Capsule Endoscopy – Medical Clinical Policy Bulletins | Aetna

Information in the [brackets] below has been added for clarification purposes.  &nbspCodes requiring a 7th character are represented by “+”:

CPT codes covered if selection criteria are met:

91110 Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus through ileum, with physician interpretation and report 91111 Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus with physician interpretation and report

CPT codes not covered for indications listed in the CPB:

Cytosponge capsule – no specific code:

0095U Inflammation (eosinophilic esophagitis), ELISA analysis of eotaxin-3 (CCL26 [C-C motif chemokine ligand 26]) and major basic protein (PRG2 [proteoglycan 2, pro eosinophil major basic protein]), specimen obtained by swallowed nylon string, algorithm reported as predictive probability index for active eosinophilic esophagitis 91113 Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), colon, with interpretation and report

Other CPT codes related to the CPB:

77261 – 77263 Therapeutic radiology treatment planning 77299 Unlisted procedure, therapeutic radiology clinical treatment planning

ICD-10 codes covered if selection criteria are met (for capsule endoscopy – esophagus through ileum):

C7a.010 – C7a.019 Malignant carcinoid tumors of the small intestine D3a.010 – D3a.019 Benign carcinoid tumors of the small intestine D50.0 Iron deficiency anemia secondary to blood loss (chronic) D50.9 Iron deficiency anemia, unspecified D62 Acute posthemorrhagic anemia D72.89 Other specified disorders of white blood cells K50.00 – K50.919 Crohn’s disease [regional enteritis] K52.0 – K52.9 Other and unspecified noninfectious gastroenteritis and colitis K90.0 Celiac disease K92.0 – K92.2 Other diseases of digestive system R10.0 – R10.33
R10.84 – R10.9 Abdominal pain R19.7 Diarrhea R50.81 Fever presenting with conditions classified elsewhere R50.9 Fever, unspecified R63.4 Abnormal loss of weight R70.0 Elevated erythrocyte sedimentation rate Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm [reevaluation of celiac disease]

ICD-10 codes covered if selection criteria are met (for capsule endoscopy – esophagus only):

I85.00 – I85.01 Esophageal varices with bleeding or without bleeding I85.11 Secondary esophageal varices with bleeding K70.2 – K70.31 Alcoholic cirrhosis of liver K74.0 Hepatic fibrosis K74.3 – K74.5 Biliary cirrhosis K74.60 – K74.69 Other and unspecified cirrhosis of liver Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm [reevaluation of celiac disease] Z15.09 Genetic susceptibility to other malignant neoplasm [Lynch syndrome]

ICD-10 codes not covered for indications listed in the CPB (not all inclusive):

B76.0 – B76.9 Hookworm disease C15.3 – C15.9 Malignant neoplasm of esophagus C17.0 – C17.9 Malignant neoplasm of small intestine, including duodenum, and colon C7A.010 – C7A.019 Malignant carcinoid tumors of the small intestine C7A.020 – C7A.029 Malignant neoplasm of the appendix, large intestine, and rectum D12.0 – D12.9 Benign neoplasm of colon D3A.020 – D3A.029 Benign carcinoid tumors of the appendix, large intestine, and rectum D72.820 Lymphocytosis (symptomatic) [duodenal lymphocytosis] I86.4 Gastric varices K22.0 – K22.9 Other diseases of esophagus K31.2 Hourglass stricture and stenosis of stomach K31.6 Fistula of stomach and duodenum K31.89 Other diseases of stomach and duodenum [Portal hypertensive gastropathy] K51.00 – K51.919 Ulcerative colitis K56.0 – K56.7 Paralytic ileus and intestinal obstruction without hernia [intussception] K57.20 – K57.93 Diverticular disease of colon K58.0 – K58.9 Irritable bowel syndrome K59.01 Slow transit constipation K59.31 – K59.39 Megacolon, not elsewhere classified K59.8 Other specified functional intestinal disorders K62.1 Rectal polyp K63.2 Fistula of intestine K63.5 Polyp of colon K90.0 Celiac disease M31.4 Aortic arch syndrome [Takayasu] Q39.5 Congenital dilatation of esophagus Q40.2 – Q40.3 Other and unspecified congenital malformations of stomach Q41.0 – Q42.9 Congenital absence, atresia and stenosis of small intestine and large intestine Q43.4 – Q43.9 Other congenital malformations of intestine [recurrent intussusception] R13.10 – R13.19 Dysphagia Z12.10 – Z12.13 Encounter for screening for malignant neoplasm of intestine Z13.810 – Z13.818 Encounter for screening for digestive system disorders [not covered for Cytosponge capsule] Z95.0 Presence of cardiac pacemaker Z96.89 Presence of other specified functional implants [electromedical devices]

Magnetic-assisted CE (e.g., the NaviCam MCCE System):

CPT codes not covered for indications listed in the CPB:

0651T Magnetically controlled capsule endoscopy, esophagus through stomach, including intraprocedural positioning of capsule, with interpretation and report

ICD-10 codes not covered for indications listed in the CPB (not all inclusive):

I85.00 – I85.01 Esophageal varices K22.70 – K22.719 Barrett’s esophagus Z13.810 Encounter for screening for upper gastrointestinal disorder