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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 state that indications which support EGD(s) for diagnostic purposes: 
 upper abdominal distress which persists despite an appropriate trial of therapy; 
 upper abdominal distress associated with symptoms and/or signs suggesting serious organic disease 
(e.g., anorexia and weight loss); 
 dysphagia or odynophagia; 
 esophageal reflux symptoms which are persistent or recurrent despite appropriate therapy; 
 persistent vomiting of unknown cause; 
 cirrhosis; 
 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. 
      Radiologic findings of: 
o a suspected neoplastic lesion, for confirmation and specific histologic diagnosis; 
o gastric or esophageal ulcer; or 
o evidence of upper GI tract stricture or obstruction. 
      The presence of GI bleeding: 
o in most actively bleeding patients; 
o when surgical therapy is contemplated; 
o when rebleeding occurs after acute self-limited blood loss or after endoscopic therapy; 
o when portal hypertension (HTN) or aorto-enteric fistula (AEF) is suspected; or 
o for presumed chronic blood loss and for iron deficiency anemia when colonoscopy is negative. 
 when sampling of duodenal or jejunal tissue or fluid is indicated; 
 to assess acute injury after caustic agent ingestion; 
 intraoperative EGD when necessary to clarify the location or pathology of a lesion. B. Indications which support EGD(s) for therapeutic purposes: 
 treatment of bleeding from lesions such as ulcers, tumors, vascular malformations (e.g., 
electrocoagulation, heater probe, laser photocoagulation or injection therapy); 
 sclerotherapy and/or band ligation for bleeding from esophageal or proximal gastric varices or banding 
of varices; 
 foreign body removal; 
 removal of selected polypoid lesions; 
 dilation of stenotic lesions (e.g., with transendoscopic balloon dilators or dilating systems employing 
guide wires); 
 palliative therapy of stenosing neoplasms (e.g., laser, bipolar electrocoagulation, stent placement); 
 management of achalasia (e.g., botulinum toxin, balloon dilatation). 
C. Noncovered Transesophageal Endoscopic Procedures for the Treatment of Gastroesophageal Reflux 
Disease (GERD) 
 
Some transesophageal endoscopic procedures for the treatment of GERD are not currently covered as the safety 
and efficacy of these procedures cannot be established by review of the available published peer reviewed 
literature. 
 
Several endoscopic or endoluminal procedures have been designed for the treatment of GERD. There are 
currently 3 transesophageal endoscopic approaches used to treat GERD including endoscopic plication or 
suturing devices; radiofrequency energy; and submucosal injection or implantation of biocompatible bulking 
agents or polymer prosthetics to treat GERD without surgery. 
 
You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage Determination (LCD) 
L34434, Upper Gastrointestinal Endoscopy and Visualization. 
 
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.