OVERVIEW
An upper GI endoscopy is a procedure that uses a lighted, flexible endoscope to see inside the upper GI tract. The upper GI tract includes the esophagus, stomach, and duodenum—the first part of the small intestine.
COVERAGE GUIDELINES
Tufts Health plan will cover an upper GI endoscopy when ONE of the following criteria sets is met.
A. Esophageal Disease
1. Dysphagia (difficulty swallowing) or odynophagia (pain with swallowing) associated with one of the following:
a. New onset or worsening of symptoms of difficulty or pain with swallowing
b. Weight loss
c. Need for therapeutic intervention for a stricture or for achalasia
2. GERD with:
a. Persistent symptoms of GERD such as heartburn or regurgitation, AND an inadequate response to Proton-pump inhibitors (PPIs) administered for at least 4 weeks or;
b. History of GERD for one year or longer at time of EGD request or;
c. Weight loss, anemia, abnormal radiological study of esophagus or stomach, GI bleeding, early satiety or recurrent vomiting
3. Surveillance in Members with established Barrett’s esophagus*, according to intervals based on pathology:
a. high-grade dysplasia on prior biopsies: EGD with biopsy will be covered every 3 months
b. low grade dysplasia on prior biopsies: EGD 6 months after initial biopsy and if still low grade dysplasia will be covered annually thereafter if no change in pathology
c. no dysplasia on prior biopsy: cover 2 EGD’s with biopsy in one year and if normal pathology remains, every three years thereafter
4. Abnormal radiological study of esophagus or stomach
5. Esophageal varices:
a. Initial screening for esophageal or gastric varices in Member with a new diagnosis of cirrhosis or;
b. Treatment of varices by sclerotherapy or endoscopic variceal ligation (EVL) in Members who has had documented bleeding from esophageal varices (active or in
past) or;
c. For Members with high risk of esophageal variceal bleed, with no prior history of bleeding. The Member must have one or more of the high risk factors listed below:
i. Medium to large varices on prior screening EGD
ii. Red marks such as red wale lines or red spots seen on screening or on prior EGD
iii. Child’s B or C cirrhosis (significant functional compromise or decompensated liver disease)
a. Repeat screenings can be covered under the following conditions:
i. If compensated cirrhosis (stable clinically and without bleeding) and no varices on initial screen, EGD may be covered every THREE years ii. If compensated cirrhosis and varices on initial EGD repeat EGD will be
covered every TWO years, only for Members not on beta blockers
iii. If decompensated cirrhosis (unstable clinical status) EGD may be covered ANNUALLY
6. Corrosive injuries to esophagus(unlimited)
B. Anemia
1. Vitamin B-12 deficiency or;
2. Iron deficiency defined as a documented ferritin below normal for laboratory and/or a
Fe/TICC saturation below 20%
C. Gastric Ulcer
Follow-up after one-two month of treatment with PPI or H-2 blocker (to confirm healing and/or rule out malignant ulcer)
D. Persistent Upper Abdominal Symptoms
1. Symptoms for at least 4 weeks (e.g., pain, nausea or vomiting) and either
a. Fails to respond to maximum PPI’s (twice daily dosing) OR reinstitution of PPI therapy after one successful course or;
b. Symptoms are associated with weight loss, GI bleeding, melena, anemia, anorexia or early satiety
E. Celiac Disease
1. Positive serology for celiac disease by IgA tissue transglutaminase (IgA-tTG), IgA endomysial antibody (IgA-EMA) or IgG-tTG or IgG-EMA may be substituted for Members with IgA deficiency or;
2. Any one of the following criteria:
a. GI symptoms consistent with chronic malabsorption, including chronic diarrhea or steatorrhea, abdominal distension, and weight loss or;
b. Otherwise unexplained iron, folate, or vitamin D deficiency, calcium deficiency, or secondary hyperparathyroidism with osteoporosis or osteomalacia or;
c. In absence of other causes: persistent aminotransferase elevation, short stature, delayed puberty, recurrent fetal loss/infertility, epilepsy or ataxia or;
d. GI symptoms, with a diagnosis of an associated high-risk conditions, such as, Type-1 Diabetes Mellitus or other autoimmune endocrinopathies (such as autoimmune
thyroiditis); first and second degree relatives with celiac disease; Turner, Down or William syndromes; IgA deficiency, or Dermatitis Herpetiformis (skin condition
strongly associated with celiac disease)
3. A repeat Upper GI Endoscopy may be covered with one of the following indications:
a. The Member fails to respond to gluten-free diet
b. Diagnosis of celiac disease is uncertain on initial testing and needs to be confirmed by re-biopsy
F. Involuntary Weight Loss
1. Weight loss of 10 pounds or more in 12 weeks or less without dietary or illness related explanation
G. Diarrhea
If all guidelines below are met:
1. Greater than 3 weeks duration and
2. Negative stool studies for infection, including O & P if indicated and
3. After completion of lower bowel work-up, including flexible sigmoidoscopy or colonoscopy and
4. For Members under 40 years old with a history consistent with irritable bowel syndrome,
failure of fiber and anti-spasmodic to resolve diarrhea.
H. Increased Risk Factor for Gastric Cancer
When the Member has one of the following risk factors:
1. Positive diagnosis of familial adenomatous polyposis
2. Positive diagnosis of hereditary nonpolyposis colorectal cancer
3. Positive family history of gastric cancer
LIMITATIONS
Tufts Health Plan does not cover upper GI endoscopies for the following indication:
EGD related to pre-evaluation of Members scheduled for bariatric surgery is not covered unless meeting one of the clinical criteria above Tufts Health Plan does not cover upper GI endoscopies to rule out celiac disease for the following indications:
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
The following CPT codes require prior authorization:
Code Description
43200 Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
43202 Esophagoscopy, rigid or flexible; with biopsy, single or multiple
43233 Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed)
43235 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
43239 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum
and/or jejunum as appropriate; with biopsy, single or multiple
An upper GI endoscopy is a procedure that uses a lighted, flexible endoscope to see inside the upper GI tract. The upper GI tract includes the esophagus, stomach, and duodenum—the first part of the small intestine.
COVERAGE GUIDELINES
Tufts Health plan will cover an upper GI endoscopy when ONE of the following criteria sets is met.
A. Esophageal Disease
1. Dysphagia (difficulty swallowing) or odynophagia (pain with swallowing) associated with one of the following:
a. New onset or worsening of symptoms of difficulty or pain with swallowing
b. Weight loss
c. Need for therapeutic intervention for a stricture or for achalasia
2. GERD with:
a. Persistent symptoms of GERD such as heartburn or regurgitation, AND an inadequate response to Proton-pump inhibitors (PPIs) administered for at least 4 weeks or;
b. History of GERD for one year or longer at time of EGD request or;
c. Weight loss, anemia, abnormal radiological study of esophagus or stomach, GI bleeding, early satiety or recurrent vomiting
3. Surveillance in Members with established Barrett’s esophagus*, according to intervals based on pathology:
a. high-grade dysplasia on prior biopsies: EGD with biopsy will be covered every 3 months
b. low grade dysplasia on prior biopsies: EGD 6 months after initial biopsy and if still low grade dysplasia will be covered annually thereafter if no change in pathology
c. no dysplasia on prior biopsy: cover 2 EGD’s with biopsy in one year and if normal pathology remains, every three years thereafter
4. Abnormal radiological study of esophagus or stomach
5. Esophageal varices:
a. Initial screening for esophageal or gastric varices in Member with a new diagnosis of cirrhosis or;
b. Treatment of varices by sclerotherapy or endoscopic variceal ligation (EVL) in Members who has had documented bleeding from esophageal varices (active or in
past) or;
c. For Members with high risk of esophageal variceal bleed, with no prior history of bleeding. The Member must have one or more of the high risk factors listed below:
i. Medium to large varices on prior screening EGD
ii. Red marks such as red wale lines or red spots seen on screening or on prior EGD
iii. Child’s B or C cirrhosis (significant functional compromise or decompensated liver disease)
a. Repeat screenings can be covered under the following conditions:
i. If compensated cirrhosis (stable clinically and without bleeding) and no varices on initial screen, EGD may be covered every THREE years ii. If compensated cirrhosis and varices on initial EGD repeat EGD will be
covered every TWO years, only for Members not on beta blockers
iii. If decompensated cirrhosis (unstable clinical status) EGD may be covered ANNUALLY
6. Corrosive injuries to esophagus(unlimited)
B. Anemia
1. Vitamin B-12 deficiency or;
2. Iron deficiency defined as a documented ferritin below normal for laboratory and/or a
Fe/TICC saturation below 20%
C. Gastric Ulcer
Follow-up after one-two month of treatment with PPI or H-2 blocker (to confirm healing and/or rule out malignant ulcer)
D. Persistent Upper Abdominal Symptoms
1. Symptoms for at least 4 weeks (e.g., pain, nausea or vomiting) and either
a. Fails to respond to maximum PPI’s (twice daily dosing) OR reinstitution of PPI therapy after one successful course or;
b. Symptoms are associated with weight loss, GI bleeding, melena, anemia, anorexia or early satiety
E. Celiac Disease
1. Positive serology for celiac disease by IgA tissue transglutaminase (IgA-tTG), IgA endomysial antibody (IgA-EMA) or IgG-tTG or IgG-EMA may be substituted for Members with IgA deficiency or;
2. Any one of the following criteria:
a. GI symptoms consistent with chronic malabsorption, including chronic diarrhea or steatorrhea, abdominal distension, and weight loss or;
b. Otherwise unexplained iron, folate, or vitamin D deficiency, calcium deficiency, or secondary hyperparathyroidism with osteoporosis or osteomalacia or;
c. In absence of other causes: persistent aminotransferase elevation, short stature, delayed puberty, recurrent fetal loss/infertility, epilepsy or ataxia or;
d. GI symptoms, with a diagnosis of an associated high-risk conditions, such as, Type-1 Diabetes Mellitus or other autoimmune endocrinopathies (such as autoimmune
thyroiditis); first and second degree relatives with celiac disease; Turner, Down or William syndromes; IgA deficiency, or Dermatitis Herpetiformis (skin condition
strongly associated with celiac disease)
3. A repeat Upper GI Endoscopy may be covered with one of the following indications:
a. The Member fails to respond to gluten-free diet
b. Diagnosis of celiac disease is uncertain on initial testing and needs to be confirmed by re-biopsy
F. Involuntary Weight Loss
1. Weight loss of 10 pounds or more in 12 weeks or less without dietary or illness related explanation
G. Diarrhea
If all guidelines below are met:
1. Greater than 3 weeks duration and
2. Negative stool studies for infection, including O & P if indicated and
3. After completion of lower bowel work-up, including flexible sigmoidoscopy or colonoscopy and
4. For Members under 40 years old with a history consistent with irritable bowel syndrome,
failure of fiber and anti-spasmodic to resolve diarrhea.
H. Increased Risk Factor for Gastric Cancer
When the Member has one of the following risk factors:
1. Positive diagnosis of familial adenomatous polyposis
2. Positive diagnosis of hereditary nonpolyposis colorectal cancer
3. Positive family history of gastric cancer
LIMITATIONS
Tufts Health Plan does not cover upper GI endoscopies for the following indication:
EGD related to pre-evaluation of Members scheduled for bariatric surgery is not covered unless meeting one of the clinical criteria above Tufts Health Plan does not cover upper GI endoscopies to rule out celiac disease for the following indications:
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
The following CPT codes require prior authorization:
Code Description
43200 Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
43202 Esophagoscopy, rigid or flexible; with biopsy, single or multiple
43233 Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed)
43235 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
43239 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum
and/or jejunum as appropriate; with biopsy, single or multiple