Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic)
L35350
Upper GI endoscopy (EGD) and ERCP are covered when specific abnormal signs, symptoms, or known disease are present and when findings or clinical circumstances would alter management—examples include persistent/refractory upper abdominal symptoms, dysphagia, GI bleeding, suspected neoplasm, strictures, or therapeutic needs (bleeding control, foreign-body removal, feeding tube placement, dilation, stenting). Routine screening, uncomplicated heartburn responsive to therapy, asymptomatic radiographic findings that respond to therapy, and surveillance in certain chronic conditions are generally not covered. Documentation must demonstrate the medical necessity, prior therapy trials when applicable, relevant imaging or colonoscopy results, and adherence to CMS medical necessity/payment rules; follow-up frequency is specified for several conditions (e.g., ulcers every 2–4 months, Barrett's every 1–2 years).
"Upper gastrointestinal endoscopy (EGD) is covered for persistent upper abdominal distress that continues despite an appropriate trial of therapy."