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.
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:
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.
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:
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.