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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 for which EGD(s) are generally not covered by Medicare are as follows: Distress which is chronic, 
non-progressive, atypical for known organic disease, and is considered functional in origin (there are 
occasional exceptions in which an endoscopic examination may be done once to rule out organic disease, 
especially if symptoms are unresponsive to therapy); Uncomplicated heartburn responding to medical therapy; 
Metastatic adenocarcinoma of unknown primary site when the results will not alter management; X-ray 
findings of: asymptomatic or uncomplicated sliding hiatal hernia; uncomplicated duodenal bulb ulcer which 
has responded to therapy; or Deformed duodenal bulb when symptoms are absent or respond adequately to 
ulcer therapy; Routine screening of the upper gastrointestinal tract; Patients without current gastrointestinal 
symptoms about to undergo elective surgery for non-upper gastrointestinal disease; or When lower G.I. 
endoscopy reveals the cause of symptoms, abnormal signs or laboratory tests (e.g., colonic neoplasm with iron 
deficiency anemia). Exceptions can be considered if medical necessity for this procedure can be demonstrated. 
You can find this rule at Centers for Medicare and Medicaid Services, Local Coverage Determination (LCD) 
L35350 Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic). 
 
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.