Esophagogastroduodenoscopy (EGD) Guidelines

EGD is covered for defined upper‑GI indications (eg, new‑onset dyspepsia ≥60 or <60 after failed H. pylori test‑and‑treat or 4‑week PPI, GERD after an 8‑week PPI trial or with alarm features, Barrett’s screening/surveillance, GI bleeding, dysphagia/odynophagia, suspicious/persistent/giant/refractory gastric or duodenal ulcers, gastric intestinal metaplasia/dysplasia surveillance, celiac/small‑bowel biopsy, post‑bariatric/post‑op concerns, tumor/genetic surveillance and therapeutic endoscopy); routine EGD for extra‑esophageal GERD symptoms, endomicroscopy, asymptomatic uncomplicated hiatal hernia, and surveillance of healed uncomplicated ulcers are excluded/considered non‑indicated. Approval requires recent documented clinical evaluation and specific prior workup and therapy trials (eg, 8‑week PPI for typical GERD, 8–12‑week twice‑daily PPI for extra‑esophageal symptoms, H. pylori test‑and‑treat or 4‑week PPI for dyspepsia <60, cross‑sectional imaging if pancreatic/biliary source suspected), pertinent labs/imaging/pathology (including second‑pathologist review for suspected dysplasia), and documentation of failed therapies or alarm features; documented PPI allergy/intolerance can substitute for required PPI trials.