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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 endoscopy procedures can only be allowed if abnormal signs or symptoms or known 
disease are present. 
 
Indications which support esophagogastroduodenoscopies (EGD[s]) for diagnostic purpose(s) are as follows: 
 
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., 
prolonged anorexia and weight loss); 
Dysphagia or odynophagia; 
Esophageal reflux symptoms which are persistent or recurrent despite appropriate therapy; 
Persistent vomiting of unknown cause; 
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; 
X-ray findings of: 
A suspected neoplastic lesion, for confirmation and specific histologic diagnosis; 
Gastric or esophageal ulcer; or 
Evidence of upper gastrointestinal tract stricture or obstruction. 
The presence of gastrointestinal bleeding: 
In most actively bleeding patients or those recently stopped; 
When surgical therapy is contemplated; 
When re-bleeding occurs after acute self-limited blood loss or after endoscopic therapy; 
When portal hypertension or aortoenteric fistula is suspected; or 
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; or 
Intraoperative EGD when necessary to clarify location or pathology of a lesion. 
Indications which support EGD(s) for therapeutic purpose(s) are as follows: 
 Treatment of bleeding from lesions such as ulcers, tumors, vascular malformations (e.g., electrocoagulation, 
heater probe, laser photocoagulation or injection therapy); 
Sclerotherapy for bleeding from esophageal or proximal gastric varices or banding of varices; 
Foreign body removal; 
Removal of selected polypoid lesions; 
Placement of feeding tubes (oral, percutaneous endoscopic gastrostomy, percutaneous endoscopic 
jejunostomy); 
Dilation of stenotic lesions (e.g., with transendoscopic balloon dilators or dilating systems employing 
guidewires); or 
Palliative therapy of stenosing neoplasms (e.g., laser, bipolar electrocoagulation, stent placement). 
Sequential or periodic diagnostic upper GI endoscopy may be indicated for an appropriate number of 
procedures for active or symptomatic conditions. 
 
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); 
For follow-up in patients with prior adenomatous gastric 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); 
For 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); 
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 
For follow-up in 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). 
The endoscopic retrograde cholangiopancreatography (ERCP) procedure is generally indicated for certain 
biliary and pancreatic conditions. 
 
ERCP is generally not indicated for the diagnosis of pancreatitis except for gallstone pancreatitis; 
ERCP is not usually indicated in early stages or in acute pancreatitis and could possibly exacerbate it; 
ERCP may be useful in traumatic pancreatitis to accurately localize the injury and provide endoscopic 
drainage; 
ERCP may be useful in pancreatic duct stricture evaluation; 
ERCP may be useful for the extraction of bile duct stones in severe gallstone induced pancreatitis; 
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; 
ERCP may be useful in detecting gallstones in symptomatic patients whose oral cholecystogram and 
gallbladder ultrasonograms are normal; and 
ERCP may be indicated in patients with radiologic imaging suggestive of common bile duct stones or other 
potential pathology. 
 
You can find this information 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.