Capsule Endoscopy Guidelines

Capsule endoscopy (CPT 91110/91111/91113) is covered for evaluation of known or suspected small‑bowel Crohn’s disease, refractory celiac symptoms, obscure/overt GI bleeding after negative EGD and colonoscopy, suspected small‑bowel tumors, specified hereditary polyposis syndromes (with stated surveillance intervals), colon capsule when standard colonoscopy is high‑risk or incomplete, and esophageal capsule when EGD is contraindicated; excluded or investigational uses include the patency capsule and colon capsule for colorectal cancer screening, and it is not indicated for isolated chronic abdominal pain or diarrhea without elevated Crohn’s biomarkers. Coverage requires prior negative/complete endoscopy or appropriate imaging where specified, a recent detailed clinical evaluation and supporting labs/imaging/pathology/procedure reports to establish medical necessity, and for primary colon capsule use documentation from a qualified endoscopist that the patient is at major risk for standard colonoscopy or moderate sedation.