Coverage of any medical intervention discussed in a Dean Health Plan m - PDF document

Coverage of any medical intervention discussed in a Dean Health Plan medical policy is subject to the limitations and exclusions outlined in the member's benefit certificate or policyand to applicable state and/or federal laws ��Upper Endoscopy (EGD)Esophagogastroduodenoscopy Upper Endoscopy (EGD)Esophagogastroduodenoscopy517 Covered Service: Yes Prior Authorization Required: No Additional Information: An appropriate diagnosis code must appear on the claim. Claims will deny in the absence of an appropriate diagnosis code. Medicare Policy: rior authorization is required. BadgerCare Plus Policy: Dean Health Plan covers when BadgerCare Plus also covers the benefit. Dean Health Plan Medical Policy Coverage of any medical intervention discussed in a Dean Health Plan medical policy is subject to the limitations and exclusions outlined in the member's benefit certificate or policyand to applicable state and/or federal laws ��Upper Endoscopy (EGD)Esophagogastroduodenoscopyof 1.2.4In evaluation of esophageal reflux symptoms that are persistent orrecurrent despite appropriate therapy; 1.2.5In evaluation of esophageal masses and for directing biopsies fordiagnosing esophageal cancer; 1.2.6In evaluation of persons with signs or symptoms of locoregionalrecurrence after resection of esophageal cancer; 1.2.7In evaluation of persistent vomiting of unknown cause1.2.8In evaluation of other diseases in which the presence of uppergastrointestinal (GI) pathological conditions might modify

other planned management; 1.2.9In evaluation of familial adenomatous polyposis syndromes1.2.10For confirmation and specific histological diagnosis ofradiologically demonstrated lesions (e.ggastric oresophageal ulcer, suspected neoplastic lesion, upper GI tract stricture or obstruction); 1.2.11adiologically demonstrated lesionsg. gastric or esophageal ulcer, suspected neoplastic lesion, upper GI tract stricture or obstruction); 1.2.12Evaluation of GI bleeding and upper GI source is suspected; 1.2.13Sampling of upper GI tissue or fluid1.2.14Evaluation of persons with suspected portal hypertension todocument or treat esophageal varices; 1.2.15Evaluation of acute injury after caustic ingestion1.2.16Evaluation of dyspepsia when other symptoms or signs suggestpathology that requires further evaluation (e.g. epigastric mass,chronic GI bleeding,progressive unintentional weight loss or difficulty swallowing); 1.2.17Diagnosis of irritable bowel syndrome when other studies (e.g., colonoscopy, enteroscopy, ileoscopy, capsule endoscopy, and flexible sigmoidoscopy) have negative results; 1.2.18ifferentiation of Crohn's disease from ulcerative colitis in indeterminate colitis. 1.3Surveillance of the member is needed and esophagoscopy and/or EGD is the clinically appropriate procedure, as demonstrated by of the following:1.3.1For surveillance of persons with Barret’s Esophagus (BE)withoutdysplasiaor with dysplasia (lowgrade or highgrade) at clinically appropriate intervals; 1.3.2For urveillance of persons with a severe caustic esophagealinjury a

t clinically appropriate intervals; Coverage of any medical intervention discussed in a Dean Health Plan medical policy is subject to the limitations and exclusions outlined in the member's benefit certificate or policyand to applicable state and/or federal laws ��Upper Endoscopy (EGD)Esophagogastroduodenoscopyof 1.3.3For surveillance of persons with tylosis (HowelEvans syndrome) at clinically appropriate intervals; 1.3.4For surveillance of recurrence of adenomatous polyps in synchronousand metachronous sites at clinically appropriate intervals; 1.3.5For surveillance of persons with familial adenomatous polyposisat clinically appropriate intervals1.3.6For surveillance of persons with hereditary nonpolyposis colorectal cancerat clinically appropriate intervals1.4Treatment or therapy for a condition is neededand esophagoscopy and/orEGD is the clinically appropriate procedure, as demonstrated by of the following:1.4.1For banding or sclerotherapy of varices1.4.2For dilation of stenotic lesions (e.g., with transendoscopic balloon dilators ordilation systems using guide wires); 1.4.3For management of achalasia by means of botulinum toxin, balloon dilation1.4.4For palliative treatment of stenosing neoplasms by means of laser,multipolar electrocoagulation, stent placement; 1.4.5For placement of feeding or drainage tubes (peroral, transnasal,percutaneous, endoscopic gastrostomy, percutaneous endoscopic jejunostomy); 1.4.6For removal of foreign bodies or selected polypoid lesions 1.4.7In treatment of bleeding lesions such as ulc

ers, tumors, and vascularabnormalities by means of electrocoagulation, heater probe, laser photocoagulation, or injection therapy.1.5ophagoscopy and/orEGDis considered not medically necessary and therefore is not a covered service when the criteria of 1.0 have not been met, or when performed for other indications, including but not limited to the following:1.5.1For screening of malignant neoplasm of the colon.1.5.2To evaluate unspecified chronic gastritis without bleeding.1.5.3To evaluate unspecified or generalized abdominal pain.1.5.4To evaluate duodenitis without bleeding. Coverage of any medical intervention discussed in a Dean Health Plan medical policy is subject to the limitations and exclusions outlined in the member's benefit certificate or policyand to applicable state and/or federal laws ��Upper Endoscopy (EGD)Esophagogastroduodenoscopyof Committee/Source Date(s) Document Created : Medical Policy Committee/Quality and Care Management Division January 10, 2018 Revised: Medical Policy Committee/Health Services Division Medical Policy Committee/Health Services Division Medical Policy Committee/Health Services Division February 20, 2019 July 21, 2021 July 20, 2022 Reviewed: Medical Policy Committee/Health Services Division Medical Policy Committee/Health Services Division Medical Policy Committee/Health Services Divis ion Medical Policy Committee/Health Services Division February 20, 2019 July 15, 2020July 21, 2021 July 20, 2022 ublish: 08/01/2022Effective: 08/01/202