Capsule Endoscopy Guidelines

Covered for small‑bowel capsule endoscopy in suspected/known Crohn’s (when ileocolonoscopy and/or CT/MRI are negative/inconclusive or for mucosal healing), refractory celiac disease after ≥6 months gluten‑free diet, obscure/ongoing GI bleeding after negative EGD/colonoscopy (including select repeat CE), suspected small‑bowel tumors, surveillance in specified polyposis syndromes, selective colon capsule only when standard colonoscopy is high‑risk or incomplete, and esophageal capsule when EGD is contraindicated; patency capsules, colon capsule for colorectal cancer screening, use after a negative celiac biopsy, and CE for isolated chronic abdominal pain/diarrhea without elevated Crohn’s biomarkers are excluded/investigational. Key requirements include prior negative or inconclusive conventional endoscopy/imaging and relevant biomarkers or specialty evaluation as applicable, detailed documentation of symptoms/imaging/results, and Medical Director review for follow‑up/repeat requests.