Harvard Pilgrim Health Care Home
  Learn more.
  Sign up for HPHConnect.
Medical Management
For Your Patient
News Center
Network Matters
Newsletter Archives
Newsletter Registration
Office Support
Provider Manual
Medicare Advantage
Research & Teaching
Resources & Links
Print    Text Size

Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

August 2017

Updates to Capsule Endoscopy Medical Policy

Effective for dates of service beginning Nov. 1, 2017, Harvard Pilgrim is making several updates to our medical policy for capsule endoscopy — a noninvasive procedure in which a swallowable capsule takes a video recording of the mucosal lining of the esophagus and/or small bowel as it moves through the gastrointestinal tract.

Changes to the policy include: editing the criteria for coverage of the procedure; adding exclusions to coverage; adding numerous ICD-10 codes to the policy as eligible for coverage; and removing some ICD-10 codes that are inconsistent with policy criteria.
Harvard Pilgrim considers capsule endoscopy to be reasonable and medically necessary when the procedure is performed once for any episode of illness and documentation confirms any of the criteria listed on the policy. Exclusions to coverage include:

  • SmartPillTM GI Monitoring System
  • Patency capsule (AGILETM Patency System)
  • Repeat use to determine surgical effectiveness
  • Evaluation of the colon, such as detection of polyps or colorectal cancer
  • Evaluation of gastrointestinal diseases with no evidence of GI bleeding
  • Evaluation of esophageal disease

For more information about coverage criteria, exclusions, or covered and non-covered codes, refer to the updated Capsule Endoscopy Medical Policy.

Email this article to a colleague   

Network Matters Archives

Download printer-friendly version


Harvard Pilgrim Selects MedImpact Direct as New Mail-Order Pharmacy

New Sleep Program Reminder and FAQ

Institute Study: Sugary Beverages During Pregnancy Could Contribute to Childhood Obesity

Success at BMC’s Inaugural Boston Trans Health Institute


New Extended Care Facility Prior Authorization Request Form

Updates to Capsule Endoscopy Medical Policy

Billing for Services for Multiple-Gestation Pregnancies


Reminder: Use our Dedicated StrideSM (HMO) Medicare Advantage Resources

Harvard Pilgrim 270/271 Eligibility Response Enhancements


Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Senior Vice President, Network Services

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator