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

Section: Miscellaneous
Effective Date: May 01, 2020
Revised Date: March 16, 2020
Last Reviewed: March 16, 2020

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.

Wireless Capsule Endoscopy of Small Intestine

WCE of the small bowel may be consideredmedically necessaryfor the following indications:

  • Suspected small bowel bleeding, as evidenced by prior inconclusive upper and lower gastrointestinal (GI) endoscopic studies performed during the current episode of illness; or
  • Initial diagnosis in individuals with suspected Crohn disease without evidence of disease on conventional diagnostic tests such as small bowel follow-through and upper and lower endoscopy; or
  • In individuals with an established diagnosis of Crohn disease, when thereareunexpected change(s) in the course of disease or response to treatment, suggesting the initial diagnosis may beincorrectand reexamination maybe 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 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.

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:

  • 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
    • Celiac sprue; or
    • Irritable bowel syndrome; or
    • Lynch syndrome (risk for hereditary nonpolyposis colorectal cancer); or
    • Portal hypertensive enteropathy or gastropathy; or
    • Small bowel neoplasm; 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 evaluationof 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.

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.

 

Procedure Codes

91110 91111 0355T

Diagnosis Codes

D12.6 D13.2 D13.30 D13.39 G89.29 K20.0 K20.8
K20.9 K21.0 K21.9 K22.0 K22.10 K22.11 K22.2
K22.3 K22.4 K22.5 K22.6 K22.70 K22.710 K22.711
K22.719 K22.8 K22.9 K23 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 K52.22 K90.0 K92.0
K92.1 K92.2 Q85.8 Q85.9 R10.0 R10.10 R10.11
R10.12 R10.13 R10.30 R10.31 R10.32 R10.33 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 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:

  • “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 shouldbe reservedfor 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 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)

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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.