C17.8 C17.9 C49.A0
C49.A1 C49.A2 C49.A3 C49.A4 C49.A5 C49.A9 C78.4
D01.40 D01.49 D13.2 D13.30 D13.39 D37.2 D50.0
D50.1 D50.8 D50.9 I77.6 I85.10 I85.11 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 K57.11
K57.13 K57.51 K57.53 K63.81 K90.0 K92.0 K92.1
K92.2 Q85.8

Professional Statements and Societal Positions

The American College of Gastroenterology issued 2013 guidelines on the diagnosis and management of celiac disease. The guideline recommendations state that capsule endoscopy should not be used for initial diagnosis except for patients with positive-celiac specific serology who are unwilling or unable to undergo upper endoscopy with biopsy.

Links