Capsule Endoscopy Guidelines

EviCore covers capsule endoscopy types only for specified indications — e.g., small‑bowel capsule for defined Crohn’s scenarios, refractory celiac after ≥6 months gluten‑free diet, obscure GI bleeding after negative EGD/colonoscopy, small‑bowel tumors, listed hereditary polyposis surveillance, colon capsule only for patients at high risk for standard colonoscopy or as a secondary test after incomplete colonoscopy, esophageal capsule when EGD is contraindicated, and wireless motility capsule for motility disorders after structural causes are excluded — while patency capsules and colon capsule for routine colorectal cancer screening and several other uses (e.g., isolated chronic abdominal pain/diarrhea, suspected celiac with negative biopsy) are investigational/excluded. Approval requires recent detailed clinical evaluation (history/physical within ~60 days or equivalent contact), relevant labs, imaging/pathology and prior procedure reports, use of the appropriate CPT code, and demonstration that required prior testing (e.g., negative EGD/colonoscopy for obscure bleeding) has been done.