Esophagogastroduodenoscopy (EGD) Guidelines

EGD is covered for specified diagnostic and therapeutic indications (e.g., dyspepsia with red flags, new-onset symptoms ≥60, refractory GERD, Barrett’s screening/surveillance per intervals, GI bleeding, iron‑deficiency anemia, dysphagia/odynophagia, persistent vomiting, abnormal imaging, and therapeutic procedures) and excluded for non‑indications such as asymptomatic uncomplicated radiographic findings (e.g., sliding hiatal hernia, healed duodenal ulcer), routine surveillance of healed benign disease or fundic gland polyps, metastatic adenocarcinoma when results won’t alter management, and investigational procedures like endomicroscopy. Approval requires documentation of prior appropriate evaluation and conservative therapy where applicable (e.g., H. pylori test‑and‑treat or 4‑week PPI for <60 dyspepsia; 8‑week PPI for typical GERD; 8–12‑week twice‑daily PPI for extra‑esophageal symptoms; cross‑sectional imaging to exclude pancreatic/biliary causes for epigastric pain) plus recent (≈60 days) detailed history/physical, labs, imaging, pathology and confirmation of prior treatment trials (with GI pathology second review for Barrett’s/dysplasia when indicated).