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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 the coverage indications for wireless capsule endoscopy (WCE) are: 
1. WCE is indicated for the diagnosis of occult gastrointestinal bleeding (i.e., likely involving the small 
intestine), the site of which has not previously been identified by any of the following: upper 
gastrointestinal endoscopy, colonoscopy, push enteroscopy, nuclear imaging or radiological procedures. 
2. WCE is limited to those patients who have undergone upper GI endoscopy and colonoscopy and these 
tests have failed to reveal a source of bleeding. Medicare would not expect to see a WCE provided if 
upper and lower endoscopy has not previously been performed. Documentation in the medical record 
must indicate that the beneficiary has suspected GI blood loss with or without anemia. Appropriate 
differential diagnoses for the evaluation of such bleeding include: 
- Angiodysplasia, Neoplasm, Iron deficiency anemia, which is unexplained after upper and lower 
endoscopy, Zollinger-Ellison syndrome, Tuberculosis, Vasculitis, Radiation enteritis, Meckels 
diverticulum, Jejunal diverticula, Chronic mesenteric ischemia 
3. Other indications include the management of celiac disease (e.g., surveillance for small-intestinal 
cancer) and of Crohns disease (that is, either Crohns disease is suspected, but not diagnosed, or 
colonic involvement of Crohns disease is known, but it is necessary to determine whether there is also 
involvement of the small bowel). In addition, WCE is indicated where an indeterminate type of colitis 
exists, but where a more specific diagnosis is being sought via small bowel evaluation. 
4. Esophageal capsule endoscopy may be used in the evaluation of esophageal varices in patients with 
portal hypertension, as an alternative to upper GI endoscopy. 
 
In addition to any specific indications noted above, WCE is limited as follows: 
1. Erosive esophagitis and Barretts esophagus may be viable clinical indications in the future, but further 
peer-reviewed literature is being sought before this additional coverage might become available. 
2. This test is not reimbursable for colorectal cancer screening. 
3. The test is payable only for services using Food & Drug Administration (FDA)-approved devices. 
4. This test is not reimbursable for the confirmation of lesions or pathology normally within the reach of 
upper or lower endoscopes (lesions proximal to the ligament of Treitz or distal to the ileum). 5. This test is only covered when performed by physicians trained in endoscopy or for independent 
diagnostic testing facilities, which are under the general supervision of a physician trained in endoscopy 
procedures. 
6. Contraindications include: pregnancy, cardiac pacemaker and other implanted electro-medical devices, 
swallowing disorders, known or suspected gastrointestinal (GI) obstruction, strictures or fistulas based 
on the clinical picture or preprocedure testing. 
7. Medicare would not expect to see a second capsule administered per episode of illness unless it was to 
guarantee an adequate examination (e.g., the initial capsule does not penetrate the pylorus). Please note 
that any other procedure codes that are used to ensure proper passage of the capsule must be reasonable 
and necessary and documented appropriately. 
8. Medicare expects repeat wireless capsule endoscopic studies for any patient to be for medically 
reasonable and necessary clinical circumstances consistent with accepted standards of medical practice 
and that the medical records demonstrate such. 
 
You can find these rules in Local Coverage Determination (LCD) Wireless Capsule Endoscopy (L35089). 
 
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.