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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 CFR 422.101.
The rules say that the indications for wireless capsule endoscopy:
-For investigating suspected small intestinal bleeding in persons with objective evidence of recurrent, obscure
GI bleeding (e.g., persistent or recurrent iron-deficiency anemia and/or persistent or recurrent positive fecal
occult blood test (FOBT), or visible bleeding) who have had upper and lower GI endoscopies within the past 12
months (esophagogastroduodenoscopy (EGD) and colonoscopy) that have failed to identify a bleeding source;
-For evaluation of regional non-metastatic carcinoid tumors of the small bowel in persons with carcinoid
syndrome;
-For evaluation of persons with celiac disease with a positive serology and negative biopsy;
-For re-evaluation of persons with celiac disease who remain symptomatic despite treatment and there is no
suspected or confirmed GI obstruction, stricture, or fistulae;
-For initial diagnosis in persons with suspected Crohn's disease (abdominal pain or diarrhea plus 1 or more
signs of inflammation (e.g., fever, elevated white blood cell (WBC) count, elevated erythrocyte sedimentation
rate, or bleeding) without evidence of disease on conventional diagnostic tests, including small-bowel followthrough
or abdominal computed tomography (CT) scan/CT enterography and upper and lower endoscopy
(EGD and colonoscopy);
-For re-evaluation of persons with Crohn's disease who remain symptomatic despite treatment and there is no
suspected or confirmed GI obstruction, stricture, or fistulae;
-For surveillance of small intestinal tumors in persons with Lynch syndrome, Peutz-Jeghers syndrome and
other polyposis syndromes affecting the small bowel; or
-For screening or surveillance of esophageal varices.
You can find this rule in Local Coverage Determination (LCD): Wireless Capsule Endoscopy (L36427) -
Effective October 24, 2019.
The rules say that wireless capsule endoscopy:
-is NOT indicated for repeat use to verify the effectiveness of surgery.
-is NOT indicated for use as a screening test (other than esophageal varices) and is NOT reimbursable for
colorectal cancer screening.
-is NOT indicated for use as an initial test in diagnosing GI bleeding.
-is NOT indicated for use for evaluating intussusception.
-is NOT indicated for use for evaluating the colon, as it is not indicated for the confirmation of lesions of
pathology normally within the reach of upper and lower endoscopes (lesions proximal to the ligament of Treitz,
or distal to the ileum).
-is NOT indicated for use for evaluating diseases involving the esophagus other than esophageal varices.
-is NOT indicated for use for follow-up of persons with known small bowel disease other than Crohn's disease.
-is NOT indicated for use in confirming pathology identified by other diagnostic means.
-is NOT indicated for use in evaluating the stomach, as it is not indicated for the confirmation of lesions of
pathology normally within the reach of upper and lower endoscopes (lesions proximal to the ligament of Treitz,
or distal to the ileum).
-is NOT indicated for use in investigating duodenal lymphocytosis, small bowel neoplasm, or suspected
irritable bowel syndrome (IBS).
You can find this rule in Local Coverage Determination (LCD): Wireless Capsule Endoscopy (L36427) -
Effective October 24, 2019.
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.