This policy version was replaced October 31, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).
Wireless capsule endoscopy (WCE) enables physicians to see areas of the gastrointestinal tract that are not accessible via upper or lower endoscopy, mainly the small bowel. An ingestible capsule carrying a miniature video camera records and transmits images as it moves through the gastrointestinal (GI) tract. The images are stored in sensors worn around the patient’s waist. After eight to twelve hours the patient returns the belt and data recorder to the clinic. The images are then downloaded and the video is evaluated.
WCE has primarily been used to enhance visualization of the small intestine for evaluation of obscure GI bleeding and diseases of the small intestine, such as Crohn’s disease. WCE has also been proposed as a method of evaluating diseases of the esophagus (e.g., chronic gastroesophageal reflux disease and Barrett’s esophagus) and detecting colonic polyps or colon cancer.
Due to the risk of capsule retention, WCE is contraindicated in patients with small bowel strictures. While radiological tests (such as CT scan, CT enterography, MR enterography, or small bowel follow-through) have typically been used to evaluate small bowel patency prior to WCE, another option is a non-radiological device called the PillCam® patency capsule. The patency capsule is an ingestible, solid, biodegradable capsule composed of compressed lactose and 5% barium sulfate. It carries a tracer material that can be detected by a scanning device. This additional procedure is intended to confirm small bowel patency in patients with known or suspected strictures who may, in fact, be successful candidates for WCE.
I. Wireless capsule endoscopy may be considered MEDICALLY NECESSARY AND APPROPRIATE for ANY of the following indications:
II. The use of wireless capsule endoscopy is considered EXPERIMENTAL/INVESTIGATIVE for all other indications, including, but not limited to:
III. Use of the patency capsule prior to wireless capsule endoscopy is considered EXPERIMENTAL/INVESTIGATIVE due to a lack of clinical evidence demonstrating its impact on improved health outcomes.
91110 91111 91113 91299 0651T
No additional statements.
Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.
Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.
Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites.
Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.
Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.
These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Acknowledgements:
CPT® codes copyright American Medical Association® 2022. All rights reserved.
CDT codes copyright American Dental Association® 2022. All rights reserved.