Clinical UM Guideline

 

Subject: Upper Gastrointestinal Endoscopy
Guideline #:  CG-MED-59 Publish Date:    11/09/2017
Status: Revised Last Review Date:    11/02/2017

Description

This document addresses indications for upper gastrointestinal (GI) endoscopy, also referred to as esophagogastroduodenoscopy (EGD), which uses a flexible fiber-optic scope with a light and camera to examine the upper part of the GI system. The scope is inserted through the mouth into the upper GI tract allowing for direct visualization of the esophagus, stomach, and duodenum through the camera. This document does not address wireless capsule endoscopy, virtual endoscopy or in vivo analysis of gastrointestinal lesions via endoscopy.

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

Clinical Indications

Medically Necessary:

I.  Diagnostic Esophagogastroduodenoscopy (EGD)

EGD for diagnostic purposes is considered medically necessary for any of the following indications:

  1. Upper abdominal signs or symptoms:
    1. Gastroesophageal reflux symptoms, that persist or reoccur following an appropriate trial of therapy for 2 months or more; or
    2. Persistent vomiting of unknown cause; or
    3. New-onset of dyspepsia in individuals 50 years of age of older; or
    4. Unexplained dysphagia or odynophagia; or
    5. Signs or symptoms suggesting structural disease, such as a gastroduodenal obstruction (for example, anorexia and weight loss); 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. Suspected chronic blood loss (for example, iron deficiency anemia when the clinical situation suggests an upper gastrointestinal source or colonoscopy is inconclusive); or
    9. To assess symptoms suspicious of inflammatory bowel disease (for example, abdominal pain or discomfort and changes in stools); 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 findings on an esophagram suggestive of achalasia.

II.  Therapeutic EGD

EGD for therapeutic purposes 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, in the absence of life-limiting comorbidities, and any of the following (ablative treatment of Barrett’s esophagus is addressed in SURG.00106 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 without life-limiting comorbidities and stage T1a esophageal adenocarcinoma.

III.  Screening EGD

Screening EGD 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 of the following risk factors:
    1. At least 50 years of age; or
    2. Caucasian race; or
    3. Presence of central obesity (waist circumference greater than102 cm or waist–hip ratio greater than 0.9); or
    4. Current or past history of smoking; or
    5. Confirmed family history of Barrett’s esophagus or esophageal adenocarcinoma (in a first-degree relative); or
  3. As part of the initial evaluation of pediatric inflammatory bowel disease in individuals 17 years of age or younger.

IV.  Sequential or Periodic Diagnostic EGD

Sequential or periodic diagnostic EGD 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 and 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 and without life-limiting comorbidity 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 life-limiting comorbidities that preclude endoscopic eradication therapy, endoscopic surveillance of metaplastic gastric tissue may be performed every 3 months.

Not Medically Necessary:

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

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT

 

43233

Esophagogastroduodenoscopy, flexible transoral; diagnostic, with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed)

43235

Esophagogastroduodenoscopy, flexible transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

43236

Esophagogastroduodenoscopy, flexible transoral; with directed submucosal injection(s), any substance [other than injections related to gastroesophageal reflux or dysphagia]

43238

Esophagogastroduodenoscopy, flexible transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures)

43239

Esophagogastroduodenoscopy, flexible transoral; with biopsy, single or multiple

43241

Esophagogastroduodenoscopy, flexible transoral; with insertion of intraluminal tube or catheter

43242

Esophagogastroduodenoscopy, flexible transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis)

43243

Esophagogastroduodenoscopy, flexible transoral; with injection sclerosis of esophageal/gastric varices

43244

Esophagogastroduodenoscopy, flexible transoral; with band ligation of esophageal/gastric varices

43245

Esophagogastroduodenoscopy, flexible transoral; with dilation of gastric/duodenal stricture(s) (eg, balloon, bougie)

43246

Esophagogastroduodenoscopy, flexible transoral; with directed placement of percutaneous gastrostomy tube

43247

Esophagogastroduodenoscopy, flexible transoral; with removal of foreign body(s)

43248

Esophagogastroduodenoscopy, flexible transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire

43249

Esophagogastroduodenoscopy, flexible transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)

43250

Esophagogastroduodenoscopy, flexible transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps

43251

Esophagogastroduodenoscopy, flexible transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

43253

Esophagogastroduodenoscopy, flexible transoral; with transendoscopic ultrasound-guided transmural injection of diagnostic or therapeutic substance(s) (eg, anesthetic, neurolytic agent) or fiducial marker(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis)

43254

Esophagogastroduodenoscopy, flexible transoral; with endoscopic mucosal resection

43255

Esophagogastroduodenoscopy, flexible transoral; with control of bleeding, any method

43266

Esophagogastroduodenoscopy, flexible transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)

43270

Esophagogastroduodenoscopy, flexible transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed) [other than ablation related to Barrett’s esophagus]

ICD-10 Diagnosis

 

 

All diagnoses

Discussion/General Information

Upper gastrointestinal (GI) endoscopy, or EGD is usually performed to evaluate symptoms of persistent upper abdominal pain, nausea, vomiting, and difficulty swallowing or bleeding from the upper GI tract. EGD is more accurate than x-ray films for detecting inflammation, ulcers, or tumors of the esophagus, stomach and duodenum and can detect early cancer, as well as distinguish between benign and malignant conditions when biopsies of suspicious areas are obtained.  

The quality of evidence concerning the safety and efficacy of EGD is lacking for the majority of the most common uses of the technology. In an effort to provide safe recommendations to guide clinical practice in the use of EGD, the American Society for Gastrointestinal Endoscopy (ASGE), the American Gastroenterological Association (AGA), the American College of Gastroenterology (ACG), and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) have established practice guidelines based largely on consensus within these respective specialty medical societies.

In 2012, the ASGE published a broad guideline entitled, Appropriate use of GI Endoscopy. The guideline contains several position statements based on a critical review of the available data as well as expert consensus. The ASGE has also published a number of indication-specific guidelines such as, The Role of Endoscopy in Barrett’s Esophagus and other Premalignant Conditions of the Esophagus (2012), The Role of Endoscopy in Gastroduodenal Obstruction and Gastroparesis (2011) and The Role of Endoscopy in Dyspepsia (2015). The indication-specific guidelines also contain recommendations based on consensus and a review of the literature; each recommendation was graded on the quality of the supporting evidence in accordance with the definitions in Table 1. The ACG has also published indication-specific clinical practice guidelines on the use of endoscopy in commonly encountered clinical scenarios. For example, ACG Clinical Guideline: Diagnosis and Management of Barrett’s Esophagus (2015) and Guidelines for the Clinical Management of Familial Adenomatous Polyposis (FAP). The ACG’s recommendations are graded in accordance with the same definitions as the ASGE, which appear in Table 1. The medically necessary indications in this clinical guideline are largely based on ASGE, ACG and AGA recommendations that are graded as ‘moderate’ to ‘high’ quality where the ACG has not considered the recommendation ‘conditional’ (“uncertainty about the tradeoffs”) or the AGA has not considered the recommendation ‘weak’ (“recommendation not suitable for quality or performance measure”). Where there was discordance, criteria are based on expert consensus.

The role of surveillance EGD in screening and surveillance of persons found to have Barrett’s esophagus has not been clearly established. The three aforementioned major gastroenterological specialty societies (ACG, 2015; AGA, 2011 and ASGE, 2012) recommend screening only for individuals at high risk for development of Barret’s esophagus. Well-known risk factors associated with the development of Barrett’s esophagus include long-standing GERD (5 years or more), male gender, obesity, advanced age (50 years of age or older) and history of smoking.

The clinical trial data to date, is largely based on observational studies and has not consistently shown a benefit from routine surveillance of persons with Barrett’s esophagus. Surveillance EGD can be associated with false positives, false negatives, and procedural complications. Citing a preponderance of weak evidence, the ACG, AGA, and ASGE have all produced similar recommendations for EGD surveillance of individuals with Barrett’s esophagus. All acknowledge a role for surveillance and recommend surveillance frequencies, but they each also recommend counselling individuals about potential risks and benefits prior to conducting surveillance.

Table 1. Quality of Evidence Grading of Recommendations Assessment, Development and Evaluation (GRADE) System (ACG, 2017; AGA, 2011; ASGE, 2015).

‘High’              Further research is very unlikely to change our confidence in the estimate of effect.

‘Moderate’       Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. 

‘Low’               Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

‘Very Low’      Any estimate of effect is very uncertain.

 

Table 2. Spigelman Stage classification (0-IV) of duodenal polyposis (ACG, 2015).

Spigelman classification

Endoscopic frequency

Stage 0

4 years

Stage I

2-3 years

Stage II

1-3 years

Stage III

6-12 months

Stage IV

Surgical evaluation

References

Peer Reviewed Publications:

  1. Kovacs M, Muller KE, Arato A, et al. Diagnostic yield of upper endoscopy in paediatric patients with Crohn’s disease and ulcerative colitis. Subanalysis of the HUPIR registry. J Crohns Colitis. 2012; 6(1):86-94.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American College of Gastroenterology. Practice Guidelines. Available at: https://gi.org/clinical-guidelines/clinical-guidelines-sortable-list/. Accessed on September 21, 2017:
    • Diagnosis and management of achalasia. Revised 2013.
    • Diagnosis and management of Barrett’s esophagus. Revised 2015.
    • Diagnosis and management of celiac disease. Revised 2013.
    • Diagnosis and management of gastroesophageal reflux disease (GERD). Revised 2013.
    • Diagnosis and management of small bowel bleeding. Revised 2015.
    • Evidenced based approach to the diagnosis and management of esophageal eosinophilia and eosinophilic esophagitis (EoE). Revised 2013.
    • Genetic testing and management of hereditary gastrointestinal cancer syndromes. Revised 2015.
    • Guidelines for the clinical management of familial adenomatous polyposis (FAP). Revised 2008.
    • Management of dyspepsia. Revised 2017.
    • Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Revised 2007.
  2. American Gastroenterological Association; Spechler SJ, Sharma P, Souza RF, et al. American Gastroenterological Association medical position statement on the management of Barrett's esophagus. Gastroenterology. 2011; 140(3):1084-1091.
  3. ASGE Standards of Practice Committee; Chandrasekhara V, Early DS, Acosta RD, et al. ASGE guideline: modifications in endoscopic practice for the elderly. Gastrointest Endosc. 2013; 78(1):1-7.
  4. ASGE Standards of Practice Committee; Early DS, Ben-Menachem T, Decker GA, et al. Appropriate use of GI endoscopy. Gastrointest Endosc. 2012; 75(6):1127-1131.
  5. ASGE Standards of Practice Committee; Evans JA, Early DS, Fukami N, et al. The role of endoscopy in Barrett's esophagus and other premalignant conditions of the esophagus. Gastrointest Endosc. 2012; 76(6):1087-1094.
  6. ASGE Standards of Practice Committee; Lightdale JR, Acosta R, Shergill AK, et al. Modifications in endoscopic practice for pediatric patients. Gastrointest Endosc. 2014; 79(5):699-710.
  7. ASGE Standards of Practice Committee; Muthusamy VR, Lightdale JR, Acosta RD, et al. Role of endoscopy in the management of GERD. Gastrointest Endosc. 2015; 81(6):1305-1310.
  8. ASGE Standards of Practice Committee; Pasha SF, Acosta RD, Chandrasekhara V, et al. The role of endoscopy in the evaluation and management of dysphagia. Gastrointest Endosc. 2014; 79(2):191-201.
  9. Centers for Medicare and Medicaid Services. National Coverage Determination for Endoscopy. NCD #100.2. Effective date not posted. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=81&ncdver=1&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA%7cNCD&ArticleType=SAD%7cEd&PolicyType=Both&s=All&KeyWord=endoscopy&KeyWordLookUp=Title&KeyWordSearchType=Exact&kq=true&bc=IAAAACAAAAAAAA%3d%3d&. Accessed on October 13, 2017.
  10. Hirota WK, Zuckerman MJ, Adler DG, et al.; Standards of Practice Committee, American Society for Gastrointestinal Endoscopy. ASGE guideline: the role of endoscopy in the surveillance of premalignant conditions of the upper GI tract. Gastrointest Endosc. 2006; 63(4):570-580.
  11. Hwang JH, Fisher DA, Ben-Menachem T, et al. ASGE guideline: the role of endoscopy in acute non-variceal upper-GI hemorrhage. Gastrointest Endosc 2012; 75(6):1132-1138.
  12. Hwang JH, Shergill AK, Acosta RD, Chandrasekhara V, et al. Standards of Practice Committee. ASGE Guideline: the role of endoscopy in the management of variceal hemorrhage. Gastrointest Endosc. 2014; 80(2):221-227.
  13. Ikenberry SO, Harrison ME, Lichtenstein D, et al. ASGE Standards of Practice Committee. The role of endoscopy in dyspepsia. Gastrointest Endosc. 2007; 66(6):1071-1075.
  14. Kahrilas PJ, Shaheen NJ, Vaezi MF, et al. American Gastroenterological Association Medical Position Statement on the management of gastroesophageal reflux disease. Gastroenterology. 2008; 135(4):1383-1391.
  15. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013; 108(3):308-328.
  16. Leighton JA, Shen B, Baron TH, et al.; Standards of Practice Committee, American Society for Gastrointestinal Endoscopy. ASGE guideline: endoscopy in the diagnosis and treatment of inflammatory bowel disease. Gastrointest Endosc. 2006; 63(4):558-565.
  17. Levine A, Griffiths A, Markowitz J, et al. Pediatric modification of the Montreal classification for inflammatory bowel disease: the Paris classification. Inflamm Bowel Dis. 2011; 17(6):1314-1321.
  18. Levine A, Koletzko S, Turner D, et al. ESPGHAN revised porto criteria for the diagnosis of inflammatory bowel disease in children and adolescents. J Pediatr Gastroenterol Nutr. 2014; 58(6):795-806.
  19. Moayyedi PM, Lacy BE, Andrews CN, et al. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterol. 2017; 112(7):988-1013.
  20. National Comprehensive Cancer Network (NCCN). Clinical Practice Guidelines in Oncology®. © 2017 National Comprehensive Cancer Network, Inc. For additional information visit the NCCN website at: http://www.nccn.org. Accessed on September 30, 2017.
    • Genetic/familial high-risk assessment: colorectal. V.2.2017. Revised August 09, 2017.
  21. Shaheen NJ, Falk GW, Iyer PG, et al. ACG clinical guideline: diagnosis and management of Barrett's esophagus. Am J Gastroenterol. 2016; 111(1):30-50.
  22. Spechler SJ, Sharma P, Souza RF, et al. American Gastroenterological Association medical position statement on the management of Barrett's esophagus. Gastroenterology 2011; 140(3):1084-1091.
  23. Spechler SJ, Souza RF. Barrett's esophagus. N Engl J Med. 2014; 371(9):836-845.
  24. Turner D, Levine A, Escher JC, et al. Management of pediatric ulcerative colitis: joint ECCO and ESPGHAN evidence-based consensus guidelines. J Pediatr Gastroenterol Nutr. 2012; 55(3):340-361.
History

Status

Date

Action

Revised

11/02/2017

Medical Policy & Technology Assessment Committee (MPTAC) review. Updated header language from “Current Effective Date” to “Publish Date.” Added therapeutic indications to the document. Revised Title, Position Statement and Coding sections. Updated Rationale and References.

New

09/13/2017

MPTAC review. Initial document development.