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.
Use of an U.S. FDA approved WCE may be considered medically necessary for ANY of the following indications:
WCE is considered experimental/investigational for the following indications, this is not an all inclusive list:
WCE not meeting the criteria as indicated in this policy is considered experimental/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 patency capsule, including use to evaluate patency of the GI tract before WCE is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
91110 |
91111 |
91113 |
0651T |
91299 |
|
|
The American College of Gastroenterology (ACG) – 2013
The ACG (2013) issued guidelines on the diagnosis and management of celiac disease. The guidelines recommended that capsule endoscopy (CE) 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.
CE should be considered for the evaluation of small bowel mucosa in patients with complicated Crohn disease.
The ACG (2018) updated its guidelines on the management of CD in adults. It makes two recommendations 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 patients 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 should be reserved for patients in whom a source of bleeding cannot be identified anywhere in the GI tract).
Covered Diagnosis Codes for Procedure Codes 91110 and 91111
C17.0 |
C17.1 |
C17.2 |
C17.3 |
C17.8 |
C17.9 |
C78.4 |
C7A.010 |
C7A.011 |
C7A.012 |
C7A.019 |
D13.2 |
D13.30 |
D13.39 |
D13.91 |
D13.99 |
D37.2 |
D3A.010 |
D3A.011 |
D3A.012 |
D3A.019 |
D50.0 |
D50.1 |
D50.8 |
D50.9 |
I85.00 |
I85.01 |
I85.10 |
I85.11 |
K20.0 |
K22.0 |
K22.10 |
K22.11 |
K22.4 |
K22.5 |
K22.6 |
K22.81 |
K22.82 |
K22.89 |
K22.9 |
K23 |
K31.A0 |
K31.A11 |
K31.A12 |
K31.A13 |
K31.A14 |
K31.A15 |
K31.A19 |
K31.A21 |
K31.A22 |
K31.A29 |
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 |
K52.3 |
K58.0 |
K58.1 |
K58.2 |
K58.8 |
K58.9 |
K90.0 |
K92.0 |
K92.1 |
K92.2 |
Q85.81 |
Q85.82 |
Q85.83 |
Q85.89 |
Q85.9 |
Z84.89 |
|
|
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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.
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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.
This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.
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:
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.