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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 Endoscopy procedures can only be allowed if abnormal signs or symptoms or known disease are present.1.Indications which support esophagogastroduodenoscopies(EGD[s]) for diagnostic purpose(s) are as follows: o Upper abdominal distress which persists despite an appropriate trial of therapy;o Upper abdominal distress associated with symptoms and/or signs suggesting serious organic disease (e.g., prolonged anorexia and weight loss);o Dysphagia or odynophagia;o Esophageal reflux symptoms which are persistent or recurrent despite appropriate therapy;o Persistent vomiting of unknown cause;o Other systemic diseases 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;o X-ray findings of:&#9642;A suspected neoplastic lesion, for confirmation and specific histologic diagnosis;&#9642;Gastric or esophageal ulcer; or&#9642;Evidence of upper gastrointestinal tract stricture or obstruction.o The presence of gastrointestinal bleeding:&#9642;In most actively bleeding patients or those recently stopped;&#9642;When surgical therapy is contemplated;&#9642;When re-bleeding occurs after acute self-limited blood loss or after endoscopic therapy;&#9642;When portal hypertension or aortoenteric fistula is suspected; or&#9642;For presumed chronic blood loss and for iron deficiency anemia when colonoscopy is negative.o When sampling of duodenal or jejunal tissue or fluid is indicated;o To assess acute injury after caustic agent ingestion; oroIntraoperative EGD when necessary to clarify location or pathology of a lesion.2.Indications which support EGD(s) for therapeutic purpose(s) are as follows:o Treatment of bleeding from lesions such as ulcers, tumors, vascular malformations (e.g., electrocoagulation, heater probe, laser photocoagulation or injection therapy);o Sclerotherapy for bleeding from esophageal or proximal gastric varices or banding of varices;o Foreign body removal;o Removal of selected polypoid lesions;o Placement of feeding tubes (oral, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy);o Dilation of stenotic lesions (e.g., with transendoscopic balloon dilators or dilating systems employing guidewires); or o Palliative therapy of stenosing neoplasms (e.g., laser, bipolar electrocoagulation, stent placement).3.Sequential or periodic diagnostic upper GI endoscopy may be indicated for an appropriate number of procedures for active or symptomatic conditions.
o For follow-up of selected esophageal, gastric or stomal ulcers to demonstrate healing (frequency of follow-up EGDs is variable, but every two to four months until healing is demonstrated is reasonable);o For follow-up in patients with prior adenomatousgastric polyps (approximate frequency of follow-up EGDs would be every one to four years depending on the clinical circumstances, with occasional patients with sessile polyps requiring every six-month surveillance initially);oFor follow-up for adequacy of prior sclerotherapy or banding of esophageal varices (approximate frequency of follow-up EGDs is very variable depending on the state of the patient but every six to twenty-four months is reasonable after the initial sclerotherapy/banding sessions are completed);o For follow-up of Barrett's esophagus (approximate frequency of follow-up EGDs is one to two years with biopsies, unless dysplasia or atypia is demonstrated, in which case a repeat biopsy in two to three months might be indicated); or o For follow-upin patients with familial adenomatous polyposis (approximate frequency of follow-up EGDs would be every two to four years, but might be more frequent, such as every six to twelve months if gastric adenomas or adenomas of the duodenum were demonstrated).4.The endoscopic retrograde cholangiopancreatography (ERCP) procedure is generally indicated for certain biliary and pancreatic conditions.oERCP is generally not indicated for the diagnosis of pancreatitis except for gallstone pancreatitis;oERCP is not usually indicated in early stages or in acute pancreatitis and could possibly exacerbate it;o ERCP may be useful in traumatic pancreatitis to accurately localize the injury and provide endoscopic drainage;o ERCP may be useful in pancreatic duct stricture evaluation;o ERCP may be useful for the extraction of bile duct stones in severe gallstone induced pancreatitis;o ERCP may be useful in detecting pancreatic ductal changes in chronic pancreatitis and also the presence of calcified stones in the ductal system. A pancreatogram may be performed and is likely to be abnormal in chronic alcoholic pancreatitis but less so in non-alcoholic induced types;o ERCP may be useful in detecting gallstones in symptomatic patients whose oralcholecystogram and gallbladder ultrasonograms are normal; and o ERCP may be indicated in patients with radiologic imaging suggestive of common bile duct stones or other potential pathology.You can find this rule in the Local Coverage Determination (LCD): Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic) (L35350).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plancovers items and services in accordance with Medicare rules.