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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.

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