Clinical UM Guideline

This document addresses indications for upper gastrointestinal (GI) endoscopy in adults. This document does not address upper gastrointestinal (GI) endoscopy in children, wireless capsule endoscopy, virtual endoscopy or in vivo analysis of gastrointestinal lesions via endoscopy.

Note: Please see the following related documents for additional information:

• CG-MED-70 Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule
• CG-SURG-70 Gastric Electrical Stimulation
• CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity
• CG-SURG-101 Ablative Techniques as a Treatment for Barrett’s Esophagus
• SURG.00047 Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis

Medically Necessary:

I.     Diagnostic Esophagogastroduodenoscopy (EGD) in Adults

EGD for diagnostic purposes for adults aged 18 years or older is considered medically necessary for any of the following indications:

1. Upper abdominal signs or symptoms:
   1. Gastroesophageal reflux symptoms that persist or recur following an appropriate trial of therapy for 2 months or more; or
   2. Persistent vomiting of unknown cause; or
   3. New-onset dyspepsia in individuals 50 years of age or older; or
   4. Unexplained dysphagia or odynophagia; or
   5. Signs or symptoms suggesting structural disease of the upper gastrointestinal tract such as anorexia, weight loss, early satiety, or persistent nausea; or
   6. Postoperative bariatric surgery with persistent abdominal pain, nausea, or vomiting despite counseling and behavior modification related to diet adherence; or
   7. Recent or active gastrointestinal bleed; or
   8. Unexplained anemia due to either blood loss or malabsorption from a mucosal process; or
   9. To assess symptoms suspicious for inflammatory bowel disease (for example, bloody diarrhea); or
2. Intraoperative evaluation of anatomic reconstructions typical of modern foregut surgery (for example, evaluation of anastomotic leak and patency, fundoplication formation, pouch configuration during bariatric surgery); or
3. For confirmation and specific histologic diagnosis of radiologically demonstrated lesions, including, but not limited to:
   1. Suspected neoplastic lesion; or
   2. Gastric or esophageal ulcer; or
   3. Upper tract stricture or obstruction; or
4. Documentation of esophageal varices in individuals with suspected portal hypertension or cirrhosis; or
5. To assess acute injury after caustic ingestion; or
6. To identify upper gastrointestinal etiology of lower gastrointestinal symptoms, such as diarrhea, in individuals suspected of having small-bowel disease (for example, celiac disease); or
7. To evaluate persons with radiographic findings suggestive of achalasia.

II.   Therapeutic EGD in Adults

EGD for therapeutic purposes for adults aged 18 years or older is considered medically necessary for any of the following indications:

1. Treatment of bleeding from lesions such as ulcers, tumors, vascular malformations (for example, electrocoagulation or injection therapy); or
2. For esophageal varices using endoscopic variceal ligation:
   1. Variceal ligation may be repeated every 1 to 8 weeks until varices are eradicated; and
   2. Sclerotherapy may be performed in individuals when variceal ligation is technically difficult; or
3. Removal of foreign body (including food impaction); or
4. Removal of selected polypoid or submucosal lesions; or
5. Placement of feeding tubes (per oral when unguided placement unsuccessful, or percutaneous); or
6. Dilation of stenotic lesions of the esophagus, pylorus or duodenum (for example, with transendoscopic balloon dilators or dilating systems employing guidewires); or
7. Dilation for adults with eosinophilic esophagitis who have a dominant esophageal stricture or ring and remain symptomatic despite medical therapy; or
8. Management of achalasia (for example, dilatation or treatment with botulinum toxin injection); or
9. Endoscopic placement of self-expandable metal stents (SEMS) for palliative treatment of malignant gastric or biliary obstruction in individuals with poor performance status or inoperable disease; or
10. Management of gastroduodenal dysmotility when symptoms persist despite optimal medical and dietary management; or
11. Palliative therapy of stenosing neoplasms; or
12. Endoscopic resection for individuals with Barrett’s esophagus and any of the following (ablative treatment of Barrett’s esophagus is addressed in CG-SURG-101 Ablative Techniques as a Treatment for Barrett's Esophagus):
    1. Low-grade dysplasia; or
    2. Flat high-grade dysplasia; or
    3. Intestinal metaplasia; or
13. Endoscopic resection or radiofrequency ablation for individuals with stage T1a esophageal adenocarcinoma.

III.   Screening EGD in Adults

Screening EGD for adults aged 18 years or older is considered medically necessary for any of the following indications:

1. Individuals with familial adenomatous polyposis:
   1. Starting at age 25 years if asymptomatic; and
   2. Subsequent follow up every 6 months to 4 years depending on the Spigelman Stage classification (0-III) of duodenal polyposis (see Table 2.); or
2. Screening for Barrett’s esophagus and esophageal adenocarcinoma may be considered in men with chronic (5 years or more) or frequent (weekly or more) symptoms of gastroesophageal reflux disease (GERD), such as heartburn or acid regurgitation, and at least two risk factors (see Discussion/General Information section).

IV.   Sequential or Periodic Diagnostic EGD in Adults

Sequential or periodic diagnostic EGD for adults aged 18 years or older is considered medically necessary for any of the following indications:

1. For surveillance of individuals with portal hypertension or compensated cirrhosis who meet any of the following criteria:
   1. With small varices or high-risk stigmata (“red wale markings”), every 1 to 2 years; or
   2. Without varices, every 2 to 3 years; or
   3. Secondary to alcohol abuse or decompensated liver disease, annually; or
2. Following esophageal variceal eradication, surveillance in the following intervals:
   1. 1 to 3 months following initial eradication; and
   2. Every 6 to 12 months thereafter to monitor for recurrence; or
3. In individuals with Barrett’s esophagus in any of the following scenarios:
   1. Without dysplasia, endoscopic surveillance should take place at intervals of 3 to 5 years; or
   2. With confirmed low-grade dysplasia, endoscopic surveillance of metaplastic gastric tissue may be performed every 6-12 months (endoscopic therapy is preferred); or
   3. With confirmed high-grade dysplasia and comorbidities that preclude endoscopic eradication therapy, endoscopic surveillance of metaplastic gastric tissue may be performed every 3 months.

Not Medically Necessary:

EGD for adults aged 18 years or older is considered not medically necessary when the above criteria are not met, and for all other indications, including but not limited to the following:

1. Screening of any of the following:
   1. Asymptomatic upper gastrointestinal tract of an average risk individual; or
   2. Follow-up screening for Barrett’s esophagus after a prior EGD screening examination was negative for Barrett’s esophagus; or
   3. Aerodigestive cancer; or
2. Surveillance for any of the following:
   1. Healed benign disease (for example, esophagitis, gastric or duodenal ulcer); or
   2. Gastric atrophy; or
   3. Pernicious anemia; or
   4. Fundic gland or hyperplastic polyps; or
   5. Gastric intestinal metaplasia; or
   6. Previous gastric operations for benign disease; or
   7. Achalasia; or
3. Radiographic findings of any of the following:
   1. Asymptomatic or uncomplicated sliding hiatal hernia; or
   2. Uncomplicated duodenal ulcer that has responded to therapy; or
   3. Deformed duodenal bulb when symptoms are absent or respond adequately to ulcer therapy; or
4. Confirming Helicobacter pylori eradication; or
5. Isolated pylorospasm, known congenital hypertrophic pyloric stenosis, constipation and encopresis, or inflammatory bowel disease responding to therapy; or
6. Prior to bariatric or non-gastroesophageal surgery in asymptomatic individuals; or
7. Metastatic adenocarcinoma of unknown primary site when the results will not alter management; or
8. Obtaining tissue samples from endoscopically normal tissue to diagnose GERD or exclude Barrett’s esophagus in adults; or
9. Symptoms that are considered functional in origin; or
10. To evaluate benign appearing, uncomplicated duodenal ulcers identified on radiologic imaging; or
11. When there is clinical evidence of acute perforation.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.

Upper GI endoscopy, or EGD, is usually performed to evaluate symptoms of persistent upper abdominal pain, nausea, vomiting, and difficulty swallowing or bleeding from the upper GI tract. This procedure is more accurate than x-ray imaging for detecting inflammation, ulcers, or tumors of the esophagus, stomach and duodenum and can detect early cancer, as well as distinguish between benign and malignant conditions when biopsies of suspicious areas are obtained. EGD uses a flexible fiber-optic scope with a light and camera to examine the upper part of the GI system. The scope is inserted through the mouth into the upper GI tract allowing for direct visualization of the esophagus, stomach, and duodenum through the camera.

The quality of evidence concerning the safety and efficacy of EGD is lacking for the majority of the most common uses of the technology. In an effort to provide safe recommendations to guide clinical practice in the use of EGD, the American Society for Gastrointestinal Endoscopy (ASGE), the American Gastroenterological Association (AGA), and the American College of Gastroenterology (ACG) have established practice guidelines based largely on consensus within these respective specialty medical societies.

In 2012, the ASGE published a broad guideline entitled, Appropriate use of GI Endoscopy. The guideline contains several position statements based on a critical review of the available data as well as expert consensus. The ASGE has also published a number of indication-specific guidelines such as, The Role of Endoscopy in Barrett’s Esophagus and other Premalignant Conditions of the Esophagus (2012), The Role of Endoscopy in Gastroduodenal Obstruction and Gastroparesis (2011), The Role of Endoscopy in the Management of Benign and Malignant Gastroduodenal Obstruction (2021), and The Role of Endoscopy in Dyspepsia (2015). The indication-specific guidelines also contain recommendations based on consensus and a review of the literature; each recommendation was graded on the quality of the supporting evidence in accordance with the definitions in Table 1. The ACG has also published indication-specific clinical practice guidelines on the use of endoscopy in commonly encountered clinical scenarios, such as Diagnosis and Management of Barrett's Esophagus: an Updated ACG Guideline (Shaheen 2022), Diagnosis and Management of Achalasia (Vaezi, 2020), and Gastroparesis (Camilleri, 2022). The ACG’s recommendations are graded in accordance with the same definitions as the ASGE, which appear in Table 1. The medically necessary indications in this clinical guideline are largely based on ASGE, ACG and AGA recommendations that are graded as ‘moderate’ to ‘high’ quality where the ACG has not considered the recommendation ‘conditional’ (“uncertainty about the tradeoffs”) or the AGA has not considered the recommendation ‘weak’ (“recommendation not suitable for quality or performance measure”). Where there was discordance, criteria are based on expert consensus.

Screening for Barrett’s esophagus

Major gastroenterological specialty societies recommend screening only for individuals at high risk for development of Barret’s esophagus or esophageal adenocarcinoma (abbreviated as BE and EAC, respectively in the guidelines).

The ACG guideline on diagnosis and management of Barrett’s esophagus (Shaheen, 2022) includes the following statement on screening:

We suggest a single screening endoscopy for patients with chronic GERD symptoms and 3 or more additional risk factors for BE, including male sex, age >50 years, White race, tobacco smoking, obesity, and family history of BE or EAC in a first-degree relative (strength of recommendation: conditional; quality of evidence: very low).

The ASGE (2012) guideline states, “Risk factors for BE and EAC include male sex, white race, age older than 50 years, family history of BE, increased duration of reflux symptoms, smoking, and obesity”.

Neither the ACG (Shaheen, 2022) nor the ASGE (2012) recommend screening the general population for Barrett’s esophagus.

GERD

GERD is defined as “symptoms or complications resulting from the reflux of gastric contents into the esophagus or beyond, into the oral cavity (including larynx) or lung” (Flores, 2019). Increased BMI, waist circumference and weight gain are associated with the presence of GERD (Katz, 2013; Flores, 2019). The typical symptoms of GERD include dyspepsia, epigastric pain, early satiety, belching, and bloating (Katz, 2013). As noted by Brethauer (2014) “treatment of GERD is initially medical with acid suppression but if symptoms are refractory to medical therapy or if there is an associated anatomic etiology for the GERD, surgical revision may be required”.

The ACG 2022 guideline on GERD (Katz, 2022) notes that “There is no gold standard for the diagnosis of GERD. Thus, the diagnosis is based on a combination of symptom presentation, endoscopic evaluation of esophageal mucosa, reflux monitoring, and response to therapeutic intervention.” For patients with classic GERD symptoms of heartburn and regurgitation who have no alarm symptoms, an 8-week trial of empiric proton pump inhibitors (PPIs) once daily before a meal is recommended. The AGA (Yadlapati, 2022) concurs and further finds that “if troublesome heartburn, regurgitation, and/or non-cardiac chest pain do not respond adequately to a PPI trial or when alarm symptoms exist, clinicians should investigate with endoscopy.” The ACG recommendation on upper endoscopy for diagnosing GERD is as follows:

Upper endoscopy is the most widely used objective test for evaluating the esophageal mucosa. For patients with GERD symptoms who also have alarm symptoms such as dysphagia, weight loss, bleeding, vomiting, and/or anemia, endoscopy should be performed as soon as feasible. The endoscopic findings of EE [erosive esophagitis] and Barrett’s esophagus are specific for the diagnosis of GERD.

Table 1. Quality of Evidence Grading of Recommendations Assessment, Development and Evaluation (GRADE) System (AGA, 2011; ASGE, 2015; ASGE, 2018).

Table 2. Spigelman Stage classification (0-IV) of duodenal polyposis (Brosens, 2005).

Peer Reviewed Publications:

1. Brosens LA, Keller JJ, Offerhaus GJ et al. Prevention and management of duodenal polyps in familial adenomatous polyposis. Gut. 2005; 54(7):1034-1043.
2. Flores L, Krause C, Pokala B, et al. Novel therapies for gastroesophageal reflux disease. Curr Probl Surg. 2019; 56(12):100692.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Gupta S, Li D, El Serag HB, et al. AGA clinical practice guidelines on management of gastric intestinal metaplasia. Gastroenterology. 2020; 158(3):693-702.
2. American Gastroenterological Association; Spechler SJ, Sharma P, Souza RF, et al. American Gastroenterological Association medical position statement on the management of Barrett's esophagus. Gastroenterology. 2011; 140(3):1084-1091.
3. ASGE Standards of Practice Committee, Banerjee S, Cash BD, Dominitz JA, et al. The role of endoscopy in the management of patients with peptic ulcer disease. Gastrointest Endosc. 2010; 71(4):663-668.
4. ASGE Standards of Practice Committee; Chandrasekhara V, Early DS, Acosta RD, et al. ASGE guideline: modifications in endoscopic practice for the elderly. Gastrointest Endosc. 2013; 78(1):1-7.
5. ASGE Standards of Practice Committee; Early DS, Ben-Menachem T, Decker GA, et al. Appropriate use of GI endoscopy. Gastrointest Endosc. 2012; 75(6):1127-1131.
6. ASGE Standards of Practice Committee, Evans JA, Chandrasekhara V, Chathadi KV, et al. The role of endoscopy in the management of premalignant and malignant conditions of the stomach. Gastrointest Endosc. 2015; 82(1):1-8.
7. ASGE Standards of Practice Committee; Evans JA, Early DS, Fukami N, et al. The role of endoscopy in Barrett's esophagus and other premalignant conditions of the esophagus. Gastrointest Endosc. 2012; 76(6):1087-1094.
8. ASGE Standards of Practice Committee; Evans JA, Muthusamy VR, Acosta RD, et al. The role of endoscopy in the bariatric surgery patient. Surg Obes Relat Dis. 2015; 11(3):507-517.
9. ASGE Standards of Practice Committee; Fukami N, Anderson MA, Khan K, et al. The role of endoscopy in gastroduodenal obstruction and gastroparesis. Gastrointest Endosc. 2011; 74(1):13-21.
10. ASGE Standards of Practice Committee, Jue TL, Storm AC, Naveed M, et al. ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction. Gastrointest Endosc. 2021; 93(2):309-322.e4.
11. ASGE Standards of Practice Committee; Khashab MA, Vela MF, Thosani N, et al. ASGE guideline on the management of achalasia. Gastrointest Endosc. 2020; 91(2):213-227.
12. ASGE Standards of Practice Committee; Muthusamy VR, Lightdale JR, Acosta RD, et al. Role of endoscopy in the management of GERD. Gastrointest Endosc. 2015; 81(6):1305-1310.
13. ASGE Standards of Practice Committee; Pasha SF, Acosta RD, Chandrasekhara V, et al. The role of endoscopy in the evaluation and management of dysphagia. Gastrointest Endosc. 2014; 79(2):191-201.
14. ASGE Standards of Practice Committee; Qumseya B, Sultan S, Bain P, et al. ASGE guideline on screening and surveillance of Barrett's esophagus. Gastrointest Endosc. 2019; 90(3):335-359.
15. ASGE Standards of Practice Committee; Wani S, Qumseya B, Sultan S, et al. Endoscopic eradication therapy for patients with Barrett's esophagus-associated dysplasia and intramucosal cancer. Gastrointest Endosc. 2018; 87(4):907-931.
16. Brethauer SA, Kothari S, Sudan R, et al. Systematic review on reoperative bariatric surgery: American Society for Metabolic and Bariatric Surgery Revision Task Force. Surg Obes Relat Dis. 2014;10(5):952-972.
17. Camilleri M, Kuo B, Nguyen L, et al. ACG clinical guideline: gastroparesis. Am J Gastroenterol. 2022; 117(8):1197-1220.
18. Centers for Medicare and Medicaid Services. National Coverage Determination for Endoscopy. NCD #100.2. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=81&ncdver=1&bc=AAAAQAAAAAAA&. Accessed on May 3, 2023.
19. Hirano I, Chan ES, Rank MA, et al. AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters clinical guidelines for the management of eosinophilic esophagitis. Gastroenterology. 2020; 158(6):1776-1786.
20. Hwang JH, Fisher DA, Ben-Menachem T, et al. ASGE guideline: the role of endoscopy in the management of acute non-variceal upper GI hemorrhage. Gastrointest Endosc 2012; 75(6):1132-1138.
21. Hwang JH, Shergill AK, Acosta RD, Chandrasekhara V, et al. ASGE Guideline: the role of endoscopy in the management of variceal hemorrhage. Gastrointest Endosc. 2014; 80(2):221-227.
22. Ikenberry SO, Harrison ME, Lichtenstein D, et al.; ASGE Standards of Practice Committee. The role of endoscopy in dyspepsia. Gastrointest Endosc. 2007; 66(6):1071-1075.
23. Kahrilas PJ, Shaheen NJ, Vaezi MF, et al. American Gastroenterological Association Medical Position Statement on the management of gastroesophageal reflux disease. Gastroenterology. 2008; 135(4):1383-1391.
24. Katz PO, Dunbar KB, Schnoll-Sussman FH, et al. ACG clinical guideline for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2022; 117(1):27-56.
25. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013; 108(3):308-328.
26. Leighton JA, Shen B, Baron TH, et al. ASGE guideline: endoscopy in the diagnosis and treatment of inflammatory bowel disease. Gastrointest Endosc. 2006; 63(4):558-565.
27. Levine A, Koletzko S, Turner D, et al. ESPGHAN revised porto criteria for the diagnosis of inflammatory bowel disease in children and adolescents. J Pediatr Gastroenterol Nutr. 2014; 58(6):795-806.
28. Moayyedi PM, Lacy BE, Andrews CN, et al. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterol. 2017; 112(7):988-1013.
29. Qumseya BJ, Jamil LH, Elmunzer BJ, et al. ASGE guideline on the role of endoscopy in the management of malignant hilar obstruction. Gastrointest Endosc. 2021; 94(2):222-234.e22.
30. Shaheen NJ, Falk GW, Iyer PG, et al. ACG clinical guideline: diagnosis and management of Barrett’s esophagus. Am J Gastroenterol. 2016; 111(1):30-50.
31. Shaheen NJ, Falk GW, Iyer PG, et al. Diagnosis and management of Barrett's esophagus: an updated ACG guideline. Am J Gastroenterol. 2022; 117(4):559-587.
32. Spechler SJ, Sharma P, Souza RF, et al. American Gastroenterological Association medical position statement on the management of Barrett’s esophagus. Gastroenterology 2011; 140(3):1084-1091.
33. Spechler SJ, Souza RF. Barrett’s esophagus. N Engl J Med. 2014; 371(9):836-845.
34. Vaezi MF, Pandolfino JE, Yadlapati RH, et al. ACG clinical guidelines: diagnosis and management of achalasia. Am J Gastroenterol. 2020; 115(9):1393-1411.
35. Yadlapati R, Gyawali CP, Pandolfino JE. AGA clinical practice update on the personalized approach to the evaluation and management of GERD: expert review. Clin Prac Update. 2022; 20(5):984-994.
36. Yang J, Gurudu SR, Koptiuch C, et al. ASGE guideline on the role of endoscopy in familial adenomatous polyposis syndromes. Gastrointest Endosc. 2020; 91(5):963-982.e2.

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