Point32 Upper Gastrointestinal Endoscopy (Esophagogastroduodenoscopy, EGD) Form

Esophagogastroduodenoscopy (EGD)

Esophagogastroduodenoscopy (EGD) is a test used to examine the lining of the esophagus, stomach, and the duodenum. EGD is also known as upper gastrointestinal endoscopy, gastroscopy, or upper endoscopy.

EGD is indicated for the diagnosis of numerous conditions such as, but not limited to, Celiac disease, esophageal varices, esophagitis, gastritis, GERD, hiatal hernia, ulcers, Mallory-Weiss syndrome, and esophageal rings.

EGD may also be indicated for the investigation of symptoms such as upper gastrointestinal symptoms and upper gastrointestinal bleeding. Abnormal imaging or caustic ingestion may also indicate the need for EGD.

Clinical Guideline Coverage Criteria

The Plan considers Esophagogastroduodenoscopy (EGD) medically necessary for the following (this list is NOT all inclusive):

• Diagnostic/Evaluation for dyspepsia or upper abdominal symptoms:
  • Celiac Disease
  • Acute caustic ingestion
  • Confirmation of gastric or esophageal ulcer, suspected neoplastic lesion, or upper GI tract stricture or obstruction
  • Dysphagia or odynophagia
  • Esophageal cancer evaluation post resection with signs or symptoms of loco-regional recurrence
  • Esophageal masses and diagnostic esophageal cancer biopsies
  • Familial adenomatous polyposis syndromes.

Point32Health companies Upper Gastrointestinal Endoscopy 6717584 (Esophagogastroduodenoscopy, EGD)

1. Indeterminate colitis (differentiation of Crohn’s disease from ulcerative colitis)
2. Irritable bowel syndrome when other studies have negative results
3. Persistent or recurrent esophageal reflux symptoms despite therapy
4. Persistent (four weeks or greater) upper abdominal symptoms such as pain, nausea or vomiting that

• Fail to respond to medication therapy OR
• Symptoms are associated with weight loss, GI bleeding, melena, anemia, anorexia or early satiety

5. Persistent vomiting of unknown cause
6. Recent or active GI bleeding
7. Suspected portal hypertension
8. Upper abdominal symptoms associated with other signs or symptoms suggesting serious organic disease or new onset symptoms in members over 50 years of age who are refractory to treatment with a proton pump inhibitor trial
9. Upper GI tissue or fluid sampling

High-risk screening for:

• Chronic (at least 5 years) gastro-esophageal reflux disease (GERD) at risk for Barrett’s esophagus (BE) who have had no prior negative EGD screening.
• Cirrhosis and portal hypertension without prior variceal hemorrhage, especially those with platelet counts less than 140,000/mm3, or Child’s class B or C disease.
• Symptomatic pernicious anemia
• Symptoms consistent with celiac disease

Therapeutic EGD treatment for:

• Achalasia management by botulinum toxin, balloon dilation
• Banding or sclerotherapy of varices
• Dilation of stenotic lesions
• Feeding or drainage tube placement
• Removal of foreign bodies or selected polypoid lesions
• Stenosing neoplasm palliative treatment by laser, multi-polar electrocoagulation, stent placement
• Treatment of bleeding lesions (ulcers, tumors, vascular abnormalities) by electrocoagulation, heater probe, laser photocoagulation, or injection therapy.

Sequential or periodic EGD for:

• Barrett’s esophagus surveillance in the absence of dysplasia (every 3 years)
• Barrett’s esophagus surveillance with high-grade dysplasia (every 3 months)
• Barrett’s esophagus surveillance with low-grade dysplasia (yearly)
• Familial adenomatous polyposis (at time of colectomy or after age 30)
• Hereditary non-polyposis colorectal cancer
• Recurrence of adenomatous polyps in synchronous and metachronous sites (every 3 to 5 years)

Severe caustic esophageal injury

• Tylosis

Limitations

The Plan considers EGD as not medically necessary for all other indications in addition to the following:

• EGD for confirmation of gastric band placement
• EGD related to pre-evaluation of Members scheduled for bariatric surgery is not covered unless meeting one of the clinical criteria above
• EGD related to sclerotherapy for bariatric indications (e.g., revision of Roux-en-Y procedure to address weight regain) as this is considered investigational and, therefore, not medically necessary
• EGD related to endoscopic gastric suturing (e.g., with the Apollo Overstitch™ System) for revision of gastric bypass or as a primary bariatric procedure as these procedures are considered investigational and, therefore, not medically necessary
• EGD related to placement of the TransPyloric Shuttle device for bariatric indications as this is considered investigational and, therefore, not medically necessary

Point32Health companies Upper Gastrointestinal Endoscopy (Esophagogastroduodenoscopy, EGD)2

Upper GI endoscopies to rule out celiac disease for the following:

• Individuals with low risk of disease (for example infertility, GI symptoms with negative serology and without indicators of malabsorption, or osteoporosis without other evidence of malabsorption)

Codes