Anthem Blue Cross Connecticut CG-SURG-101 Ablative Techniques as a Treatment for Barrett’s Esophagus Form

This document addresses the use of the following ablative techniques for treating Barrett’s esophagus (BE): radiofrequency ablation, cryoablation, laser ablation, argon plasma coagulation, and electrocoagulation.

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

• CG-MED-59 Upper Gastrointestinal Endoscopy in Adults

Clinical Indications

Medically Necessary:

I. High grade dysplasia (HG) or Intramucosal cancer (IMC):

Ablative treatment of Barrett’s esophagus is considered medically necessary when the following criterion have been met (A, B, and C):

1. The pathology findings include either of the following:
   1. High grade dysplasia (HG); or
   2. Intramucosal cancer (IMC);
      and
2. The procedure is intended as an alternative to esophagectomy; and
3. Either of the following techniques are used:
   1. Radiofrequency ablation; or
   2. Cryoablation treatment.

II. Low grade dysplasia (LGD):

Ablative treatment of Barrett’s esophagus is considered medically necessary when the following criterion have been met (A, B, and C):

1. The pathology finding is low grade dysplasia (LGD); and
2. The biopsy finding of LGD has been confirmed by two independent physicians*; and
3. Either of the following techniques are used;
   1. Radiofrequency ablation; or
   2. Cryoablation treatment.

*Note: The American Gastroenterological Association recommends that LGD should be confirmed by two pathologists since published studies have reported higher rates of progression of LGD when initial readings have been confirmed by expert pathologists, thereby eliminating or minimizing the rate of false positive diagnoses of LGD.

Not Medically Necessary:

Cryoablation and radiofrequency ablation treatments for Barrett’s esophagus are each considered not medically necessary when the above criteria have not been met, and for all other indications.

The following techniques as ablative treatment for Barrett’s esophagus are considered not medically necessary under all circumstances:

1. Electrocoagulation
2. Laser ablation
3. Argon plasma coagulation.