CG-MED-59 Upper Gastrointestinal Endoscopy in Adults

This policy addresses diagnostic upper gastrointestinal endoscopy (esophagogastroduodenoscopy, EGD) in adults (≥18 years). EGD is medically necessary to evaluate: GERD symptoms persisting or recurring after ≥2 months of appropriate therapy; persistent unexplained vomiting; new-onset dyspepsia at age ≥50; unexplained dysphagia or odynophagia; signs of structural upper GI disease (e.g., anorexia, weight loss, early satiety, persistent nausea); persistent abdominal symptoms after bariatric surgery despite diet counseling; recent/active GI bleeding; or unexplained anemia due to blood loss or mucosal malabsorption. It is not medically necessary when these criteria are not met, including for screening asymptomatic average-risk individuals, repeat screening for Barrett’s esophagus after a prior negative EGD, or screening for aerodigestive cancer.

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