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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 say that Wwireless capsule endoscopy of the small bowel is considered medically reasonable and 
necessary when the following conditions have been met:  
1. documented continuous blood loss and anemia secondary to obscure bleeding of the small bowel; 
2. the site of bleeding could not be previously identified by colonoscopy, or endoscopy, or;  
3. radiographic exams of the small bowel have failed to reveal a source, or; 
4. intraoperative enteroscopy is being considered, or; 
5. initial diagnosis of suspected Crohns Disease when there is no evidence provided by conventional 
diagnostic tests such as small bowel follow-through (SBFT), and upper and lower endoscopy. 
Wireless capsule endoscopy of the esophagus is considered medically reasonable and necessary for the 
following condition, if the criteria have been met: 
1. Patient diagnosed with portal hypertension who requires immediate evaluation of esophageal varices  
2. AND the esophageal capsule endoscopy is performed in lieu of conventional endoscopy because the 
provider who would perform the endoscopy has determined that the patients current medical condition 
prohibits a conventional endoscopy.  
3. AND the medical record clearly reflects why the patient was not a candidate for conventional 
endoscopy and how the capsule endoscopy would contribute to the patients care. 
Limitations 
1. Wireless capsule endoscopy of the esophagus will be considered medically necessary only as specified 
under Covered Indications. Performance of wireless capsule endoscopy for any other reason will be 
considered not medically necessary. 
2. Wireless capsule endoscopy is not reimbursable for colorectal cancer screening. 
3. This test is covered only for services using Food and Drug Administration (FDA) approved devices. 
4. Wireless capsule endoscopy is not indicated for the confirmation of lesions of pathology normally 
within the reach of upper and lower endoscopes (proximal to the ligament of Treitz, or distal to the 
ileum). 
5. The use of wireless capsule endoscopy should not be used in patients with a cardiac pacemaker, or other 
implanted electromagnetic device. 6. This test is not indicated for patients in whom a radiological exam of the small bowel has confirmed an 
intestinal blockage, a significantly narrow small bowel, or an abnormal connection between the bowel 
and another organ.  
7. An x-ray exam of the small bowel should be done if there is concern that it may be too narrow for the 
camera. 
Wireless capsule endoscopy of the small bowel is payable only once per episode of illness for patients who 
have previously undergone an upper GI endoscopy, and lower GI colonoscopy, but have failed to reveal a 
source of bleeding. An episode of illness is defined as the time frame from the onset of signs and symptoms 
until the GI bleeding is resolved. 
You can find this rule in Local Coverage Determination (LCD): Wireless Capsule Endoscopy (L33774). 
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.