Esophagogastroduodenoscopy (EGD) Guidelines

EGD is covered for specified diagnostic, surveillance, and therapeutic upper‑GI indications (eg, new dyspepsia ≥60 years, dyspepsia <60 after failed 4‑week PPI or H. pylori test‑and‑treat, GERD after specified PPI trials, alarm features, Barrett’s screening/surveillance per risk criteria, varices, post‑bariatric issues, suspected/known malignancy), and excluded for investigational procedures (eg, endomicroscopy), routine unbundling of EUS/ERCP from EGD, isolated belching/bloating, routine evaluation of extra‑esophageal GERD without specified indications, and other non‑recommended surveillance uses. Key requirements are documentation of a recent pertinent clinical evaluation and prior appropriate therapies (specified PPI trial lengths, confirmed H. pylori eradication when applicable), condition‑specific labs/biopsy protocols (eg, iron studies, celiac serologies, ≥4 duodenal biopsies, Barrett’s pathology/second‑opinion when indicated), and sufficient medical records or the request will not be approved.