Aetna Capsule Endoscopy coverage criteria

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

Coverage criteria

• Capsule endoscopy is considered medically necessary for ANY ONE of the indications listed below.
• Detection or surveillance of colon polyp(s) IF diagnostic optical colonoscopy was incomplete (i.e., complete evaluation of the colon was not technically possible despite adequate preparation).
• Evaluation of chronic diarrhea in members with non-diagnostic esophagogastroduodenoscopy (EGD) with biopsies, colonoscopy with biopsies, AND negative stool cultures, to exclude celiac disease (ALL of these prior work-ups required).
• Evaluation of familial adenomatous polyposis (FAP), attenuated familial adenomatous polyposis (AFAP) syndromes, and MUTYH-associated polyposis.
• Evaluation of juvenile polyposis syndrome (defined as ONE of: 5 or more juvenile polyps in the colorectum, OR any juvenile polyps in other parts of the GI tract, OR evidence of SMAD4 or BMPR1A mutations).
• Evaluation of known or suspected small bowel tumors (including genetic polyposis syndromes).
• Evaluation of locoregional carcinoid tumors of the small bowel.
• Evaluation of persons with celiac disease with positive serology who are unable to undergo esophagogastroduodenoscopy (EGD) with biopsy (e.g., medically unstable, presence of known or suspected perforated viscus).
• Evaluation of Peutz-Jeghers syndrome (PJS; defined as ONE of: perioral or buccal pigmentation and/or 2 or more histologically characteristic hamartomatous polyps, OR family history of PJS, OR STK11 mutations).
• Evaluation of biallelic mismatch repair deficiency (BMMRD).
• Re-evaluation of persons with celiac disease who remain symptomatic despite treatment AND there is no suspected or confirmed GI obstruction, stricture, or fistulae.
• Initial diagnosis in persons with suspected Crohn's disease (abdominal pain or diarrhea, PLUS one or more signs of inflammation [e.g., fever, elevated white blood cell count, elevated erythrocyte sedimentation rate, elevated C-reactive protein] OR bleeding) WITHOUT evidence of disease on conventional diagnostic tests, including small-bowel follow-through or abdominal CT scan/CT enterography AND upper and lower endoscopy (EGD and colonoscopy).
• 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.
• 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, or visible bleeding) who have had upper and lower GI endoscopies (EGD AND colonoscopy) within the past 12 months that failed to identify a bleeding source.
• Surveillance of small intestinal tumors in persons with Lynch syndrome, Peutz-Jeghers syndrome, and other polyposis syndromes affecting the small bowel.
• Screening or surveillance of esophageal varices in cirrhotic persons with significantly compromised liver function (i.e., Child-Pugh score of Class B or greater) OR other situations where standard upper endoscopy with sedation or anesthesia is contraindicated.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

• 91110·PA verdict·Rate
• 91111·PA verdict·Rate
• 91113·PA verdict·Rate

Frequently asked questions

When does Aetna cover Capsule Endoscopy (CPT 91110), and what gets it denied?

Aetna covers capsule endoscopy as medically necessary only for a defined set of GI indications — chiefly suspected/known Crohn's disease, obscure small-intestinal bleeding after non-diagnostic EGD and colonoscopy, celiac disease work-up, hereditary polyposis/small-bowel tumor syndromes (FAP, Peutz-Jeghers, Lynch, juvenile polyposis, BMMRD), colon polyp evaluation after an incomplete colonoscopy, and esophageal-varices screening in cirrhotics with compromised liver function. It is considered experimental/investigational for general screening, colorectal cancer screening, and many other uses, and is not covered in persons with GI obstruction/strictures/fistulas, cardiac pacemakers or other implanted electro-medical devices, or swallowing disorders. The bulletin is silent on precertification/prior authorization. Coverage criteria include: Capsule endoscopy is considered medically necessary for ANY ONE of the indications listed below.; Detection or surveillance of colon polyp(s) IF diagnostic optical colonoscopy was incomplete (i.e., complete evaluation of the colon was not technically possible despite adequate preparation).; Evaluation of chronic diarrhea in members with non-diagnostic esophagogastroduodenoscopy (EGD) with biopsies, colonoscopy with biopsies, AND negative stool cultures, to exclude celiac disease (ALL of these prior work-ups required).; Evaluation of familial adenomatous polyposis (FAP), attenuated familial adenomatous polyposis (AFAP) syndromes, and MUTYH-associated polyposis.; Evaluation of juvenile polyposis syndrome (defined as ONE of: 5 or more juvenile polyps in the colorectum, OR any juvenile polyps in other parts of the GI tract, OR evidence of SMAD4 or BMPR1A mutations).; Evaluation of known or suspected small bowel tumors (including genetic polyposis syndromes).; Evaluation of locoregional carcinoid tumors of the small bowel.; Evaluation of persons with celiac disease with positive serology who are unable to undergo esophagogastroduodenoscopy (EGD) with biopsy (e.g., medically unstable, presence of known or suspected perforated viscus).; Evaluation of Peutz-Jeghers syndrome (PJS; defined as ONE of: perioral or buccal pigmentation and/or 2 or more histologically characteristic hamartomatous polyps, OR family history of PJS, OR STK11 mutations).; Evaluation of biallelic mismatch repair deficiency (BMMRD).; Re-evaluation of persons with celiac disease who remain symptomatic despite treatment AND there is no suspected or confirmed GI obstruction, stricture, or fistulae.; Initial diagnosis in persons with suspected Crohn's disease (abdominal pain or diarrhea, PLUS one or more signs of inflammation [e.g., fever, elevated white blood cell count, elevated erythrocyte sedimentation rate, elevated C-reactive protein] OR bleeding) WITHOUT evidence of disease on conventional diagnostic tests, including small-bowel follow-through or abdominal CT scan/CT enterography AND upper and lower endoscopy (EGD and colonoscopy).; 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.; 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, or visible bleeding) who have had upper and lower GI endoscopies (EGD AND colonoscopy) within the past 12 months that failed to identify a bleeding source.; Surveillance of small intestinal tumors in persons with Lynch syndrome, Peutz-Jeghers syndrome, and other polyposis syndromes affecting the small bowel.; Screening or surveillance of esophageal varices in cirrhotic persons with significantly compromised liver function (i.e., Child-Pugh score of Class B or greater) OR other situations where standard upper endoscopy with sedation or anesthesia is contraindicated.. Applies to 3 codes: 91110, 91111, 91113. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Policy exclusions and limitations: Experimental, investigational, or unproven: as a screening test (other than for esophageal varices).; Experimental, investigational, or unproven: as an initial test in diagnosing GI bleeding.; Experimental, investigational, or unproven: capsule endoscopy of the intestine for evaluating abdominal pain UNLESS one or more of the medically-necessary criteria are met.; Experimental, investigational, or unproven: colon capsule endoscopy for monitoring ulcerative colitis.; Experimental, investigational, or unproven: in persons with known or suspected GI obstruction, strictures, or fistulas based on the clinical picture or pre-procedure testing and profile.; Experimental, investigational, or unproven: in persons with cardiac pacemakers or other implanted electro-medical devices.; Experimental, investigational, or unproven: in persons with dysphagia or other swallowing disorders.; Experimental, investigational, or unproven: in colorectal cancer screening.; Experimental, investigational, or unproven: in confirming pathology identified by other diagnostic means.; Experimental, investigational, or unproven: in detecting gastric varices.; Experimental, investigational, or unproven: in detecting hookworms.; Experimental, investigational, or unproven: in diagnosing and evaluating mucosal inflammation in ulcerative colitis.; Experimental, investigational, or unproven: in diagnosing intestinal graft-versus-host disease.; Experimental, investigational, or unproven: in diagnosing Takayasu's arteritis.; Experimental, investigational, or unproven: in evaluating diseases involving the esophagus other than esophageal varices.; Experimental, investigational, or unproven: in evaluating intussusception.; Experimental, investigational, or unproven: in evaluating the colon for indications other than incomplete colonoscopy (as noted in the medically-necessary criteria).; Experimental, investigational, or unproven: in evaluating the stomach.; Experimental, investigational, or unproven: in follow-up of persons with known small bowel disease other than Crohn's disease.; Experimental, investigational, or unproven: in identifying occult primary malignancies (e.g., primary site in individuals with metastatic melanoma).; Experimental, investigational, or unproven: in investigating duodenal lymphocytosis, small bowel neoplasm, or suspected irritable bowel syndrome.; Experimental, investigational, or unproven: in planning for radiation therapy.; Experimental, investigational, or unproven: in staging portal hypertensive gastropathy.; Experimental, investigational, or unproven: magnetic-assisted capsule endoscopy (e.g., NaviCam MCCE System) for upper GI tract screening and detection of esophageal varices and Barrett's esophagus.; Experimental, investigational, or unproven: panenteric capsule endoscopy.; Experimental, investigational, or unproven: QRNet (quaternion-based Retinex framework) for enhancement of wireless capsule endoscopy image quality.; Experimental, investigational, or unproven: repeat use to verify effectiveness of surgery.; Experimental, investigational, or unproven: use of the Agile patency capsule for evaluating patency of the GI tract before wireless capsule endoscopy, and for all other indications.; Experimental, investigational, or unproven: use of the Cytosponge capsule and Esophageal String Test for diagnosis of esophageal pathology (e.g., eosinophilic esophagitis and esophageal varices).; Experimental, investigational, or unproven: use of the Cytosponge capsule for screening of Barrett's esophagus.; Experimental, investigational, or unproven: use of artificial intelligence in reviewing colon CE images, and for management of inflammatory bowel disease.; Experimental, investigational, or unproven: video capsule endoscopy for diagnosis of gastro-intestinal graft-versus-host disease.; Contraindication / non-coverage: known or suspected GI obstruction, strictures, or fistulas (capsule endoscopy not covered in these persons).; Contraindication / non-coverage: cardiac pacemakers or other implanted electro-medical devices (capsule endoscopy not covered in these persons).; Contraindication / non-coverage: dysphagia or other swallowing disorders (capsule endoscopy not covered in these persons). Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Does Aetna require prior authorization for Capsule Endoscopy?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.

What does Aetna exclude for Capsule Endoscopy?

Policy exclusions and limitations: Experimental, investigational, or unproven: as a screening test (other than for esophageal varices).; Experimental, investigational, or unproven: as an initial test in diagnosing GI bleeding.; Experimental, investigational, or unproven: capsule endoscopy of the intestine for evaluating abdominal pain UNLESS one or more of the medically-necessary criteria are met.; Experimental, investigational, or unproven: colon capsule endoscopy for monitoring ulcerative colitis.; Experimental, investigational, or unproven: in persons with known or suspected GI obstruction, strictures, or fistulas based on the clinical picture or pre-procedure testing and profile.; Experimental, investigational, or unproven: in persons with cardiac pacemakers or other implanted electro-medical devices.; Experimental, investigational, or unproven: in persons with dysphagia or other swallowing disorders.; Experimental, investigational, or unproven: in colorectal cancer screening.; Experimental, investigational, or unproven: in confirming pathology identified by other diagnostic means.; Experimental, investigational, or unproven: in detecting gastric varices.; Experimental, investigational, or unproven: in detecting hookworms.; Experimental, investigational, or unproven: in diagnosing and evaluating mucosal inflammation in ulcerative colitis.; Experimental, investigational, or unproven: in diagnosing intestinal graft-versus-host disease.; Experimental, investigational, or unproven: in diagnosing Takayasu's arteritis.; Experimental, investigational, or unproven: in evaluating diseases involving the esophagus other than esophageal varices.; Experimental, investigational, or unproven: in evaluating intussusception.; Experimental, investigational, or unproven: in evaluating the colon for indications other than incomplete colonoscopy (as noted in the medically-necessary criteria).; Experimental, investigational, or unproven: in evaluating the stomach.; Experimental, investigational, or unproven: in follow-up of persons with known small bowel disease other than Crohn's disease.; Experimental, investigational, or unproven: in identifying occult primary malignancies (e.g., primary site in individuals with metastatic melanoma).; Experimental, investigational, or unproven: in investigating duodenal lymphocytosis, small bowel neoplasm, or suspected irritable bowel syndrome.; Experimental, investigational, or unproven: in planning for radiation therapy.; Experimental, investigational, or unproven: in staging portal hypertensive gastropathy.; Experimental, investigational, or unproven: magnetic-assisted capsule endoscopy (e.g., NaviCam MCCE System) for upper GI tract screening and detection of esophageal varices and Barrett's esophagus.; Experimental, investigational, or unproven: panenteric capsule endoscopy.; Experimental, investigational, or unproven: QRNet (quaternion-based Retinex framework) for enhancement of wireless capsule endoscopy image quality.; Experimental, investigational, or unproven: repeat use to verify effectiveness of surgery.; Experimental, investigational, or unproven: use of the Agile patency capsule for evaluating patency of the GI tract before wireless capsule endoscopy, and for all other indications.; Experimental, investigational, or unproven: use of the Cytosponge capsule and Esophageal String Test for diagnosis of esophageal pathology (e.g., eosinophilic esophagitis and esophageal varices).; Experimental, investigational, or unproven: use of the Cytosponge capsule for screening of Barrett's esophagus.; Experimental, investigational, or unproven: use of artificial intelligence in reviewing colon CE images, and for management of inflammatory bowel disease.; Experimental, investigational, or unproven: video capsule endoscopy for diagnosis of gastro-intestinal graft-versus-host disease.; Contraindication / non-coverage: known or suspected GI obstruction, strictures, or fistulas (capsule endoscopy not covered in these persons).; Contraindication / non-coverage: cardiac pacemakers or other implanted electro-medical devices (capsule endoscopy not covered in these persons).; Contraindication / non-coverage: dysphagia or other swallowing disorders (capsule endoscopy not covered in these persons). Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT