CG-SURG-101 Ablative Techniques as a Treatment for Barrett’s Esophagus

This policy addresses endoscopic ablative techniques for Barrett’s esophagus, specifically radiofrequency ablation (RFA) and cryoablation. Ablation is covered as medically necessary only when pathology confirms high-grade dysplasia (HGD) or intramucosal cancer (IMC) and all policy criteria are met; it is not covered if these criteria are not met or for any other indications. Electrocoagulation, argon plasma coagulation, and laser ablation are considered not medically necessary in all circumstances.

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