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.
Coverage is subject to the specific terms of the member’s benefit plan.
WCE of the small bowel may be consideredmedically necessaryfor the following indications:
The following indications for WCE are consideredexperimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature, include but are not limited to:
The patency capsule, including use to evaluate patency of the GI tract before WCE is consideredexperimental/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 American College of Gastroenterology (ACG) – 2013
The ACG (2013) issued guidelines on the diagnosis and management of celiac disease. The guidelines recommended thatcapsule endoscopy (CE)notbeused 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 makestworecommendations specific to video capsule endoscopy:
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 shouldbe reservedfor individuals in whom a source of bleeding cannot be identified anywhere in the GI tract).
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)
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.