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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that the indications which support EGD for diagnostic purposes are: 1. upper abdominal distress which persists despite an appropriate trial of therapy; 2. upper abdominal distress associated with symptoms and/or signs suggesting serious organic disease (e.g., anorexia and weight loss); 3. dysphagia or odynophagia; 4. esophageal reflux symptoms which are persistent or recurrent despite appropriate therapy; 5. persistent vomiting of unknown cause; 6. cirrhosis; 7. other symptoms of disease in which the presence of upper GI pathology might modify other planned management. Examples include patients with a history of GI bleeding who are scheduled for organ transplantation; long-term anticoagulation; and chronic non-steroidal therapy for arthritis. Other examples include patients with cirrhosis being considered for liver transplantation and those with cancer of the neck. 8. Radiologic findings of: -a suspected neoplastic lesion, for confirmation and specific histologic diagnosis; -gastric or esophageal ulcer; or -evidence of upper GI tract stricture or obstruction. 9. The presence of gastrointestinal bleeding: -in most actively bleeding patients; -when surgical therapy is contemplated; -when rebleeding occurs after acute self-limited blood loss or after endoscopic therapy; -when portal hypertension (HTN) or aorto-enteric fistula (AEF) is suspected; or -for presumed chronic blood loss and for iron deficiency anemia when colonoscopy is negative. 10. when sampling of duodenal or jejunal tissue or fluid is indicated; 11. to assess acute injury after caustic agent ingestion;
12. intraoperative EGD when necessary to clarify the location or pathology of a lesion. You can find this rule in Local Coverage Determination (LCD) - Upper Gastrointestinal Endoscopy and Visualization (L34434) - Effective July 1, 2021. The rules say that the covered indications for a colonoscopy are: 1. For evaluation of an abnormality discovered on barium enema and/or other imaging technique that is likely to be clinically significant, such as a filling defect or stricture or an inadequate examination; 2. For evaluation of unexplained gastrointestinal bleeding: a. Hematochezia not thought to be from rectum or perianal source b. Melena of unknown origin c. Presence of fecal occult blood 3. For unexplained iron deficiency anemia; 4. For surveillance of colonic neoplasia; a. For examination to evaluate the entire colon for synchronous cancer or polyps in a patient with treatable cancer or polyps. b. For follow-up 1 year after surgery for treatment of colorectal cancer when the patient is identified as being at high-risk for colon cancer and is eligible for continued screenings at 24-month intervals. c. For follow-up at least 3-6 months after colonoscopic removal of a large sessile adenoma (i.e., greater than 2 cm in greatest dimension). d. For patients with Crohn's colitis, chronic ulcerative colitis (UC), pancolitis of greater than 7 years duration or left-sided colitis of over 15 years duration (no surveillance needed for disease limited to rectosigmoid) may have a colonoscopy every 1-2 years for multiple biopsies to detect cancer and/or dysplasia. 5. For chronic inflammatory bowel disease (IBD) of the colon (if a more precise diagnosis or if a determination of the extent of activity of disease will influence immediate management); 6. For clinically significant diarrhea of unexplained origin with additional findings (e.g., weight loss or negative stool cultures persisting for more than 3 weeks); 7. For intraoperative identification of the site of a lesion that cannot be detected by palpation or gross inspection at surgery (e.g., polypectomy site or location of a bleeding source); 8. For evaluation of acute colonic ischemia/ischemic bowel disease; 9. For evaluation of a patient with Streptococcus bovis (S. bovis) endocarditis or bacteremia; 10 For treatment of bleeding from such lesions as vascular anomalies, ulceration and neoplasia; 11. For removal of a foreign body; 12. For excision of colonic polyps; 13. For decompression of pseudo-obstruction of the colon (Olgilvie's Syndrome) following a trial of neostigmine or cathartics or a documented reason that this would be either unsafe or inappropriate for the beneficiary; 14. For treatment of colonic volvulus or stricture; 15. For evaluation of an unexplained, new onset constipation, refractory to medical therapy; 16. For evaluation of an anorectal polyp (adenomatous polyp only); or, 17. For palliative treatment of stenosing, bleeding neoplasms (e.g., laser, electrocoagulation, stenting). You can find this rule in Local Coverage Determination (LCD) - Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy (L34454) - Effective April 29, 2021.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.