Appeal type: unknown
Decision: unknown

 
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 say that the indications for wireless capsule endoscopy are: 
 
1. For investigating suspected small intestinal bleeding in persons with objective evidence of recurrent, 
  
  obscure GI bleeding (e.g., persistent or recurrent iron-deficiency anemia and/or persistent or recurrent positive 
fecal occult blood test (FOBT), or visible bleeding) who have had upper and lower GI endoscopies within the 
past 12 months (esophagogastroduodenoscopy (EGD) and colonoscopy) that have failed to identify a bleeding 
source; 
2. For evaluation of regional non-metastatic carcinoid tumors of the small bowel in persons with carcinoid 
syndrome; 
3. For evaluation of persons with celiac disease with a positive serology and negative biopsy; 
4. For re-evaluation of persons with celiac disease who remain symptomatic despite treatment and there is no 
suspected or confirmed GI obstruction, stricture, or fistulae; 
5. For initial diagnosis in persons with suspected Crohn's disease (abdominal pain or diarrhea plus 1 or more 
signs of inflammation (e.g., fever, elevated white blood cell (WBC) count, elevated erythrocyte sedimentation 
rate, or bleeding) without evidence of disease on conventional diagnostic tests, including small-bowel follow-
through or abdominal computed tomography (CT) scan/CT enterography and upper and lower endoscopy 
(EGD and colonoscopy); 
6. For re-evaluation of persons with Crohn's disease who remain symptomatic despite treatment and there is no 
suspected or confirmed GI obstruction, stricture, or fistulae; 
7. For surveillance of small intestinal tumors in persons with Lynch syndrome, Peutz-Jeghers syndrome and 
other polyposis syndromes affecting the small bowel; or 
8. For screening or surveillance of esophageal varices. 
 
You can find this rule in the Local Coverage Determination (LCD) - Wireless Capsule Endoscopy (L37427). 
 
The rules say that in terms of limitations, wireless capsule endoscopy: 
 
1. is NOT indicated for repeat use to verify the effectiveness of surgery. 
2. is NOT indicated for use as a screening test (other than esophageal varices) and is NOT reimbursable for 
colorectal cancer screening. 
3. is NOT indicated for use as an initial test in diagnosing GI bleeding. 
4. is NOT indicated for use for evaluating intussusception. 
5. is NOT indicated for use for evaluating the colon, as it is not indicated for the confirmation of lesions of 
pathology normally within the reach of upper and lower endoscopes (lesions proximal to the ligament of Treitz, 
or distal to the ileum). 
6. is NOT indicated for use for evaluating diseases involving the esophagus other than esophageal varices. 
7. is NOT indicated for use for follow-up of persons with known small bowel disease other than Crohn's 
disease. 
8. is NOT indicated for use in confirming pathology identified by other diagnostic means. 
9. is NOT indicated for use in evaluating the stomach, as it is not indicated for the confirmation of lesions of 
pathology normally within the reach of upper and lower endoscopes (lesions proximal to the ligament of Treitz, 
or distal to the ileum). 
10. is NOT indicated for use in investigating duodenal lymphocytosis, small bowel neoplasm, or suspected 
irritable bowel syndrome (IBS). 
 
You can find this rule in the Local Coverage Determination (LCD) - Wireless Capsule Endoscopy (L36427). 
 
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.