RETIRED LCD: Centers for Medicare & Medicaid Services

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Contractor Information

Contractor Name ^{back to top}

TrailBlazer Health Enterprises, LLC
Contractor Number ^{back to top}
00901
Contractor Type ^{back to top}
Carrier

LCD Information

LCD ID Number ^{back to top}

L18515

LCD Title ^{back to top}
Diagnostic and Therapeutic Esophagogastroduodenoscopy (EGD) – S-125B-R4

Contractor's Determination Number ^{back to top}
S-125

AMA CPT / ADA CDT Copyright Statement ^{back to top}
CPT codes, descriptions and other data only are copyright 2009 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy ^{back to top}
- Medicare Benefit Policy Manual-Pub. 100-02. - Medicare National Coverage Determinations Manual-Pub. 100-03. - Correct Coding Initiative-Medicare Contractor Beneficiary and Provider Communications Manual-Pub. 100-09, Chapter 5. - Social Security Act (Title XVIII) Standard References, Sections: -- 1862 (a)(1)(A) Medically Reasonable & Necessary. -- 1862 (a)(1)(D) Investigational or Experimental.

Primary Geographic Jurisdiction ^{back to top}
Maryland

Oversight Region ^{back to top}
Region III

Original Determination Effective Date ^{back to top}
For services performed on or after 04/21/2005

Original Determination Ending Date ^{back to top}
07/11/2008

Revision Effective Date ^{back to top}
For services performed on or after 08/01/2007

Revision Ending Date ^{back to top}
07/11/2008

Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
The following conditions are generally accepted as indications for the performance of EGD(s). Indications that support EGD(s) for diagnostic purpose(s) are: - Upper abdominal distress that persists despite an appropriate trial of therapy. - Upper abdominal distress associated with symptoms and/or signs suggesting serious organic disease (e.g., anorexia and weight loss). - Dysphagia or odynophagia. - Esophageal reflux symptoms that are persistent or recurrent despite appropriate therapy. - Persistent vomiting of unknown cause. - Other system disease in which the presence of upper GI pathology might modify other planned management. Examples include patients with a history of GI bleeding who are scheduled for organ transplantation, long-term anticoagulation, and chronic non-steroidal therapy for arthritis. Please note that this Indication does not provide coverage for routine pre-operative EGD for patients in whom bariatric surgical procedures are contemplated or planned. See LCD S131-AB “Bariatric Surgical Management of Morbid Obesity”. - X-ray findings of: -- A suspected neoplastic lesion for confirmation and specific histologic diagnosis. -- Gastric or esophageal ulcer. Or, -- Evidence of upper gastrointestinal tract stricture or obstruction. - Gastrointestinal bleeding: -- In most actively bleeding patients. -- When surgical therapy is contemplated. -- When rebleeding occurs after acute self-limited blood loss. -- When portal hypertension or aorto-enteric fistula is suspected. Or, -- For presumed chronic blood loss and for iron deficiency anemia when colonoscopy is negative. - When sampling of duodenal or jejunal tissue or fluid is indicated. - To assess acute injury after caustic agent ingestion. Or, - Intraoperative EGD when necessary to clarify location or pathology of a lesion. Indications that support EGD(s) for therapeutic purpose(s) are: - Treatment of bleeding from lesions such as ulcers, tumors, vascular malformations (e.g., electrocoagulation, heater probe, laser photocoagulation or injection therapy). - Sclerotherapy and/or band ligation for bleeding from esophageal or proximal gastric varices. - Foreign body removal. - Removal of selected polypoid lesions. - Placement of feeding tubes (per oral, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy). - Dilation of stenotic lesions (e.g., with transendoscopic balloon dilators or dilating systems employing guide wires). Or, - Palliative therapy of stenosing neoplasms (e.g., laser, bipolar electrocoagulation, stent placement). Sequential or periodic diagnostic EGD may be indicated: - For follow up of selected esophageal, gastric or stomal ulcers to demonstrate healing (frequency of follow-up EGD is variable, but every two to four months until healing is demonstrated is reasonable). - For follow up in patients with prior adenomatous gastric polyps (approximate frequency of follow-up EGDs would be every one to four years depending on the clinical circumstances, with occasional patients with sessile polyps requiring every six months surveillance initially), and similarly with surveillance of confirmed high-grade gastric dysplasia. - For follow up for adequacy of prior sclerotherapy and/or band ligation of esophageal varices (approximate frequency of follow-up EGDs is variable depending on the state of the patient but every six to 24 months is reasonable after the initial sclerotherapy sessions are completed). - For follow-up of Barrett’s esophagus (approximate frequency of follow-up EGDs is one to two years with biopsies, unless dysplasia is demonstrated, in which case, a repeat biopsy in two to three months might be indicated). Or, - For follow-up in patients with familial adenomatous polyposis (approximate frequency of follow-up EGDs would be every two to four years, but might be more frequent, such as every six to 12 months, if gastric adenomas or adenomas of the duodenum were demonstrated). - For follow-up of patients with severe, refractory gastroesophageal reflux disease where the concern of malignant degeneration exists (approximate frequency of every ten years)

Coding Information

Bill Type Codes: ^{back to top}

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x	Not Applicable

Revenue Codes: ^{back to top}

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes ^{back to top}

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.

43234	Upper GI endoscopy, exam
43235	Uppr gi endoscopy, diagnosis
43236	Uppr gi scope w/submuc inj
43237	Endoscopic us exam, esoph
43238	Uppr gi endoscopy w/us fn bx
43239	Upper GI endoscopy, biopsy
43240	Esoph endoscope w/drain cyst
43241	Upper GI endoscopy with tube
43242	Uppr gi endoscopy w/us fn bx
43243	Upper gi endoscopy & inject
43244	Upper GI endoscopy/ligation
43245	Uppr gi scope dilate strictr
43246	Place gastrostomy tube
43247	Operative upper GI endoscopy
43248	Uppr gi endoscopy/guide wire
43249	Esoph endoscopy, dilation
43250	Upper GI endoscopy/tumor
43251	Operative upper GI endoscopy
43255	Operative upper GI endoscopy
43256	Uppr gi endoscopy w/stent
43258	Operative upper GI endoscopy
43259	Endoscopic ultrasound exam

ICD-9 Codes that Support Medical Necessity ^{back to top}

The CPT/HCPCS codes included in this LCD will be subjected to "procedure to diagnosis" editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 43234, 43235, 43236, 43239, 43240, 43241, 43243, 43244, 43245, 43246, 43247, 43248, 43249, 43250, 43251, 43255, 43256 and 43258:

Covered for:

150.0 - 150.5	MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS - MALIGNANT NEOPLASM OF LOWER THIRD OF ESOPHAGUS
150.8 - 150.9	MALIGNANT NEOPLASM OF OTHER SPECIFIED PART OF ESOPHAGUS - MALIGNANT NEOPLASM OF ESOPHAGUS UNSPECIFIED SITE
151.0 - 151.6	MALIGNANT NEOPLASM OF CARDIA - MALIGNANT NEOPLASM OF GREATER CURVATURE OF STOMACH UNSPECIFIED
151.8 - 151.9	MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF STOMACH - MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE
152.0	MALIGNANT NEOPLASM OF DUODENUM
211.0 - 211.3	BENIGN NEOPLASM OF ESOPHAGUS - BENIGN NEOPLASM OF COLON
230.1 - 230.2	CARCINOMA IN SITU OF ESOPHAGUS - CARCINOMA IN SITU OF STOMACH
235.2 - 235.3	NEOPLASM OF UNCERTAIN BEHAVIOR OF STOMACH INTESTINES AND RECTUM - NEOPLASM OF UNCERTAIN BEHAVIOR OF LIVER AND BILIARY PASSAGES
235.5	NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED DIGESTIVE ORGANS
239.0	NEOPLASM OF UNSPECIFIED NATURE OF DIGESTIVE SYSTEM
261	NUTRITIONAL MARASMUS
263.0	MALNUTRITION OF MODERATE DEGREE
263.8 - 263.9	OTHER PROTEIN-CALORIE MALNUTRITION - UNSPECIFIED PROTEIN-CALORIE MALNUTRITION
280.0	IRON DEFICIENCY ANEMIA SECONDARY TO BLOOD LOSS (CHRONIC)
280.9	IRON DEFICIENCY ANEMIA UNSPECIFIED
285.1	ACUTE POSTHEMORRHAGIC ANEMIA
438.82	DYSPHAGIA CEREBROVASCULAR DISEASE
447.2	RUPTURE OF ARTERY
456.0 - 456.1	ESOPHAGEAL VARICES WITH BLEEDING - ESOPHAGEAL VARICES WITHOUT BLEEDING
456.20 - 456.21	ESOPHAGEAL VARICES IN DISEASES CLASSIFIED ELSEWHERE WITH BLEEDING - ESOPHAGEAL VARICES IN DISEASES CLASSIFIED ELSEWHERE WITHOUT BLEEDING
530.0	ACHALASIA AND CARDIOSPASM
530.10 - 530.11	ESOPHAGITIS UNSPECIFIED - REFLUX ESOPHAGITIS
530.19	OTHER ESOPHAGITIS
530.20 - 530.21	ULCER OF ESOPHAGUS WITHOUT BLEEDING - ULCER OF ESOPHAGUS WITH BLEEDING
530.3 - 530.7	STRICTURE AND STENOSIS OF ESOPHAGUS - GASTROESOPHAGEAL LACERATION-HEMORRHAGE SYNDROME
530.81 - 530.85	ESOPHAGEAL REFLUX - BARRETT'S ESOPHAGUS
531.00 - 531.01	ACUTE GASTRIC ULCER WITH HEMORRHAGE WITHOUT OBSTRUCTION - ACUTE GASTRIC ULCER WITH HEMORRHAGE WITH OBSTRUCTION
531.30 - 531.31	ACUTE GASTRIC ULCER WITHOUT HEMORRHAGE OR PERFORATION WITHOUT OBSTRUCTION - ACUTE GASTRIC ULCER WITHOUT HEMORRHAGE OR PERFORATION WITH OBSTRUCTION
531.40 - 531.41	CHRONIC OR UNSPECIFIED GASTRIC ULCER WITH HEMORRHAGE WITHOUT OBSTRUCTION - CHRONIC OR UNSPECIFIED GASTRIC ULCER WITH HEMORRHAGE WITH OBSTRUCTION
531.70 - 531.71	CHRONIC GASTRIC ULCER WITHOUT HEMORRHAGE OR PERFORATION WITHOUT OBSTRUCTION - CHRONIC GASTRIC ULCER WITHOUT HEMORRHAGE OR PERFORATION WITH OBSTRUCTION
531.90 - 531.91	GASTRIC ULCER UNSPECIFIED AS ACUTE OR CHRONIC WITHOUT HEMORRHAGE OR PERFORATION WITHOUT OBSTRUCTION - GASTRIC ULCER UNSPECIFIED AS ACUTE OR CHRONIC WITHOUT HEMORRHAGE OR PERFORATION WITH OBSTRUCTION
532.00 - 532.01	ACUTE DUODENAL ULCER WITH HEMORRHAGE WITHOUT OBSTRUCTION - ACUTE DUODENAL ULCER WITH HEMORRHAGE WITH OBSTRUCTION
532.30 - 532.31	ACUTE DUODENAL ULCER WITHOUT HEMORRHAGE OR PERFORATION WITHOUT OBSTRUCTION - ACUTE DUODENAL ULCER WITHOUT HEMORRHAGE OR PERFORATION WITH OBSTRUCTION
532.40 - 532.41	CHRONIC OR UNSPECIFIED DUODENAL ULCER WITH HEMORRHAGE WITHOUT OBSTRUCTION - CHRONIC OR UNSPECIFIED DUODENAL ULCER WITH HEMORRHAGE WITH OBSTRUCTION
532.70 - 532.71	CHRONIC DUODENAL ULCER WITHOUT HEMORRHAGE OR PERFORATION WITHOUT OBSTRUCTION - CHRONIC DUODENAL ULCER WITHOUT HEMORRHAGE OR PERFORATION WITH OBSTRUCTION
532.90 - 532.91	DUODENAL ULCER UNSPECIFIED AS ACUTE OR CHRONIC WITHOUT HEMORRHAGE OR PERFORATION WITHOUT OBSTRUCTION - DUODENAL ULCER UNSPECIFIED AS ACUTE OR CHRONIC WITHOUT HEMORRHAGE OR PERFORATION WITH OBSTRUCTION
533.00 - 533.01	ACUTE PEPTIC ULCER OF UNSPECIFIED SITE WITH HEMORRHAGE WITHOUT OBSTRUCTION - ACUTE PEPTIC ULCER OF UNSPECIFIED SITE WITH HEMORRHAGE WITH OBSTRUCTION
533.30 - 533.31	ACUTE PEPTIC ULCER OF UNSPECIFIED SITE WITHOUT HEMORRHAGE AND PERFORATION WITHOUT OBSTRUCTION - ACUTE PEPTIC ULCER OF UNSPECIFIED SITE WITHOUT HEMORRHAGE AND PERFORATION WITH OBSTRUCTION
533.40 - 533.41	CHRONIC OR UNSPECIFIED PEPTIC ULCER OF UNSPECIFIED SITE WITH HEMORRHAGE WITHOUT OBSTRUCTION - CHRONIC OR UNSPECIFIED PEPTIC ULCER OF UNSPECIFIED SITE WITH HEMORRHAGE WITH OBSTRUCTION
533.70 - 533.71	CHRONIC PEPTIC ULCER OF UNSPECIFIED SITE WITHOUT HEMORRHAGE OR PERFORATION WITHOUT OBSTRUCTION - CHRONIC PEPTIC ULCER OF UNSPECIFIED SITE WITHOUT HEMORRHAGE OR PERFORATION WITH OBSTRUCTION
533.90 - 533.91	PEPTIC ULCER OF UNSPECIFIED SITE UNSPECIFIED AS ACUTE OR CHRONIC WITHOUT HEMORRHAGE OR PERFORATION WITHOUT OBSTRUCTION - PEPTIC ULCER OF UNSPECIFIED SITE UNSPECIFIED AS ACUTE OR CHRONIC WITHOUT HEMORRHAGE OR PERFORATION WITH OBSTRUCTION
534.00 - 534.01	ACUTE GASTROJEJUNAL ULCER WITH HEMORRHAGE WITHOUT OBSTRUCTION - ACUTE GASTROJEJUNAL ULCER WITH HEMORRHAGE WITH OBSTRUCTION
534.30 - 534.31	ACUTE GASTROJEJUNAL ULCER WITHOUT HEMORRHAGE OR PERFORATION WITHOUT OBSTRUCTION - ACUTE GASTROJEJUNAL ULCER WITHOUT HEMORRHAGE OR PERFORATION WITH OBSTRUCTION
534.40 - 534.41	CHRONIC OR UNSPECIFIED GASTROJEJUNAL ULCER WITH HEMORRHAGE WITHOUT OBSTRUCTION - CHRONIC OR UNSPECIFIED GASTROJEJUNAL ULCER WITH HEMORRHAGE WITH OBSTRUCTION
534.70 - 534.71	CHRONIC GASTROJEJUNAL ULCER WITHOUT HEMORRHAGE OR PERFORATION WITHOUT OBSTRUCTION - CHRONIC GASTROJEJUNAL ULCER WITHOUT HEMORRHAGE OR PERFORATION WITH OBSTRUCTION
534.90 - 534.91	GASTROJEJUNAL ULCER UNSPECIFIED AS ACUTE OR CHRONIC WITHOUT HEMORRHAGE OR PERFORATION WITHOUT OBSTRUCTION - GASTROJEJUNAL ULCER UNSPECIFIED AS ACUTE OR CHRONIC WITHOUT HEMORRHAGE OR PERFORATION WITH OBSTRUCTION
535.00 - 535.01	ACUTE GASTRITIS (WITHOUT HEMORRHAGE) - ACUTE GASTRITIS WITH HEMORRHAGE
535.10 - 535.11	ATROPHIC GASTRITIS (WITHOUT HEMORRHAGE) - ATROPHIC GASTRITIS WITH HEMORRHAGE
535.20 - 535.21	GASTRIC MUCOSAL HYPERTROPHY (WITHOUT HEMORRHAGE) - GASTRIC MUCOSAL HYPERTROPHY WITH HEMORRHAGE
535.30 - 535.31	ALCOHOLIC GASTRITIS (WITHOUT HEMORRHAGE) - ALCOHOLIC GASTRITIS WITH HEMORRHAGE
535.40 - 535.41	OTHER SPECIFIED GASTRITIS (WITHOUT HEMORRHAGE) - OTHER SPECIFIED GASTRITIS WITH HEMORRHAGE
535.50 - 535.51	UNSPECIFIED GASTRITIS AND GASTRODUODENITIS (WITHOUT HEMORRHAGE) - UNSPECIFIED GASTRITIS AND GASTRODUODENITIS WITH HEMORRHAGE
535.60 - 535.61	DUODENITIS (WITHOUT HEMORRHAGE) - DUODENITIS WITH HEMORRHAGE
536.2 - 536.3	PERSISTENT VOMITING - GASTROPARESIS
537.0 - 537.4	ACQUIRED HYPERTROPHIC PYLORIC STENOSIS - FISTULA OF STOMACH OR DUODENUM
537.6	HOURGLASS STRICTURE OR STENOSIS OF STOMACH
537.81 - 537.84	PYLOROSPASM - DIEULAFOY LESION (HEMORRHAGIC) OF STOMACH AND DUODENUM
537.89	OTHER SPECIFIED DISORDERS OF STOMACH AND DUODENUM
552.3	DIAPHRAGMATIC HERNIA WITH OBSTRUCTION
553.3	DIAPHRAGMATIC HERNIA WITHOUT OBSTRUCTION OR GANGRENE
555.0	REGIONAL ENTERITIS OF SMALL INTESTINE
555.2	REGIONAL ENTERITIS OF SMALL INTESTINE WITH LARGE INTESTINE
571.2	ALCOHOLIC CIRRHOSIS OF LIVER
571.5 - 571.6	CIRRHOSIS OF LIVER WITHOUT ALCOHOL - BILIARY CIRRHOSIS
572.3	PORTAL HYPERTENSION
578.0 - 578.1	HEMATEMESIS - BLOOD IN STOOL
578.9	HEMORRHAGE OF GASTROINTESTINAL TRACT UNSPECIFIED
579.0 - 579.4	CELIAC DISEASE - PANCREATIC STEATORRHEA
579.8 - 579.9	OTHER SPECIFIED INTESTINAL MALABSORPTION - UNSPECIFIED INTESTINAL MALABSORPTION
747.20	CONGENITAL ANOMALY OF AORTA UNSPECIFIED
747.61	GASTROINTESTINAL VESSEL ANOMALY
750.3 - 750.4	CONGENITAL TRACHEOESOPHAGEAL FISTULA ESOPHAGEAL ATRESIA AND STENOSIS - OTHER SPECIFIED CONGENITAL ANOMALIES OF ESOPHAGUS
750.7	OTHER SPECIFIED CONGENITAL ANOMALIES OF STOMACH
783.0	ANOREXIA
783.21	LOSS OF WEIGHT
787.1	HEARTBURN
787.20 - 787.24	DYSPHAGIA, UNSPECIFIED - DYSPHAGIA, PHARYNGOESOPHAGEAL PHASE
787.29	OTHER DYSPHAGIA
789.01 - 789.02	ABDOMINAL PAIN RIGHT UPPER QUADRANT - ABDOMINAL PAIN LEFT UPPER QUADRANT
789.05 - 789.06	ABDOMINAL PAIN PERIUMBILIC - ABDOMINAL PAIN EPIGASTRIC
792.1	NONSPECIFIC ABNORMAL FINDINGS IN STOOL CONTENTS
793.4	NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF GASTROINTESTINAL TRACT
935.1 - 935.2	FOREIGN BODY IN ESOPHAGUS - FOREIGN BODY IN STOMACH
936	FOREIGN BODY IN INTESTINE AND COLON
947.0	BURN OF MOUTH AND PHARYNX
947.2 - 947.3	BURN OF ESOPHAGUS - BURN OF GASTROINTESTINAL TRACT
V10.03 - V10.04	PERSONAL HISTORY OF MALIGNANT NEOPLASM OF ESOPHAGUS - PERSONAL HISTORY OF MALIGNANT NEOPLASM OF STOMACH
V12.72*	PERSONAL HISTORY OF COLONIC POLYPS
V47.3	OTHER DIGESTIVE PROBLEMS
V58.61 - V58.63	LONG-TERM (CURRENT) USE OF ANTICOAGULANTS - LONG-TERM (CURRENT) USE OF ANTIPLATELETS/ANTITHROMBOTICS
V58.66	LONG-TERM (CURRENT) USE OF ASPIRIN
V58.69	LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS
*Note: Use V12.72 to indicate familial adenomatous polyposis.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 43237 and 43238:

Covered for:

150.0 - 150.5	MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS - MALIGNANT NEOPLASM OF LOWER THIRD OF ESOPHAGUS
150.8 - 150.9	MALIGNANT NEOPLASM OF OTHER SPECIFIED PART OF ESOPHAGUS - MALIGNANT NEOPLASM OF ESOPHAGUS UNSPECIFIED SITE
195.1	MALIGNANT NEOPLASM OF THORAX
196.1	SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRATHORACIC LYMPH NODES
211.0	BENIGN NEOPLASM OF ESOPHAGUS
230.1	CARCINOMA IN SITU OF ESOPHAGUS
239.1	NEOPLASM OF UNSPECIFIED NATURE OF RESPIRATORY SYSTEM
438.82	DYSPHAGIA CEREBROVASCULAR DISEASE
530.0	ACHALASIA AND CARDIOSPASM
530.10 - 530.11	ESOPHAGITIS UNSPECIFIED - REFLUX ESOPHAGITIS
530.19	OTHER ESOPHAGITIS
530.20 - 530.21	ULCER OF ESOPHAGUS WITHOUT BLEEDING - ULCER OF ESOPHAGUS WITH BLEEDING
530.3 - 530.7	STRICTURE AND STENOSIS OF ESOPHAGUS - GASTROESOPHAGEAL LACERATION-HEMORRHAGE SYNDROME
530.81 - 530.85	ESOPHAGEAL REFLUX - BARRETT'S ESOPHAGUS
578.0	HEMATEMESIS
750.3 - 750.4	CONGENITAL TRACHEOESOPHAGEAL FISTULA ESOPHAGEAL ATRESIA AND STENOSIS - OTHER SPECIFIED CONGENITAL ANOMALIES OF ESOPHAGUS
787.1	HEARTBURN
787.20 - 787.24	DYSPHAGIA, UNSPECIFIED - DYSPHAGIA, PHARYNGOESOPHAGEAL PHASE
787.29	OTHER DYSPHAGIA
789.01 - 789.02	ABDOMINAL PAIN RIGHT UPPER QUADRANT - ABDOMINAL PAIN LEFT UPPER QUADRANT
789.06	ABDOMINAL PAIN EPIGASTRIC
793.1 - 793.2	NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF LUNG FIELD - NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF OTHER INTRATHORACIC ORGANS
793.4	NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF GASTROINTESTINAL TRACT
935.1	FOREIGN BODY IN ESOPHAGUS
947.0	BURN OF MOUTH AND PHARYNX
947.2 - 947.3	BURN OF ESOPHAGUS - BURN OF GASTROINTESTINAL TRACT
V10.03	PERSONAL HISTORY OF MALIGNANT NEOPLASM OF ESOPHAGUS

Medicare is establishing the following limited coverage for CPT/HCPCS codes 43242 and 43259:

Covered for:

150.0 - 150.5	MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS - MALIGNANT NEOPLASM OF LOWER THIRD OF ESOPHAGUS
150.8 - 150.9	MALIGNANT NEOPLASM OF OTHER SPECIFIED PART OF ESOPHAGUS - MALIGNANT NEOPLASM OF ESOPHAGUS UNSPECIFIED SITE
151.0 - 151.6	MALIGNANT NEOPLASM OF CARDIA - MALIGNANT NEOPLASM OF GREATER CURVATURE OF STOMACH UNSPECIFIED
151.8 - 151.9	MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF STOMACH - MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE
152.0	MALIGNANT NEOPLASM OF DUODENUM
153.0 - 153.9	MALIGNANT NEOPLASM OF HEPATIC FLEXURE - MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE
157.0 - 157.4	MALIGNANT NEOPLASM OF HEAD OF PANCREAS - MALIGNANT NEOPLASM OF ISLETS OF LANGERHANS
157.8 - 157.9	MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF PANCREAS - MALIGNANT NEOPLASM OF PANCREAS PART UNSPECIFIED
195.1	MALIGNANT NEOPLASM OF THORAX
196.1	SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRATHORACIC LYMPH NODES
200.03	RETICULOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES
200.13	LYMPHOSARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES
211.0 - 211.2	BENIGN NEOPLASM OF ESOPHAGUS - BENIGN NEOPLASM OF DUODENUM JEJUNUM AND ILEUM
211.5	BENIGN NEOPLASM OF LIVER AND BILIARY PASSAGES
214.3	LIPOMA OF INTRA-ABDOMINAL ORGANS
230.1 - 230.2	CARCINOMA IN SITU OF ESOPHAGUS - CARCINOMA IN SITU OF STOMACH
230.7 - 230.8	CARCINOMA IN SITU OF OTHER AND UNSPECIFIED PARTS OF INTESTINE - CARCINOMA IN SITU OF LIVER AND BILIARY SYSTEM
235.2 - 235.5	NEOPLASM OF UNCERTAIN BEHAVIOR OF STOMACH INTESTINES AND RECTUM - NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED DIGESTIVE ORGANS
239.1	NEOPLASM OF UNSPECIFIED NATURE OF RESPIRATORY SYSTEM
456.1	ESOPHAGEAL VARICES WITHOUT BLEEDING
530.0	ACHALASIA AND CARDIOSPASM
530.20 - 530.21	ULCER OF ESOPHAGUS WITHOUT BLEEDING - ULCER OF ESOPHAGUS WITH BLEEDING
530.3	STRICTURE AND STENOSIS OF ESOPHAGUS
530.9	UNSPECIFIED DISORDER OF ESOPHAGUS
531.70 - 531.71	CHRONIC GASTRIC ULCER WITHOUT HEMORRHAGE OR PERFORATION WITHOUT OBSTRUCTION - CHRONIC GASTRIC ULCER WITHOUT HEMORRHAGE OR PERFORATION WITH OBSTRUCTION
531.90 - 531.91	GASTRIC ULCER UNSPECIFIED AS ACUTE OR CHRONIC WITHOUT HEMORRHAGE OR PERFORATION WITHOUT OBSTRUCTION - GASTRIC ULCER UNSPECIFIED AS ACUTE OR CHRONIC WITHOUT HEMORRHAGE OR PERFORATION WITH OBSTRUCTION
534.90 - 534.91	GASTROJEJUNAL ULCER UNSPECIFIED AS ACUTE OR CHRONIC WITHOUT HEMORRHAGE OR PERFORATION WITHOUT OBSTRUCTION - GASTROJEJUNAL ULCER UNSPECIFIED AS ACUTE OR CHRONIC WITHOUT HEMORRHAGE OR PERFORATION WITH OBSTRUCTION
577.0 - 577.2	ACUTE PANCREATITIS - CYST AND PSEUDOCYST OF PANCREAS
793.1 - 793.2	NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF LUNG FIELD - NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF OTHER INTRATHORACIC ORGANS
793.4	NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF GASTROINTESTINAL TRACT
793.6	NONSPECIFIC ABNORMAL FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF ABDOMINAL AREA INCLUDING RETROPERITONEUM

Diagnoses that Support Medical Necessity ^{back to top}

N/A

ICD-9 Codes that DO NOT Support Medical Necessity ^{back to top}

N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation ^{back to top}

Diagnoses that DO NOT Support Medical Necessity ^{back to top}

All diagnoses not listed in the "ICD-9-CM Codes That Support Medical Necessity" section of this LCD.

General Information

Documentation Requirements ^{back to top}

Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record, and made available to Medicare upon request.

Appendices ^{back to top}

N/A

Utilization Guidelines ^{back to top}

N/A

Sources of Information and Basis for Decision ^{back to top}

Carrier Medical Director (CMD) Endoscopy Workgroup

American Society for Gastrointestinal Endoscopy, "Appropriate Use of Gastrointestinal Endoscopy, A Consensus Statement," Section on Esophagogastroduodenoscopy (EGD), 2002

American Society for Gastrointestinal Endoscopy, “Endoscopic Ultrasound and Lung Cancer, Clinical Update,” Vol. 10, No.1, July 2002

Drewitz DJ, Sampliner, RE, Garewall, HS The incidence of adenocarcinoma in Barrett’s esophagus- A prospective study, Am J Gastroenterol 92:212-215, 1997

Bozymski,EM, Cohen,S, Sampliner,RE Gastroesophageal Reflux Disease: Judging Severity and Treatment Options, Medical Crossfire 2000; Vol.2, No 2: 35-45

Bresciani C, Perez RO, Gama-Rodrigues J. Arq. Gastroenterol. 2003 Apr-Jun; 40(2): 114-7

Advisory Committee Meeting Notes ^{back to top}

This LCD does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this LCD was developed in cooperation with advisory groups, which include representatives from gastroenterology.

Advisory Committee meeting date:

10/20/2004 MD CAC

Start Date of Comment Period ^{back to top}

10/27/2004

End Date of Comment Period ^{back to top}

12/13/2004

Start Date of Notice Period ^{back to top}

03/07/2005

Revision History Number ^{back to top}

Revision History Explanation ^{back to top}

R4
08/01/2007
Per provider request added ICD-9 code 792.1 to limited coverage group 1 (43234-43236, 43239-43241, 43243-43251, 43255, 43256 & 43258. Effective date: 07/18/2007. Per CR 5643 annual ICD-9 update, 787.2 was removed and replaced with 787.20-787.24 & 787.29 in limited coverage group 1 and group 2 (43237 & 43238). Effective date: 10/01/2007.

R3
01/30/2007
Clarification of 6th bullet under “Indications”, regarding routine pre-operative EGD in patients undergoing bariatric surgical procedures. Effective date of change is original effective date of policy (04/21/2005).

R2
10/17/2006
Per provider request, added ICD-9 codes 783.0 and 783.21 to limited coverage for 43234-43236, 43239-43241, 43243-43251, 43255, 43256 and 43258. Anorexia and abnormal weight loss are covered indications per the LCD but the ICD-9 codes were inadvertently omitted. Effective date: 04/21/2005 (original LCD date)

R1
09/28/2006
Per CR 3835, the National Uniform Billing Committee redefined TOB 14X to be limited in use for non-patient laboratory specimens; TOB 14X removed from the Part A LCD. Change Effective: 04/03/2006. Part B LCD revision number increased to maintain consistency.

Per Medicare Administrative Contractor (MAC) procurement this policy was retired effective 07/11/2008.

Reason for Change ^{back to top}

ICD9 Addition/Deletion

Last Reviewed On Date ^{back to top}

Medicare Coverage Database

LCD for Diagnostic and Therapeutic Esophagogastroduodenoscopy (EGD) – S-125B-R4 (L18515)