HIGHMARK COMMERCIAL MEDICAL POLICY - DELAWARE

 
 
Medical Policy:
G-41-008
Topic:
Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon
Section:
Miscellaneous
Effective Date:
November 27, 2017
Issued Date:
September 10, 2018
Last Revision Date:
August 2018
Annual Review:
August 2018
 
 

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.

Policy Position 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.

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WCE is 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.
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Professional Statements and Societal Positions Guidelines

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.


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Place of Service: Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

Wireless endoscopy is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

    Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.




    Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

    Discrimination is Against the Law
    The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.