Esophagogastroduodenoscopy (EGD) Guidelines

EGD is covered for specified diagnostic and therapeutic indications (eg, new‑onset dyspepsia ≥60, dyspepsia <60 after failed H. pylori test‑and‑treat or 4‑week PPI trial, red‑flag symptoms, complicated/refractory GERD, Barrett’s screening/surveillance per risk criteria, ulcers suspicious for malignancy, bleeding, dysphagia, bariatric pre/post‑op issues, and other listed indications) and is excluded for routine uncomplicated GERD, asymptomatic sliding hiatal hernia, routine surveillance of healed benign disease, metastatic adenocarcinoma when results won't change management, and investigational procedures (eg, endomicroscopy). Key requirements include specific documentation of symptoms/findings, prior therapies and durations (eg, PPI ≥1× daily ×8 weeks or 2× daily ×4 weeks for GERD failure; H. pylori test‑and‑treat or 4‑week PPI for dyspepsia <60), confirmatory pathology for Barrett’s indefinite dysplasia, specified surveillance intervals, cross‑sectional imaging if pancreatic/biliary disease suspected, and Medical Director review when EGD would only be done if it would alter management.