Humana Diagnostic Esophagogastroduodenoscopy or Esophagascopy (age 59 years or younger) Form

Description

This medical coverage policy is intended for diagnostic esophagogastroduodenoscopy (EGD) or esophagoscopy only. Criteria for screening, surveillance or therapeutic EGD or esophagoscopy are not addressed in this policy.

Esophagogastroduodenoscopy (EGD), also known as upper gastrointestinal (GI) endoscopy, is used for real-time visualization of the throat, esophagus, stomach and proximal duodenum for assessment and interpretation of the findings encountered. During the procedure, a thin, flexible fiberoptic tube with a high-definition white light and camera is passed through the mouth and upper GI tract displaying images on a video monitor. Additionally, the EGD may be used to dilate (stretch) a narrow area, obtain a biopsy (small tissue sample), perform a cytology test (the collection of cells for testing), remove polyps or treat bleeding.

Diagnostic Esophagogastroduodenoscopy or Esophagoscopy (59 years of age or younger)

Effective Date: 10/03/2023
Revision Date: 10/03/2023
Review Date: 04/27/2023
Policy Number: HUM-0567-011
Page: 2 of 15

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

An esophagoscopy is the examination of the esophagus

The esophagoscopy procedure is one of several procedures that fall under the category of upper endoscopy, including gastroscopy, EGD, and enteroscopy. Esophagoscopy alone is uncommon; it is generally performed as part of a more complete upper endoscopic procedure in which the esophagus, stomach, and portions of the small intestine are explored endoscopically. Esophagoscopy can be performed via the transnasal or transoral route.

Transnasal EGD is proposed as an alternative to the transoral approach and uses a flexible ultrathin tube. This approach reportedly does not require sedation and has been suggested for use in an individual who may have anxiety of sedation or at high risk of cardiopulmonary complications. (Refer to Coverage Limitations section)

Transoral esophageal mucosal integrity testing by electrical impedance (eg, MiVu) is being studied to aid in the diagnosis of gastroesophageal reflux disease (GERD). This testing is performed during routine endoscopy and reportedly gives real time measurements of esophageal epithelial impedance values. (Refer to Coverage Limitations section)

For information regarding capsule endoscopy, please refer to Capsule Endoscopy Medical Coverage Policy.

For information regarding endoscopy and bariatric intraoperative procedures, please refer to Bariatric Surgery Medical Coverage Policy.

Coverage Determination

Humana members may be eligible under the Plan for transoral diagnostic EGD or transnasal or transoral esophagoscopy (59 years of age or younger) for the following indications:

Diagnostic Esophagogastroduodenoscopy or Esophagoscopy (59 years of age or younger)

Effective Date: 10/03/2023
Revision Date: 10/03/2023
Review Date: 04/27/2023
Policy Number: HUM-0567-011
Page: 3 of 15

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Evaluation of dyspepsia or GERD with ANY of the following:
  • Family history of upper GI cancer in first-degree relative; OR
  • Lymphadenopathy (eg, left supraclavicular or periumbilical); OR
  • Palpable abdominal mass (eg, hepatoma); OR
  • Progressive dysphagia; OR
  • Unexplained iron deficiency anemia
• Evaluation of persistent dyspepsia symptoms (eg, epigastric pain, fullness, heartburn, nausea, vomiting) after an appropriate trial of a proton pump inhibitor (PPI) therapy (appropriate trial of therapy is a 2 to 4 week course of standard dose, once daily PPI); AND
  • Individual has undergone noninvasive testing for Helicobacter pylori (H. pylori) and was negative; OR
  • Individual has undergone noninvasive testing for H. pylori and was positive but has achieved successful eradication; OR
• Evaluation of GERD reflux symptoms (eg, acid reflux, heartburn) that are persistent or recurrent despite standard dosing of a trial of PPI (eg, Dexilant [dexlansoprazole]) for 2 months or greater; OR
• Assess acute injury after caustic ingestion; OR
• Atypical chest pain after cardiac disease has been ruled out; OR
• Clinically significant unintentional weight loss (eg, anorexia) (greater than 5 percent usual body weight over 6 to 12 months); OR
• Confirmation and specific histologic diagnosis of radiologically demonstrated findings (eg, lesions, strictures) including, but not limited to:
  • Gastric or esophageal lesion; OR
  • Suspected neoplastic lesion; OR
  • Upper tract obstruction or stricture; OR

Diagnostic Esophagogastroduodenoscopy or Esophagoscopy (59 years of age or younger)

Effective Date: 10/03/2023
Revision Date: 10/03/2023
Review Date: 04/27/2023
Policy Number: HUM-0567-011
Page: 4 of 15

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Evaluation of esophageal masses and for directing biopsies to rule out esophageal cancer; OR
• Evaluation of familial adenomatous polyposis syndromes; OR
• Evaluation of an individual with findings on an esophagram suggestive of achalasia; OR
• Evaluation of an individual with signs or symptoms of locoregional recurrence after resection of esophageal cancer; OR
• Evaluation of an individual with suspected portal hypertension to document esophageal varices; OR
• Evaluation of lower abdominal symptoms such as diarrhea in an individual suspected of having small bowel disease to identify an upper GI etiology (eg, celiac disease); OR
• Evaluation of other diseases in which the presence of upper GI pathology might modify other planned management (eg, an individual with a history of ulcer or GI bleeding who is scheduled for organ transplantation, long-term anticoagulation or chronic nonsteroidal anti-inflammatory drug [NSAID] therapy for arthritis and in an individual with cancer of the head or neck); OR
• GI bleeding and at least 1 of the following:
  • Acute or recent bleeding; OR
  • Colonoscopy result is negative; OR
  • Presumed chronic blood loss and for iron deficiency anemia when the clinical situation suggests an upper GI source; OR
• Odynophagia (painful swallowing); OR
• Persistent or recurrent dysphagia and 1 or more of the following:

Diagnostic Esophagogastroduodenoscopy or Esophagoscopy (59 years of age or younger)

Effective Date: 10/03/2023
Revision Date: 10/03/2023
Review Date: 04/27/2023
Policy Number: HUM-0567-011
Page: 5 of 15

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Eosinophilic esophagitis, suspected and need for biopsy
• Foreign body, known or suspected
• GI bleeding
• Transient obstruction with repeated episodes; OR

Persistent vomiting of unknown cause

Note: The criteria for EGD are not consistent with the Medicare National Coverage Policy and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

Coverage Limitations

Humana members may NOT be eligible under the Plan for diagnostic EGD or Esophagoscopy (59 years of age or younger) for any indications other than those listed above including, but may not be limited to:

• Individual with an asymptomatic upper GI tract (eg, prior to bariatric surgery)

All other indications are considered not medically necessary as defined in the member's individual certificate. Please refer to the member's individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for diagnostic transnasal EGD for ANY age for any indication. This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for transoral esophageal mucosal integrity testing by electrical impedance (eg, MiVu) for any indication. This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Background

Additional information about EGD, endoscopy or esophagoscopy may be found from the following websites:

Diagnostic Esophagogastroduodenoscopy or Esophagoscopy (59 years of age or younger)

Effective Date: 10/03/2023
Revision Date: 10/03/2023
Review Date: 04/27/2023
Policy Number: HUM-0567-011
Page: 6 of 15

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• American College of Gastroenterology
• American Society for Gastrointestinal Endoscopy
• National Library of Medicine

Medical Alternatives

Alternatives to EGD, endoscopy or esophagoscopy include, but may not be limited to, the following:

• Abdominal computed tomography (CT)
• Abdominal ultrasound
• Contrast swallowing evaluation
• Esophageal transit scintigraphy
• Upper gastrointestinal contrast studies

Physician consultation is advised to make an informed decision based on an individual's health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.