Capsule Endoscopy Guidelines

Capsule endoscopy (small-bowel, colon, esophageal, and wireless motility) is covered for specified indications — e.g., suspected/known Crohn’s disease, suspected/confirmed celiac when biopsy is negative or contraindicated, overt or obscure GI bleeding after negative EGD/colonoscopy, small-bowel tumors, surveillance in certain hereditary polyposis syndromes, and selected colon/esophageal capsule use when conventional endoscopy is inappropriate or incomplete — while patency capsules and colon capsule for colorectal cancer screening are investigational and motility capsules are contraindicated in settings such as obstruction, recent GI surgery, swallowing disorders, Crohn’s disease, and implanted electromechanical devices. Approval requires adequate documentation (preferably within 60 days) including history/physical, relevant labs and imaging, prior endoscopy/pathology, and use of the appropriate CPT code; insufficient records will preclude approval.

"General: Capsule endoscopy (use appropriate CPT for capsule type) for evaluation of small bowel and other GI conditions when clinically indicated and adequate clinical information is submitted."