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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 EGD(s) will be considered medically reasonable and necessary under the following 
diagnostic conditions: 

- Patient has upper abdominal distress (e.g., gastroesophageal reflux disease) which persists despite an 
appropriate trial of symptomatic therapy; 
- Patient has upper abdominal distress associated with a short history of signs and symptoms suggesting 
significant associated disease or illness (e.g., weight loss, anorexia, vomiting, nonsteroidal anti-
inflammatory drug [NSAID] intake, other gastric irritant intake); 
- Patients over the age of 40 who have experienced a significant history of heartburn that returns after a 
course of symptomatic therapy; 
- Patients who have dysphagia or odynophagia; 
- Patient has persistent, unexplained vomiting; 
- Patient has upper gastrointestinal x-ray findings of: 
o any lesion that requires biopsy for diagnosis; or 
o gastric ulcer suspicious of cancer; or 
o evidence of stricture or obstruction; 
- To assess acute injury after caustic agent ingestion; 
- When anti-reflux surgery is contemplated; or 
- Patient has gastrointestinal bleeding: 
o in most actively bleeding patients; or 
o for presumed chronic blood loss and iron deficiency anemia when investigation of large bowel 
is negative. 
EGD(s) will be considered medically reasonable and necessary for the following therapeutic purposes: 
- Treatment of bleeding lesions; 
- Removal of foreign bodies; 
- Sclerotherapy and/or band ligation for bleeding from esophageal or gastric varices; 
- Dilatation of strictures in the upper intestinal tract; - Removal of selected polypoid lesions; 
- Placement of feeding tubes; or 
- Palliative therapy of stenosing neoplasms (e.g., laser, stent placement). 
Gastrointestinal bleeding may be treated with a variety of methods. Direct contact heater probes and hemostatic 
injections into or around the bleeding vessels are both effective therapy for acute bleeding. 
Foreign body removal from the stomach or esophagus is usually successful with these flexible instruments. The 
foreign bodies can be retrieved by either of two methods. The first method is to capture the foreign body with a 
snare device/grasping forceps and pull the item out with the endoscope. The second method is accomplished by 
piecemeal destruction and pushing the bolus through the esophagus into the stomach. 
Esophageal varices may be injected with a variety of sclerosing solutions. Eradication of varices requires, on 
the average, five sclerotherapy sessions, with multiple injections given during each session. 
Dilatation of strictures may be accomplished with a balloon placed through the endoscope and inflated using 
hydrostatic pressure. Bougies are rubber dilators available in various sizes up to approximately 2.0cm. Plastic 
bougies and other dilating probes are usually passed over a guide wire. This procedure involves placing the 
guide wire into the stomach through the endoscope. The endoscope is then withdrawn leaving the guide wire in 
place. The dilating probes and plastic bougies are then passed over the guide wire. After the largest dilator is 
used, the dilator and guide wire are removed. Esophageal dilation is performed after a definitive diagnosis has 
been established in patients exhibiting dysphagia. The goal in most cases is a lumenal diameter of 16-17mm 
which allows passage of solid food. A series of dilators may be passed over the guide wire to reach the goal of 
therapy. 
Follow-up EGD(s)will be considered medically reasonable and necessary for the following indications: 
- Biopsy surveillance of patients with Barrett's esophagus every 12 to 24 months. However, if dysplasia 
is present, earlier surveillance intervals of from three to six months may be required; 
- Follow-up of gastric ulcers to healing or satisfaction that they are benign; 
- Follow-up and treatment of esophageal strictures requiring guidewire dilation; 
- Follow-up of duodenal ulcer or other lesions of the upper gastrointestinal tract that have resulted in 
serious consequences (e.g., hemorrhage); 
- Follow-up of patients having a previous gastric polypectomy for adenoma; or 
- Follow-up and treatment of patients with esophageal varices or bleeding lesions requiring recurrent 
therapy (e.g., esophageal varices, gastric varices, angiodysplastic or watermelon stomach lesions, 
radiation gastritis). 
- Follow-up for removal of percutaneous gastrostomy tube (PEG) 
Limitations 
Periodic EGD is NOT usually indicated in the following situations: 
- Surveillance of healed, benign disease such as gastric or duodenal ulcer or benign esophageal strictures; 
or 
- Cancer surveillance in patients with pernicious anemia, treated achalasia, or prior gastric resection. 
EGD is generally contraindicated for patients with recent myocardial infarction. 

You can find this rule at the Medicare Local Coverage Determination (LCD) L33583: Diagnostic and 
Therapeutic Esophagogastroduodenoscopy. 

 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.