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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 by Capsule of the Esophagus 
 
Medicare contractor local coverage determinations (LCDs) generally cover esophagoscopy in patients with 
Gastroesophageal Reflux Disease (GERD) symptoms that persist despite appropriate therapy. The American 
College of Gastroenterology (ACGE) states in regard to empirical therapy for GERD: "Further diagnostic 
testing should be considered if the patient does not respond to therapy, when there are alarm symptoms 
suggesting complicated disease (dysphagia, odynophagia, bleeding, weight loss, or anemia) and when patients 
have a sufficient duration of symptoms to put them at risk for Barrett's esophagus." 
 
The American Society for Gastrointestinal Endoscopy states "When there are clinical clues that suggest that 
reflux may be severe or that other diseases may be present, endoscopy is the diagnostic procedure of choice." 
 
The reported frequency of Barrett's esophagus in those with reflux symptoms ranges from 5% to 15%, and 
these patients without significant inflammatory changes undergo biopsy at the time of endoscopy. 
 
Indications for endoscopy in GERD assume that endoscopy has the potential to obtain tissue samples and to 
examine the stomach and duodenum. Since the capsule does not have these capabilities, the above 
recommendations cannot be carried over to the capsule. 
 
Until a clear description of the population who would benefit from endoscopy by capsule (patients who do not 
need evaluation of the stomach and duodenum and who do not need initial biopsies) becomes available, 
endoscopy by capsule is not covered for GERD evaluation. 
 
Patency Capsule Testing 
Patency Capsule Testing will also not be covered. Sufficient peer-reviewed literature supporting its use is not 
currently available. On occasion Patency Capsule has been reported to cause obstruction requiring urgent 
intervention. 
 
The ASGE Technology Status Evaluation Report Wireless Capsule Endoscopy lists, "Patients with known or 
suspected gastrointestinal (GI) obstruction, strictures, or fistulas based on the clinical picture or preprocedure 
testing" under contraindications for the small bowel capsule. 
 
Endoscopy by Capsule of the Small Intestine ICD-10-CM codes K58.0 or K58.9 and R10.11-R10.13, R10.2, R10.31-R10.33, or R10.84 for irritable bowel 
syndrome and abdominal pain have been placed on the list of covered diagnoses for use when a capsule 
endoscopy exam is normal in the face of compelling symptoms. When representing chronic stable symptoms, 
these conditions rarely represent reasonable indications for endoscopy by capsule. When these diagnostic codes 
are used, the codes must be applicable and the rationale for capsule endoscopy must be carefully documented 
in the medical record. 
 
The ingestion of the capsule is part of the test and an evaluation & management (E&M) service may not be 
billed for this purpose. 
 
Endoscopy by capsule of the small intestine is not covered in the following situations: 
 
    Colorectal cancer screening 
    When carried out by FDA non-approved devices 
    Confirmation of lesions or pathology normally within the reach of upper or lower endoscopy (lesions 
proximal to the ligament of Treitz or distal to the ileum) or for the confirmation of lesions or pathology 
discovered by prior endoscopy (including push enteroscopy), colonoscopy, or radiology 
    When performed by physicians not trained in endoscopy or for independent diagnostic testing facilities, 
which are not under the general supervision of a physician trained in endoscopy procedures. 
 
    Endoscopy by capsule performed to diagnose obscure gastrointestinal bleeding, is only covered if it is 
documented that the beneficiary had continuing GI blood loss or anemia secondary to bleeding or iron 
deficiency anemia. 
 
    Endoscopy by capsule is not generally reimbursable when used for management of patients with a confirmed 
diagnosis of Crohn's disease. Onset of new symptoms suggestive of Crohn's disease at an undiagnosed small 
bowel region may make endoscopy by capsule reasonable. 
 
    Endoscopy by capsule for the detection of small bowel malignancies, in the absence of obscure 
gastrointestinal bleeding, or symptoms suggesting Crohn's disease, or the presence of a polyposis syndrome 
associated with small bowel neoplasia or other history suggesting the presence of small bowel neoplasia is not 
covered. 
 
    Endoscopy by capsule of the esophagus is not covered in patients with a current history of dysphagia 
suggestive of esophageal stricture. 
 
You can find this information in the Local Coverage Determination (LCD) Endoscopy by Capsule L34081. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.