CG-MED-70 Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule

Anthem CG-MED-70 addresses wireless capsule endoscopy (WCE) of the small bowel (and the patency capsule) as a diagnostic tool in individuals age 2 years and older. WCE is medically necessary to evaluate obscure GI bleeding after negative upper and lower endoscopy; as initial evaluation of suspected Crohn’s disease when SBFT/enteroclysis (including CT enteroclysis) and endoscopy are non-diagnostic and there is no suspected/confirmed obstruction, stricture, or fistula; for suspected small intestinal tumors; for individuals age 35 or older with Lynch syndrome or polyposis syndromes; and for diagnostic re-evaluation of known Crohn’s disease with persistent symptoms after treatment. It is not medically necessary for other uses, including abdominal pain without GI bleeding, evaluation of esophageal disease, colorectal cancer screening or detection of colon disease, or in patients with known or suspected GI obstruction, stricture, or fistula.

"Wireless capsule endoscopy of the small bowel is consideredmedically necessaryas a diagnostic imaging tool,in adults or children 2 years of age and older, in the following clinical circumstances:To..."