Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders

This policy covers wireless capsule endoscopy (including the FDA‑approved magnetically maneuvered gastric capsule for full stomach visualization) for diagnostic evaluation of suspected small‑bowel bleeding, initial or re‑evaluation of suspected Crohn disease when conventional endoscopy/radiology are inconclusive, recurrent or unexplained iron‑deficiency anemia, and surveillance in hereditary GI polyposis syndromes. Coverage is limited to these indications — other uses are considered experimental/investigational — and CE is contraindicated in patients with GI obstruction/stenosis, dysphagia, certain implanted electronic devices, pregnancy, and age <22; patency capsules and magnetic capsule use for non‑approved indications are not covered.

"Initial diagnosis of suspected Crohn disease when conventional diagnostic tests (small bowel follow-through and upper and lower endoscopy) show no evidence of disease."