Anthem Blue Cross Connecticut CG-MED-59 Upper Gastrointestinal Endoscopy in Adults Form

This document addresses indications for upper gastrointestinal (GI) endoscopy in adults. This document does not address upper gastrointestinal (GI) endoscopy in children, wireless capsule endoscopy, virtual endoscopy or in vivo analysis of gastrointestinal lesions via endoscopy.

Note: Please see the following related documents for additional information:

• CG-MED-70 Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule
• CG-SURG-70 Gastric Electrical Stimulation
• CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity
• CG-SURG-101 Ablative Techniques as a Treatment for Barrett’s Esophagus
• SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis

Clinical Indications

Medically Necessary:

I.     Diagnostic Esophagogastroduodenoscopy (EGD) in Adults

EGD for diagnostic purposes for adults aged 18 years or older is considered medically necessary for any of the following indications:

1. Upper abdominal signs or symptoms:
   1. Gastroesophageal reflux symptoms that persist or recur following an appropriate trial of therapy for 2 months or more; or
   2. Persistent vomiting of unknown cause; or
   3. New-onset dyspepsia in individuals 50 years of age or older; or
   4. Unexplained dysphagia or odynophagia; or
   5. Signs or symptoms suggesting structural disease of the upper gastrointestinal tract such as anorexia, weight loss, early satiety, or persistent nausea; or
   6. Postoperative bariatric surgery with persistent abdominal pain, nausea, or vomiting despite counseling and behavior modification related to diet adherence; or
   7. Recent or active gastrointestinal bleed; or
   8. Unexplained anemia due to either blood loss or malabsorption from a mucosal process; or
   9. To assess symptoms suspicious for inflammatory bowel disease (for example, bloody diarrhea); or
2. Intraoperative evaluation of anatomic reconstructions typical of modern foregut surgery (for example, evaluation of anastomotic leak and patency, fundoplication formation, pouch configuration during bariatric surgery); or
3. For confirmation and specific histologic diagnosis of radiologically demonstrated lesions, including, but not limited to:
   1. Suspected neoplastic lesion; or
   2. Gastric or esophageal ulcer; or
   3. Upper tract stricture or obstruction; or
4. Documentation of esophageal varices in individuals with suspected portal hypertension or cirrhosis; or
5. To assess acute injury after caustic ingestion; or
6. To identify upper gastrointestinal etiology of lower gastrointestinal symptoms, such as diarrhea, in individuals suspected of having small-bowel disease (for example, celiac disease); or
7. To evaluate persons with radiographic findings suggestive of achalasia.

II.   Therapeutic EGD in Adults

EGD for therapeutic purposes for adults aged 18 years or older is considered medically necessary for any of the following indications:

1. Treatment of bleeding from lesions such as ulcers, tumors, vascular malformations (for example, electrocoagulation or injection therapy); or
2. For esophageal varices using endoscopic variceal ligation:
   1. Variceal ligation may be repeated every 1 to 8 weeks until varices are eradicated; and
   2. Sclerotherapy may be performed in individuals when variceal ligation is technically difficult; or
3. Removal of foreign body (including food impaction); or
4. Removal of selected polypoid or submucosal lesions; or
5. Placement of feeding tubes (per oral when unguided placement unsuccessful, or percutaneous); or
6. Dilation of stenotic lesions of the esophagus, pylorus or duodenum (for example, with transendoscopic balloon dilators or dilating systems employing guidewires); or
7. Dilation for adults with eosinophilic esophagitis who have a dominant esophageal stricture or ring and remain symptomatic despite medical therapy; or
8. Management of achalasia (for example, dilatation or treatment with botulinum toxin injection); or
9. Endoscopic placement of self-expandable metal stents (SEMS) for palliative treatment of malignant gastric or biliary obstruction in individuals with poor performance status or inoperable disease; or
10. Management of gastroduodenal dysmotility when symptoms persist despite optimal medical and dietary management; or
11. Palliative therapy of stenosing neoplasms; or
12. Endoscopic resection for individuals with Barrett’s esophagus and any of the following (ablative treatment of Barrett’s esophagus is addressed in CG-SURG-101 Ablative Techniques as a Treatment for Barrett's Esophagus):
    1. Low-grade dysplasia; or
    2. Flat high-grade dysplasia; or
    3. Intestinal metaplasia; or
13. Endoscopic resection or radiofrequency ablation for individuals with stage T1a esophageal adenocarcinoma.

III.   Screening EGD in Adults

Screening EGD for adults aged 18 years or older is considered medically necessary for any of the following indications:

1. Individuals with familial adenomatous polyposis:
   1. Starting at age 25 years if asymptomatic; and
   2. Subsequent follow up every 6 months to 4 years depending on the Spigelman Stage classification (0-III) of duodenal polyposis (see Table 2.); or
2. Screening for Barrett’s esophagus and esophageal adenocarcinoma may be considered in men with chronic (5 years or more) or frequent (weekly or more) symptoms of gastroesophageal reflux disease (GERD), such as heartburn or acid regurgitation, and at least two risk factors (see Discussion/General Information section).

IV.   Sequential or Periodic Diagnostic EGD in Adults

Sequential or periodic diagnostic EGD for adults aged 18 years or older is considered medically necessary for any of the following indications:

1. For surveillance of individuals with portal hypertension or compensated cirrhosis who meet any of the following criteria:
   1. With small varices or high-risk stigmata (“red wale markings”), every 1 to 2 years; or
   2. Without varices, every 2 to 3 years; or
   3. Secondary to alcohol abuse or decompensated liver disease, annually; or
2. Following esophageal variceal eradication, surveillance in the following intervals:
   1. 1 to 3 months following initial eradication; and
   2. Every 6 to 12 months thereafter to monitor for recurrence; or
3. In individuals with Barrett’s esophagus in any of the following scenarios:
   1. Without dysplasia, endoscopic surveillance should take place at intervals of 3 to 5 years; or
   2. With confirmed low-grade dysplasia, endoscopic surveillance of metaplastic gastric tissue may be performed every 6-12 months (endoscopic therapy is preferred); or
   3. With confirmed high-grade dysplasia and comorbidities that preclude endoscopic eradication therapy, endoscopic surveillance of metaplastic gastric tissue may be performed every 3 months.

Not Medically Necessary:

EGD for adults aged 18 years or older is considered not medically necessary when the above criteria are not met, and for all other indications, including but not limited to the following:

1. Screening of any of the following:
   1. Asymptomatic upper gastrointestinal tract of an average risk individual; or
   2. Follow-up screening for Barrett’s esophagus after a prior EGD screening examination was negative for Barrett’s esophagus; or
   3. Aerodigestive cancer; or
2. Surveillance for any of the following:
   1. Healed benign disease (for example, esophagitis, gastric or duodenal ulcer); or
   2. Gastric atrophy; or
   3. Pernicious anemia; or
   4. Fundic gland or hyperplastic polyps; or
   5. Gastric intestinal metaplasia; or
   6. Previous gastric operations for benign disease; or
   7. Achalasia; or
3. Radiographic findings of any of the following:
   1. Asymptomatic or uncomplicated sliding hiatal hernia; or
   2. Uncomplicated duodenal ulcer that has responded to therapy; or
   3. Deformed duodenal bulb when symptoms are absent or respond adequately to ulcer therapy; or
4. Confirming Helicobacter pylori eradication; or
5. Isolated pylorospasm, known congenital hypertrophic pyloric stenosis, constipation and encopresis, or inflammatory bowel disease responding to therapy; or
6. Prior to bariatric or non-gastroesophageal surgery in asymptomatic individuals; or
7. Metastatic adenocarcinoma of unknown primary site when the results will not alter management; or
8. Obtaining tissue samples from endoscopically normal tissue to diagnose GERD or exclude Barrett’s esophagus in adults; or
9. Symptoms that are considered functional in origin; or
10. To evaluate benign appearing, uncomplicated duodenal ulcers identified on radiologic imaging; or
11. When there is clinical evidence of acute perforation.