Esophagogastroduodenoscopy (EGD) Guidelines

EGD is covered for specified diagnostic and surveillance indications (e.g., new dyspepsia ≥60 or <60 after failed H. pylori test-and-treat or 4‑week PPI, GERD after failed 8‑week PPI or with alarm features, Barrett’s screening/surveillance per stated intervals, peptic ulcer surveillance/healing, GIM surveillance, GI bleeding, dysphagia/odynophagia, bariatric/tumor evaluation, placement of wireless pH, etc.) and excluded for routine/asymptomatic evaluations (e.g., uncomplicated sliding hiatal hernia), repeat assessment of healed uncomplicated disease, endomicroscopy, and other non‑indications. Approval requires adequate contemporary documentation (preferably within 60 days) of history/physical, relevant labs/imaging/pathology and prior procedure reports, plus evidence of required pre‑requisite trials (e.g., H. pylori test‑and‑treat or 4‑week PPI for dyspepsia <60, 8‑week once‑daily PPI for typical GERD, 8–12‑week twice‑daily PPI for extra‑esophageal symptoms), imaging to exclude pancreatic/biliary causes when applicable, and second‑pathologist confirmation for suspected Barrett’s dysplasia.