Esophagogastroduodenoscopy (EGD) Guidelines

EGD is covered for specific diagnostic and surveillance indications (eg, red-flag symptoms such as dysphagia, GI bleeding, iron‑deficiency anemia, unexplained weight loss, persistent vomiting; complicated GERD and defined Barrett’s surveillance, suspicious/refractory peptic ulcers, gastric intestinal metaplasia and other premalignant or post‑resection surveillance, bariatric and cancer/genetic indications) and is excluded for routine/uncomplicated GERD, functional symptoms (except one-time rule-out), asymptomatic uncomplicated radiologic findings, uncomplicated healed ulcers, and investigational endomicroscopy. Approval requires recent detailed clinical evaluation (preferably within 60 days) and documentation of prior therapies/tests (eg, PPI trials, H. pylori test-and-treat), pertinent labs/imaging/pathology (GI pathology confirmation for dysplasia) and adherence to the guideline’s specified surveillance intervals, with insufficient documentation resulting in denial.