Capsule Endoscopy Guidelines

EviCore covers small-bowel, colon, esophageal, and wireless motility capsule endoscopy only for specified indications—e.g., small‑bowel CE for suspected/known Crohn’s with compatible symptoms plus elevated inflammatory biomarkers or suspicious ileocolonoscopy/imaging; CE for celiac disease with positive serology and negative biopsy or contraindication to EGD (or persistent symptoms after ≥6 months gluten‑free diet); CE for obscure overt bleeding or unexplained iron‑deficiency anemia after negative EGD/colonoscopy; surveillance/evaluation of small‑bowel tumors and defined hereditary polyposis syndromes; colon capsule when patients are at major risk for standard colonoscopy or when colonoscopy is incomplete; esophageal capsule only when EGD is inappropriate; and wireless motility capsule only for motility disorders after structural causes are excluded. Key exclusions/limits: patency capsules and colon capsule for routine CRC screening are not covered, wireless motility capsules are not covered with suspected obstruction/recent GI surgery/swallowing disorders/Crohn’s or implanted electromechanical devices, and all requests require detailed documentation (history/physical, relevant labs, imaging, prior endoscopy/pathology) and the indication‑specific criteria listed above (including board‑certified evaluation for primary colon capsule use).