Aetna · Clinical coverage policy

Aetna Upper Gastrointestinal Endoscopy coverage criteria

Aetna CPB 0738 covers upper GI endoscopy (EGD) as medically necessary across high-risk screening, diagnostic, screening/surveillance, therapeutic, sequential/periodic surveillance, and upper-GI biopsy indications (e.g., Barrett's esophagus, dyspepsia with alarm features or age greater than 60, GI bleeding, dysphagia, variceal management, achalasia therapy), plus endoscopic submucosal dissection for Barrett's under specific lesion/staging criteria. Coverage hinges on the specific clinical indication being met; routine/screening EGD in asymptomatic persons, EndoFLIP for listed conditions, pre-bariatric EGD in asymptomatic persons, and several surveillance scenarios are considered experimental/investigational or not covered. The bulletin is silent on prior authorization (it only notes providers may be required to submit photographs of mucosal abnormalities).

Policy CPB 0738 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0738

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0738 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

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.

When does Aetna cover Upper Gastrointestinal Endoscopy (CPT 43235), and what gets it denied?

Path
Aetna CPB 0738 covers upper GI endoscopy (EGD) as medically necessary across high-risk screening, diagnostic, screening/surveillance, therapeutic, sequential/periodic surveillance, and upper-GI biopsy indications (e.g., Barrett's esophagus, dyspepsia with alarm features or age greater than 60, GI bleeding, dysphagia, variceal management, achalasia therapy), plus endoscopic submucosal dissection for Barrett's under specific lesion/staging criteria. Coverage hinges on the specific clinical indication being met; routine/screening EGD in asymptomatic persons, EndoFLIP for listed conditions, pre-bariatric EGD in asymptomatic persons, and several surveillance scenarios are considered experimental/investigational or not covered. The bulletin is silent on prior authorization (it only notes providers may be required to submit photographs of mucosal abnormalities). Coverage criteria include: EGD/upper endoscopy for high-risk screening: Persons with chronic (5 years or more) gastro-esophageal reflux disease (GERD) at risk for Barrett's esophagus (BE) — Note: after a negative screening EGD, further screening EGD is not indicated; EGD/upper endoscopy for high-risk screening: Persons with symptomatic pernicious anemia (e.g., anemia, fatigue, pallor, red tongue, shortness of breath, tingling and numbness in the hands and feet) to identify prevalent lesions (e.g., carcinoid tumors, gastric cancer); EGD/upper endoscopy for high-risk screening: Persons with cirrhosis and portal hypertension but no prior variceal hemorrhage, especially those with platelet counts less than 140,000/mm3, or Child's class B or C disease; Diagnostic EGD: Evaluation of dyspepsia symptoms in persons who have undergone non-invasive testing for H. pylori, and whose symptoms persist despite eradication of H. pylori and have failed an appropriate therapeutic trial (e.g., proton pump inhibitor [PPI], with/without prokinetic, antidepressant); Diagnostic EGD: Evaluation of dyspepsia in persons who are H. pylori negative and who have undergone an appropriate trial of PPI therapy (appropriate trial = a 2-4 week course of standard dose, once daily PPI); Diagnostic EGD: Evaluation of dyspepsia symptoms associated with multiple or progressive alarm signs (e.g., anorexia, anemia and weight loss) in persons younger than 60 years of age; Diagnostic EGD: Evaluation of dyspepsia in persons over 60 years of age; Diagnostic EGD: Evaluation of dysphagia or odynophagia or food impaction; Diagnostic EGD: Evaluation of esophageal reflux symptoms (heartburn, regurgitation, noncardiac chest pain) that are persistent or recurrent despite appropriate therapy (appropriate therapy = an 8 week trial of standard dose once daily PPI; in persons with partial response, the dose may be increased to twice daily); Diagnostic EGD: Evaluation of esophageal masses and for directing biopsies for diagnosing esophageal cancer; Diagnostic EGD: Evaluation of persons with signs or symptoms of loco-regional recurrence after resection of esophageal cancer; Diagnostic EGD: Evaluation of persistent vomiting of unknown cause; Diagnostic EGD: Evaluation of other diseases in which the presence of upper GI pathological conditions might modify other planned management (e.g., persons with a history of ulcer or GI bleeding scheduled for organ transplantation, long-term anti-coagulation, or long-term NSAID therapy for arthritis, and those with cancer of the head and neck); Diagnostic EGD: Evaluation of familial adenomatous polyposis syndromes; Diagnostic EGD: Confirmation and specific histological diagnosis of radiologically demonstrated lesions (ANY of): gastric or esophageal ulcer; OR suspected neoplastic lesion; OR upper GI tract stricture or obstruction; Diagnostic EGD: Evaluation of GI bleeding (ANY of): for persons with active or recent bleeding; OR for presumed chronic blood loss and for iron deficiency anemia when the clinical situation suggests an upper GI source or when colonoscopy results are negative; Diagnostic EGD: Sampling of upper GI tissue or fluid; Diagnostic EGD: Evaluation of persons with suspected portal hypertension to document or treat esophageal varices; Diagnostic EGD: Evaluation of acute injury after caustic ingestion; Diagnostic EGD: Evaluation of dyspepsia when ANY of the following is present: chronic GI bleeding; Crohn's disease with persistent dyspepsia; epigastric mass; iron deficiency anemia; persistent vomiting; progressive difficulty swallowing; progressive unintentional weight loss; suspicious barium meal (upper GI series); Diagnostic EGD: Evaluation of chronic dyspepsia and/or abdominal pain when other studies (e.g., colonoscopy, enteroscopy, ileoscopy, flexible sigmoidoscopy) have negative results; Diagnostic EGD: Differentiation of Crohn's disease from ulcerative colitis in indeterminate colitis; Diagnostic EGD: Evaluation of new-onset upper abdominal symptoms in a person greater than 50 years of age; Diagnostic EGD: Evaluation for placement of wireless pH capsule for esophageal or extraesophageal reflux symptoms in absence of severe erosive reflux disease; Diagnostic EGD: Evaluation of diarrhea in a person suspected of having small bowel disease (e.g., celiac disease); Diagnostic EGD: Intraoperative evaluation of anatomic reconstructions; Diagnostic EGD: Evaluation of the stomach to identify gastric premalignant conditions (GPMC) or gastric cancer (GC) — Note: includes achieving adequate mucosal visualization with cleansing and insufflation, visual station mapping, photo documentation of anatomic landmarks and any abnormalities, adequate gastric evaluation time; EGD for screening and surveillance: Screening for upper GI malignancies in persons with polyposis syndromes or Lynch syndrome; EGD for screening and surveillance: Screening for squamous cell carcinoma in persons with a history of caustic ingestions; EGD for screening and surveillance: Screening in persons with a family history of gastric cancer (GC) (first-degree relative) on an individualized basis — Note: endoscopy would start at age 45-60 or 10 years before the diagnosis of GC in the youngest affected family member; Therapeutic EGD: Banding or sclerotherapy of varices; Therapeutic EGD: Dilation of stenotic lesions (e.g., with trans-endoscopic balloon dilators or dilation systems using guide wires); Therapeutic EGD: Management of achalasia by means of endoscopic myotomy, botulinum toxin, balloon dilation; Therapeutic EGD: Palliative treatment of stenosing neoplasms by means of laser, multi-polar electrocoagulation, stent placement; Therapeutic EGD: Per-oral endoscopic myotomy (POEM) for the treatment of type III (spastic) achalasia; Therapeutic EGD: Placement of feeding or drainage tubes (per-oral, trans-nasal, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy); Therapeutic EGD: Removal of foreign bodies or selected polypoid lesions; Therapeutic EGD: Treatment of bleeding lesions such as ulcers, tumors, and vascular abnormalities by means of electrocoagulation, heater probe, laser photocoagulation, or injection therapy; Therapeutic EGD: Local injection of steroid into an anastomotic esophageal stricture at the time of endoscopic dilation for prevention of stricture; Therapeutic EGD: In persons with suspected portal hypertension to document or treat esophageal varices; Therapeutic EGD: Endoscopic therapy for internal metaplasia; Therapeutic EGD: Management of diverticular lesions (e.g., endoscopic myotomy); Therapeutic EGD: Intraoperative evaluation of anatomic reconstructions typical of modern foregut surgery (e.g., evaluation of anastomotic leak and patency, fundoplication formation, pouch configuration during bariatric surgery); Therapeutic EGD: Management of operative adverse events (e.g., dilation of anastomotic strictures, stent placement of anastomotic disruption, fistula, or leak in selected circumstances); Therapeutic EGD: Endoscopic management of dysplastic gastric premalignant conditions — in persons appropriate for endoscopic resection of dysplasia, particularly endoscopic submucosal dissection; Sequential/periodic EGD: Surveillance of persons with BE without dysplasia — for established BE of any length with no dysplasia, after 2 consecutive examinations within 1 year, an acceptable interval for additional surveillance is every 3 years; Sequential/periodic EGD: Surveillance of persons with BE and low-grade dysplasia (LGD) at 6 months — if LGD is confirmed, then surveillance at 12 months and yearly thereafter as long as dysplasia persists; Sequential/periodic EGD: Surveillance of persons with BE and high-grade dysplasia every 3 months for at least 1 year — after 1 year of no cancer detection, the interval may be lengthened if there are no dysplastic changes on 2 subsequent endoscopies performed at 3-month intervals; Sequential/periodic EGD: Surveillance of persons with a severe caustic esophageal injury every 1 to 3 years beginning 15 to 20 years after the injury; Sequential/periodic EGD: Surveillance of persons with tylosis every 1 to 3 years beginning at 30 years of age; Sequential/periodic EGD: Surveillance of recurrence of adenomatous polyps in synchronous and metachronous sites at 3- to 5-year intervals; Sequential/periodic EGD: Surveillance of persons with familial adenomatous polyposis starting around the time of colectomy or after age of 30 years; Sequential/periodic EGD: Surveillance of persons with hereditary non-polyposis colorectal cancer; Sequential/periodic EGD: Surveillance for malignancy in persons with premalignant conditions (i.e., Barrett's esophagus, gastric intestinal metaplasia); Sequential/periodic EGD: Assessment of disease activity in eosinophilic esophagitis or eosinophilic GI disease; Sequential/periodic EGD: Assessment of mucosal healing and screening for Barrett's esophagus in persons with severe erosive esophagitis; Sequential/periodic EGD: Surveillance of persons with gastric ulcers (with biopsies of the ulcer if still present) after 8 to 12 weeks when ANY ONE of the following: symptoms persist despite medical therapy; OR unclear etiology; OR giant ulcer (greater than 2 cm); OR biopsies not performed or inadequate sampling on the index upper endoscopy (minimum of four biopsies, at least one from each of the four quadrants; additional edge biopsies with jumbo forceps if endoscopic features of malignancy); OR ulcer appears suspicious for malignancy on index endoscopy (mass lesion, elevated irregular ulcer borders, or abnormal adjacent mucosal folds) — surveillance considered even if index biopsies benign, as false-negative results occur in 2-5% of malignant ulcers; OR persons with bleeding ulcers at initial presentation who show signs of continued bleeding; OR risk factors for gastric cancer (e.g., age greater than 50 years, H. pylori, immigrants from a high-prevalence region [e.g., Japan, Korea, Taiwan, Costa Rica], family history of gastric cancer, gastric atrophy, adenoma, dysplasia, intestinal metaplasia); Sequential/periodic EGD: Surveillance in persons with confirmed complete resection of dysplasia — Note: use of high-definition white light endoscopy (HDWLE) and image-enhanced endoscopy (IEE), with biopsies per systematic biopsy protocol in addition to targeted biopsies, is recommended; Sequential/periodic EGD: Surveillance in persons with gastric premalignant conditions (GPMC) who identify as a high-risk race or ethnicity (e.g., East Asian and Pacific Islander, Hispanic [Latino/a], Black, American Indian and Alaska Native) or who emigrated from a high-incidence region (e.g., East Asia, Eastern Europe including western Russia, Central/South America) — Note: recommended for 3-year endoscopic surveillance given the substantial increased GC risk; Sequential/periodic EGD: Surveillance in persons with autoimmune gastritis (AIG) — Note: use of HDWLE and IEE should be considered; Sequential/periodic EGD note: Surveillance in persons with multiple risk factors for GC may be considered for shorter than 3-year intervals (e.g., extensive gastric intestinal metaplasia [GIM] plus family history of GC may warrant 1- to 2-year interval). High-risk groups = non-neoplastic GIM with at least ONE of: high-risk GIM histology (incomplete GIM subtype vs complete subtype, OR corpus extension defined as corpus involvement with antrum or incisure involvement); OR any GIM histology with one high-risk factor (family history of GC in a first-degree relative; foreign-born with emigration from a high-incidence nation; high-risk race/ethnicity [East Asian and Pacific Islander, Hispanic (Latino/a), Black, American Indian and Alaska Native]); Sequential/periodic EGD note (GPMC management): All persons with GPMC should be tested for H. pylori using nonserologic methods, treated if positive, and confirmed eradicated irrespective of histology/severity/grade/visibility; eradication ideally confirmed at least several weeks before surveillance. Persons with indefinite dysplasia (IND) have elevated risk and warrant follow-up: IND diagnosis confirmed by a second GI pathologist; if confirmed, repeat high-quality endoscopy (HDWLE + IEE) with systematic protocol + targeted biopsies in 6-12 months; subsequent management parallels visible vs nonvisible low-grade dysplasia; if IND not confirmed on repeat, surveillance per systematic biopsy results; Sequential/periodic EGD note (gastric ulcers): Persons with gastric ulcers should undergo repeat endoscopic evaluation to assess for ulcer healing prior to discontinuing acid suppression therapy; Biopsy of upper GI tract: Gastroesophageal reflux disease (GERD) — biopsies directed to irregularities of the mucosa; Biopsy of upper GI tract: Barrett's esophagus — Seattle Protocol (4-quadrant biopsies every 1-2 cm and target biopsies from any visible lesion): without dysplasia = 4-quadrant biopsies each 2 cm; with low grade dysplasia = 4-quadrant biopsies each 1-2 cm; with high grade dysplasia = 4-quadrant biopsies each 1 cm; Biopsy of upper GI tract: Eosinophilic esophagitis — up to 8 biopsies of the esophagus, plus biopsies of the gastric antrum and duodenum if there is suspicion of eosinophilic gastroenteritis; Biopsy of upper GI tract: Infectious esophagitis — CMV infection: biopsies from the base of the ulcers; HSV infection: biopsies from the edges of the ulcers; esophageal candidiasis: biopsies from affected areas plus exfoliative cytology; Biopsy of upper GI tract: Helicobacter pylori — up to 5 biopsies (Sydney protocol). In suspected gastric atrophy with or without intestinal metaplasia, obtain biopsies per a systematic protocol (e.g., updated Sydney System): minimum of 5 total, with antrum/incisura and corpus samples placed in separately labeled jars (jar 1 'antrum/incisura', jar 2 'corpus'); Biopsy of upper GI tract: Metaplastic (chronic) atrophic gastritis — environmental metaplastic atrophic gastritis: up to 12 biopsies; autoimmune atrophic metaplastic gastritis (AMAG): biopsies of ulcers, nodules, polyps, and masses to rule out neoplasia; Biopsy of upper GI tract: Gastric polyps — number of medically necessary biopsies determined by the number of polyps — Note: all persons with hyperplastic or adenomatous gastric epithelial polyps [GEP] should have standard Sydney protocol biopsies and testing for H. pylori infection; Biopsy of upper GI tract: Peptic ulcer disease — 8 or more biopsies, from the base and edges if there is suspicion of malignancy; Biopsy of upper GI tract: Celiac disease — up to 2 biopsies of the duodenal bulb and 4 or more biopsies of the distal duodenum; Biopsy of upper GI tract: Inflammatory bowel disease, diagnosis — two or more biopsies from the esophagus, stomach and duodenum; Biopsy of upper GI tract: Acute graft versus host disease — in case of non-diagnostic flexible sigmoidoscopy, an upper endoscopy should be performed with four or more biopsies from the gastric body, antrum and duodenum; Endoscopic submucosal dissection (ESD) for treatment of BE when ANY of the following is met: Barrett's esophagus with high-grade dysplasia (HGD) with a visible lesion of greater than 1.5 cm; OR early esophageal cancer by endoscopic ultrasonography (EUS) with a negative PET scan; OR esophageal polyps unable to be removed by snare techniques; OR recurrent HGD (visible lesion(s)); OR submucosal esophageal adenocarcinoma (T1b) with low-risk features (less than 500-um invasion in the submucosa [sm1], good-to-moderate differentiation, and no lymphatic invasion); OR submucosal masses of greater than 2.0 cm. Applies to 25 codes: 43235, 43236, 43237, 43238, 43239, 43240, 43241, 43242, 43243, 43244, 43245, 43246, 43247, 43248, 43249, 43250, 43251, 43252, 43253, 43254, 43255, 43257, 43259, 43266, 43270.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Providers may be required to submit photographs of mucosal abnormalities seen on EGD and/or colonoscopy (note under sequential/periodic EGD surveillance section).
Trap
Policy exclusions and limitations: Experimental, investigational, or unproven — EGD before bariatric surgery in asymptomatic persons; Experimental, investigational, or unproven — EGD for confirming placement of gastric band; Experimental, investigational, or unproven — EGD for diagnosing laryngopharyngeal reflux; Experimental, investigational, or unproven — EGD for routine screening; Experimental, investigational, or unproven — Evaluation of symptoms that are considered functional in origin (exceptions: an EGD may be done once to rule out organic disease, especially if symptoms are unresponsive to therapy); Experimental, investigational, or unproven — Evaluation of metastatic adenocarcinoma of unknown primary site when the results will not alter management; Experimental, investigational, or unproven — Repeat EGD for persons with a prior normal EGD if symptoms remain unchanged; Experimental, investigational, or unproven — Routine evaluation of abdominal pain in children (i.e., without other signs and symptoms suggestive of serious organic disease); Experimental, investigational, or unproven — Evaluation of radiographical findings of: asymptomatic or uncomplicated sliding hiatal hernia; deformed duodenal bulb when symptoms are absent or respond adequately to ulcer therapy; uncomplicated duodenal ulcer that has responded to therapy; Experimental, investigational, or unproven — Surveillance for malignancy in persons with gastric atrophy, pernicious anemia, or prior gastric operations for benign disease (e.g., partial gastrectomy for peptic ulcer disease); Experimental, investigational, or unproven — Surveillance of healed benign disease (e.g., esophagitis or duodenal/gastric ulcer); Experimental, investigational, or unproven — Surveillance during repeated dilations of benign strictures unless there is a change in status; Experimental, investigational, or unproven — Surveillance of persons with achalasia; Experimental, investigational, or unproven — Surveillance of persons with previous aerodigestive squamous cell cancer; Experimental, investigational, or unproven — Surveillance of persons following adequate sampling or removal of non-dysplastic gastric polyps; Experimental, investigational, or unproven — Endoscopic functional luminal imaging probe (EndoFLIP) (impedance planimetry) for management of achalasia; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for management of dysphagia; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for management of esophagitis; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for management of esophagogastric junction outflow obstruction; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for management of fecal incontinence; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for management of gastro-esophageal reflux disease (GERD); Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for management of gastroparesis; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for prediction of response to endoscopic therapy of pouch strictures; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for prediction of response to flexible endoscopy in Zenker's diverticulotomy; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for management of upper GI tract stenosis (including guiding therapy for esophageal stenosis); Experimental, investigational, or unproven — Screening upper endoscopy; no current guidelines of leading medical professional organizations or Federal public health agencies recommend routine upper endoscopy screening of asymptomatic persons; Experimental, investigational, or unproven — Drug-coated balloons for the treatment of esophageal strictures. 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: Aetna CPB 0738 — Upper Gastrointestinal Endoscopy

Coverage criteria

  • EGD/upper endoscopy for high-risk screening: Persons with chronic (5 years or more) gastro-esophageal reflux disease (GERD) at risk for Barrett's esophagus (BE) — Note: after a negative screening EGD, further screening EGD is not indicated
  • EGD/upper endoscopy for high-risk screening: Persons with symptomatic pernicious anemia (e.g., anemia, fatigue, pallor, red tongue, shortness of breath, tingling and numbness in the hands and feet) to identify prevalent lesions (e.g., carcinoid tumors, gastric cancer)
  • EGD/upper endoscopy for high-risk screening: Persons with cirrhosis and portal hypertension but no prior variceal hemorrhage, especially those with platelet counts less than 140,000/mm3, or Child's class B or C disease
  • Diagnostic EGD: Evaluation of dyspepsia symptoms in persons who have undergone non-invasive testing for H. pylori, and whose symptoms persist despite eradication of H. pylori and have failed an appropriate therapeutic trial (e.g., proton pump inhibitor [PPI], with/without prokinetic, antidepressant)
  • Diagnostic EGD: Evaluation of dyspepsia in persons who are H. pylori negative and who have undergone an appropriate trial of PPI therapy (appropriate trial = a 2-4 week course of standard dose, once daily PPI)
  • Diagnostic EGD: Evaluation of dyspepsia symptoms associated with multiple or progressive alarm signs (e.g., anorexia, anemia and weight loss) in persons younger than 60 years of age
  • Diagnostic EGD: Evaluation of dyspepsia in persons over 60 years of age
  • Diagnostic EGD: Evaluation of dysphagia or odynophagia or food impaction
  • Diagnostic EGD: Evaluation of esophageal reflux symptoms (heartburn, regurgitation, noncardiac chest pain) that are persistent or recurrent despite appropriate therapy (appropriate therapy = an 8 week trial of standard dose once daily PPI; in persons with partial response, the dose may be increased to twice daily)
  • Diagnostic EGD: Evaluation of esophageal masses and for directing biopsies for diagnosing esophageal cancer
  • Diagnostic EGD: Evaluation of persons with signs or symptoms of loco-regional recurrence after resection of esophageal cancer
  • Diagnostic EGD: Evaluation of persistent vomiting of unknown cause
  • Diagnostic EGD: Evaluation of other diseases in which the presence of upper GI pathological conditions might modify other planned management (e.g., persons with a history of ulcer or GI bleeding scheduled for organ transplantation, long-term anti-coagulation, or long-term NSAID therapy for arthritis, and those with cancer of the head and neck)
  • Diagnostic EGD: Evaluation of familial adenomatous polyposis syndromes
  • Diagnostic EGD: Confirmation and specific histological diagnosis of radiologically demonstrated lesions (ANY of): gastric or esophageal ulcer; OR suspected neoplastic lesion; OR upper GI tract stricture or obstruction
  • Diagnostic EGD: Evaluation of GI bleeding (ANY of): for persons with active or recent bleeding; OR for presumed chronic blood loss and for iron deficiency anemia when the clinical situation suggests an upper GI source or when colonoscopy results are negative
  • Diagnostic EGD: Sampling of upper GI tissue or fluid
  • Diagnostic EGD: Evaluation of persons with suspected portal hypertension to document or treat esophageal varices
  • Diagnostic EGD: Evaluation of acute injury after caustic ingestion
  • Diagnostic EGD: Evaluation of dyspepsia when ANY of the following is present: chronic GI bleeding; Crohn's disease with persistent dyspepsia; epigastric mass; iron deficiency anemia; persistent vomiting; progressive difficulty swallowing; progressive unintentional weight loss; suspicious barium meal (upper GI series)
  • Diagnostic EGD: Evaluation of chronic dyspepsia and/or abdominal pain when other studies (e.g., colonoscopy, enteroscopy, ileoscopy, flexible sigmoidoscopy) have negative results
  • Diagnostic EGD: Differentiation of Crohn's disease from ulcerative colitis in indeterminate colitis
  • Diagnostic EGD: Evaluation of new-onset upper abdominal symptoms in a person greater than 50 years of age
  • Diagnostic EGD: Evaluation for placement of wireless pH capsule for esophageal or extraesophageal reflux symptoms in absence of severe erosive reflux disease
  • Diagnostic EGD: Evaluation of diarrhea in a person suspected of having small bowel disease (e.g., celiac disease)
  • Diagnostic EGD: Intraoperative evaluation of anatomic reconstructions
  • Diagnostic EGD: Evaluation of the stomach to identify gastric premalignant conditions (GPMC) or gastric cancer (GC) — Note: includes achieving adequate mucosal visualization with cleansing and insufflation, visual station mapping, photo documentation of anatomic landmarks and any abnormalities, adequate gastric evaluation time
  • EGD for screening and surveillance: Screening for upper GI malignancies in persons with polyposis syndromes or Lynch syndrome
  • EGD for screening and surveillance: Screening for squamous cell carcinoma in persons with a history of caustic ingestions
  • EGD for screening and surveillance: Screening in persons with a family history of gastric cancer (GC) (first-degree relative) on an individualized basis — Note: endoscopy would start at age 45-60 or 10 years before the diagnosis of GC in the youngest affected family member
  • Therapeutic EGD: Banding or sclerotherapy of varices
  • Therapeutic EGD: Dilation of stenotic lesions (e.g., with trans-endoscopic balloon dilators or dilation systems using guide wires)
  • Therapeutic EGD: Management of achalasia by means of endoscopic myotomy, botulinum toxin, balloon dilation
  • Therapeutic EGD: Palliative treatment of stenosing neoplasms by means of laser, multi-polar electrocoagulation, stent placement
  • Therapeutic EGD: Per-oral endoscopic myotomy (POEM) for the treatment of type III (spastic) achalasia
  • Therapeutic EGD: Placement of feeding or drainage tubes (per-oral, trans-nasal, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy)
  • Therapeutic EGD: Removal of foreign bodies or selected polypoid lesions
  • Therapeutic EGD: Treatment of bleeding lesions such as ulcers, tumors, and vascular abnormalities by means of electrocoagulation, heater probe, laser photocoagulation, or injection therapy
  • Therapeutic EGD: Local injection of steroid into an anastomotic esophageal stricture at the time of endoscopic dilation for prevention of stricture
  • Therapeutic EGD: In persons with suspected portal hypertension to document or treat esophageal varices
  • Therapeutic EGD: Endoscopic therapy for internal metaplasia
  • Therapeutic EGD: Management of diverticular lesions (e.g., endoscopic myotomy)
  • Therapeutic EGD: Intraoperative evaluation of anatomic reconstructions typical of modern foregut surgery (e.g., evaluation of anastomotic leak and patency, fundoplication formation, pouch configuration during bariatric surgery)
  • Therapeutic EGD: Management of operative adverse events (e.g., dilation of anastomotic strictures, stent placement of anastomotic disruption, fistula, or leak in selected circumstances)
  • Therapeutic EGD: Endoscopic management of dysplastic gastric premalignant conditions — in persons appropriate for endoscopic resection of dysplasia, particularly endoscopic submucosal dissection
  • Sequential/periodic EGD: Surveillance of persons with BE without dysplasia — for established BE of any length with no dysplasia, after 2 consecutive examinations within 1 year, an acceptable interval for additional surveillance is every 3 years
  • Sequential/periodic EGD: Surveillance of persons with BE and low-grade dysplasia (LGD) at 6 months — if LGD is confirmed, then surveillance at 12 months and yearly thereafter as long as dysplasia persists
  • Sequential/periodic EGD: Surveillance of persons with BE and high-grade dysplasia every 3 months for at least 1 year — after 1 year of no cancer detection, the interval may be lengthened if there are no dysplastic changes on 2 subsequent endoscopies performed at 3-month intervals
  • Sequential/periodic EGD: Surveillance of persons with a severe caustic esophageal injury every 1 to 3 years beginning 15 to 20 years after the injury
  • Sequential/periodic EGD: Surveillance of persons with tylosis every 1 to 3 years beginning at 30 years of age
  • Sequential/periodic EGD: Surveillance of recurrence of adenomatous polyps in synchronous and metachronous sites at 3- to 5-year intervals
  • Sequential/periodic EGD: Surveillance of persons with familial adenomatous polyposis starting around the time of colectomy or after age of 30 years
  • Sequential/periodic EGD: Surveillance of persons with hereditary non-polyposis colorectal cancer
  • Sequential/periodic EGD: Surveillance for malignancy in persons with premalignant conditions (i.e., Barrett's esophagus, gastric intestinal metaplasia)
  • Sequential/periodic EGD: Assessment of disease activity in eosinophilic esophagitis or eosinophilic GI disease
  • Sequential/periodic EGD: Assessment of mucosal healing and screening for Barrett's esophagus in persons with severe erosive esophagitis
  • Sequential/periodic EGD: Surveillance of persons with gastric ulcers (with biopsies of the ulcer if still present) after 8 to 12 weeks when ANY ONE of the following: symptoms persist despite medical therapy; OR unclear etiology; OR giant ulcer (greater than 2 cm); OR biopsies not performed or inadequate sampling on the index upper endoscopy (minimum of four biopsies, at least one from each of the four quadrants; additional edge biopsies with jumbo forceps if endoscopic features of malignancy); OR ulcer appears suspicious for malignancy on index endoscopy (mass lesion, elevated irregular ulcer borders, or abnormal adjacent mucosal folds) — surveillance considered even if index biopsies benign, as false-negative results occur in 2-5% of malignant ulcers; OR persons with bleeding ulcers at initial presentation who show signs of continued bleeding; OR risk factors for gastric cancer (e.g., age greater than 50 years, H. pylori, immigrants from a high-prevalence region [e.g., Japan, Korea, Taiwan, Costa Rica], family history of gastric cancer, gastric atrophy, adenoma, dysplasia, intestinal metaplasia)
  • Sequential/periodic EGD: Surveillance in persons with confirmed complete resection of dysplasia — Note: use of high-definition white light endoscopy (HDWLE) and image-enhanced endoscopy (IEE), with biopsies per systematic biopsy protocol in addition to targeted biopsies, is recommended
  • Sequential/periodic EGD: Surveillance in persons with gastric premalignant conditions (GPMC) who identify as a high-risk race or ethnicity (e.g., East Asian and Pacific Islander, Hispanic [Latino/a], Black, American Indian and Alaska Native) or who emigrated from a high-incidence region (e.g., East Asia, Eastern Europe including western Russia, Central/South America) — Note: recommended for 3-year endoscopic surveillance given the substantial increased GC risk
  • Sequential/periodic EGD: Surveillance in persons with autoimmune gastritis (AIG) — Note: use of HDWLE and IEE should be considered
  • Sequential/periodic EGD note: Surveillance in persons with multiple risk factors for GC may be considered for shorter than 3-year intervals (e.g., extensive gastric intestinal metaplasia [GIM] plus family history of GC may warrant 1- to 2-year interval). High-risk groups = non-neoplastic GIM with at least ONE of: high-risk GIM histology (incomplete GIM subtype vs complete subtype, OR corpus extension defined as corpus involvement with antrum or incisure involvement); OR any GIM histology with one high-risk factor (family history of GC in a first-degree relative; foreign-born with emigration from a high-incidence nation; high-risk race/ethnicity [East Asian and Pacific Islander, Hispanic (Latino/a), Black, American Indian and Alaska Native])
  • Sequential/periodic EGD note (GPMC management): All persons with GPMC should be tested for H. pylori using nonserologic methods, treated if positive, and confirmed eradicated irrespective of histology/severity/grade/visibility; eradication ideally confirmed at least several weeks before surveillance. Persons with indefinite dysplasia (IND) have elevated risk and warrant follow-up: IND diagnosis confirmed by a second GI pathologist; if confirmed, repeat high-quality endoscopy (HDWLE + IEE) with systematic protocol + targeted biopsies in 6-12 months; subsequent management parallels visible vs nonvisible low-grade dysplasia; if IND not confirmed on repeat, surveillance per systematic biopsy results
  • Sequential/periodic EGD note (gastric ulcers): Persons with gastric ulcers should undergo repeat endoscopic evaluation to assess for ulcer healing prior to discontinuing acid suppression therapy
  • Biopsy of upper GI tract: Gastroesophageal reflux disease (GERD) — biopsies directed to irregularities of the mucosa
  • Biopsy of upper GI tract: Barrett's esophagus — Seattle Protocol (4-quadrant biopsies every 1-2 cm and target biopsies from any visible lesion): without dysplasia = 4-quadrant biopsies each 2 cm; with low grade dysplasia = 4-quadrant biopsies each 1-2 cm; with high grade dysplasia = 4-quadrant biopsies each 1 cm
  • Biopsy of upper GI tract: Eosinophilic esophagitis — up to 8 biopsies of the esophagus, plus biopsies of the gastric antrum and duodenum if there is suspicion of eosinophilic gastroenteritis
  • Biopsy of upper GI tract: Infectious esophagitis — CMV infection: biopsies from the base of the ulcers; HSV infection: biopsies from the edges of the ulcers; esophageal candidiasis: biopsies from affected areas plus exfoliative cytology
  • Biopsy of upper GI tract: Helicobacter pylori — up to 5 biopsies (Sydney protocol). In suspected gastric atrophy with or without intestinal metaplasia, obtain biopsies per a systematic protocol (e.g., updated Sydney System): minimum of 5 total, with antrum/incisura and corpus samples placed in separately labeled jars (jar 1 'antrum/incisura', jar 2 'corpus')
  • Biopsy of upper GI tract: Metaplastic (chronic) atrophic gastritis — environmental metaplastic atrophic gastritis: up to 12 biopsies; autoimmune atrophic metaplastic gastritis (AMAG): biopsies of ulcers, nodules, polyps, and masses to rule out neoplasia
  • Biopsy of upper GI tract: Gastric polyps — number of medically necessary biopsies determined by the number of polyps — Note: all persons with hyperplastic or adenomatous gastric epithelial polyps [GEP] should have standard Sydney protocol biopsies and testing for H. pylori infection
  • Biopsy of upper GI tract: Peptic ulcer disease — 8 or more biopsies, from the base and edges if there is suspicion of malignancy
  • Biopsy of upper GI tract: Celiac disease — up to 2 biopsies of the duodenal bulb and 4 or more biopsies of the distal duodenum
  • Biopsy of upper GI tract: Inflammatory bowel disease, diagnosis — two or more biopsies from the esophagus, stomach and duodenum
  • Biopsy of upper GI tract: Acute graft versus host disease — in case of non-diagnostic flexible sigmoidoscopy, an upper endoscopy should be performed with four or more biopsies from the gastric body, antrum and duodenum
  • Endoscopic submucosal dissection (ESD) for treatment of BE when ANY of the following is met: Barrett's esophagus with high-grade dysplasia (HGD) with a visible lesion of greater than 1.5 cm; OR early esophageal cancer by endoscopic ultrasonography (EUS) with a negative PET scan; OR esophageal polyps unable to be removed by snare techniques; OR recurrent HGD (visible lesion(s)); OR submucosal esophageal adenocarcinoma (T1b) with low-risk features (less than 500-um invasion in the submucosa [sm1], good-to-moderate differentiation, and no lymphatic invasion); OR submucosal masses of greater than 2.0 cm

Covered codes

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

Documentation required

  • Providers may be required to submit photographs of mucosal abnormalities seen on EGD and/or colonoscopy (note under sequential/periodic EGD surveillance section)

Frequently asked questions

When does Aetna cover Upper Gastrointestinal Endoscopy (CPT 43235), and what gets it denied?
Aetna CPB 0738 covers upper GI endoscopy (EGD) as medically necessary across high-risk screening, diagnostic, screening/surveillance, therapeutic, sequential/periodic surveillance, and upper-GI biopsy indications (e.g., Barrett's esophagus, dyspepsia with alarm features or age greater than 60, GI bleeding, dysphagia, variceal management, achalasia therapy), plus endoscopic submucosal dissection for Barrett's under specific lesion/staging criteria. Coverage hinges on the specific clinical indication being met; routine/screening EGD in asymptomatic persons, EndoFLIP for listed conditions, pre-bariatric EGD in asymptomatic persons, and several surveillance scenarios are considered experimental/investigational or not covered. The bulletin is silent on prior authorization (it only notes providers may be required to submit photographs of mucosal abnormalities). Coverage criteria include: EGD/upper endoscopy for high-risk screening: Persons with chronic (5 years or more) gastro-esophageal reflux disease (GERD) at risk for Barrett's esophagus (BE) — Note: after a negative screening EGD, further screening EGD is not indicated; EGD/upper endoscopy for high-risk screening: Persons with symptomatic pernicious anemia (e.g., anemia, fatigue, pallor, red tongue, shortness of breath, tingling and numbness in the hands and feet) to identify prevalent lesions (e.g., carcinoid tumors, gastric cancer); EGD/upper endoscopy for high-risk screening: Persons with cirrhosis and portal hypertension but no prior variceal hemorrhage, especially those with platelet counts less than 140,000/mm3, or Child's class B or C disease; Diagnostic EGD: Evaluation of dyspepsia symptoms in persons who have undergone non-invasive testing for H. pylori, and whose symptoms persist despite eradication of H. pylori and have failed an appropriate therapeutic trial (e.g., proton pump inhibitor [PPI], with/without prokinetic, antidepressant); Diagnostic EGD: Evaluation of dyspepsia in persons who are H. pylori negative and who have undergone an appropriate trial of PPI therapy (appropriate trial = a 2-4 week course of standard dose, once daily PPI); Diagnostic EGD: Evaluation of dyspepsia symptoms associated with multiple or progressive alarm signs (e.g., anorexia, anemia and weight loss) in persons younger than 60 years of age; Diagnostic EGD: Evaluation of dyspepsia in persons over 60 years of age; Diagnostic EGD: Evaluation of dysphagia or odynophagia or food impaction; Diagnostic EGD: Evaluation of esophageal reflux symptoms (heartburn, regurgitation, noncardiac chest pain) that are persistent or recurrent despite appropriate therapy (appropriate therapy = an 8 week trial of standard dose once daily PPI; in persons with partial response, the dose may be increased to twice daily); Diagnostic EGD: Evaluation of esophageal masses and for directing biopsies for diagnosing esophageal cancer; Diagnostic EGD: Evaluation of persons with signs or symptoms of loco-regional recurrence after resection of esophageal cancer; Diagnostic EGD: Evaluation of persistent vomiting of unknown cause; Diagnostic EGD: Evaluation of other diseases in which the presence of upper GI pathological conditions might modify other planned management (e.g., persons with a history of ulcer or GI bleeding scheduled for organ transplantation, long-term anti-coagulation, or long-term NSAID therapy for arthritis, and those with cancer of the head and neck); Diagnostic EGD: Evaluation of familial adenomatous polyposis syndromes; Diagnostic EGD: Confirmation and specific histological diagnosis of radiologically demonstrated lesions (ANY of): gastric or esophageal ulcer; OR suspected neoplastic lesion; OR upper GI tract stricture or obstruction; Diagnostic EGD: Evaluation of GI bleeding (ANY of): for persons with active or recent bleeding; OR for presumed chronic blood loss and for iron deficiency anemia when the clinical situation suggests an upper GI source or when colonoscopy results are negative; Diagnostic EGD: Sampling of upper GI tissue or fluid; Diagnostic EGD: Evaluation of persons with suspected portal hypertension to document or treat esophageal varices; Diagnostic EGD: Evaluation of acute injury after caustic ingestion; Diagnostic EGD: Evaluation of dyspepsia when ANY of the following is present: chronic GI bleeding; Crohn's disease with persistent dyspepsia; epigastric mass; iron deficiency anemia; persistent vomiting; progressive difficulty swallowing; progressive unintentional weight loss; suspicious barium meal (upper GI series); Diagnostic EGD: Evaluation of chronic dyspepsia and/or abdominal pain when other studies (e.g., colonoscopy, enteroscopy, ileoscopy, flexible sigmoidoscopy) have negative results; Diagnostic EGD: Differentiation of Crohn's disease from ulcerative colitis in indeterminate colitis; Diagnostic EGD: Evaluation of new-onset upper abdominal symptoms in a person greater than 50 years of age; Diagnostic EGD: Evaluation for placement of wireless pH capsule for esophageal or extraesophageal reflux symptoms in absence of severe erosive reflux disease; Diagnostic EGD: Evaluation of diarrhea in a person suspected of having small bowel disease (e.g., celiac disease); Diagnostic EGD: Intraoperative evaluation of anatomic reconstructions; Diagnostic EGD: Evaluation of the stomach to identify gastric premalignant conditions (GPMC) or gastric cancer (GC) — Note: includes achieving adequate mucosal visualization with cleansing and insufflation, visual station mapping, photo documentation of anatomic landmarks and any abnormalities, adequate gastric evaluation time; EGD for screening and surveillance: Screening for upper GI malignancies in persons with polyposis syndromes or Lynch syndrome; EGD for screening and surveillance: Screening for squamous cell carcinoma in persons with a history of caustic ingestions; EGD for screening and surveillance: Screening in persons with a family history of gastric cancer (GC) (first-degree relative) on an individualized basis — Note: endoscopy would start at age 45-60 or 10 years before the diagnosis of GC in the youngest affected family member; Therapeutic EGD: Banding or sclerotherapy of varices; Therapeutic EGD: Dilation of stenotic lesions (e.g., with trans-endoscopic balloon dilators or dilation systems using guide wires); Therapeutic EGD: Management of achalasia by means of endoscopic myotomy, botulinum toxin, balloon dilation; Therapeutic EGD: Palliative treatment of stenosing neoplasms by means of laser, multi-polar electrocoagulation, stent placement; Therapeutic EGD: Per-oral endoscopic myotomy (POEM) for the treatment of type III (spastic) achalasia; Therapeutic EGD: Placement of feeding or drainage tubes (per-oral, trans-nasal, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy); Therapeutic EGD: Removal of foreign bodies or selected polypoid lesions; Therapeutic EGD: Treatment of bleeding lesions such as ulcers, tumors, and vascular abnormalities by means of electrocoagulation, heater probe, laser photocoagulation, or injection therapy; Therapeutic EGD: Local injection of steroid into an anastomotic esophageal stricture at the time of endoscopic dilation for prevention of stricture; Therapeutic EGD: In persons with suspected portal hypertension to document or treat esophageal varices; Therapeutic EGD: Endoscopic therapy for internal metaplasia; Therapeutic EGD: Management of diverticular lesions (e.g., endoscopic myotomy); Therapeutic EGD: Intraoperative evaluation of anatomic reconstructions typical of modern foregut surgery (e.g., evaluation of anastomotic leak and patency, fundoplication formation, pouch configuration during bariatric surgery); Therapeutic EGD: Management of operative adverse events (e.g., dilation of anastomotic strictures, stent placement of anastomotic disruption, fistula, or leak in selected circumstances); Therapeutic EGD: Endoscopic management of dysplastic gastric premalignant conditions — in persons appropriate for endoscopic resection of dysplasia, particularly endoscopic submucosal dissection; Sequential/periodic EGD: Surveillance of persons with BE without dysplasia — for established BE of any length with no dysplasia, after 2 consecutive examinations within 1 year, an acceptable interval for additional surveillance is every 3 years; Sequential/periodic EGD: Surveillance of persons with BE and low-grade dysplasia (LGD) at 6 months — if LGD is confirmed, then surveillance at 12 months and yearly thereafter as long as dysplasia persists; Sequential/periodic EGD: Surveillance of persons with BE and high-grade dysplasia every 3 months for at least 1 year — after 1 year of no cancer detection, the interval may be lengthened if there are no dysplastic changes on 2 subsequent endoscopies performed at 3-month intervals; Sequential/periodic EGD: Surveillance of persons with a severe caustic esophageal injury every 1 to 3 years beginning 15 to 20 years after the injury; Sequential/periodic EGD: Surveillance of persons with tylosis every 1 to 3 years beginning at 30 years of age; Sequential/periodic EGD: Surveillance of recurrence of adenomatous polyps in synchronous and metachronous sites at 3- to 5-year intervals; Sequential/periodic EGD: Surveillance of persons with familial adenomatous polyposis starting around the time of colectomy or after age of 30 years; Sequential/periodic EGD: Surveillance of persons with hereditary non-polyposis colorectal cancer; Sequential/periodic EGD: Surveillance for malignancy in persons with premalignant conditions (i.e., Barrett's esophagus, gastric intestinal metaplasia); Sequential/periodic EGD: Assessment of disease activity in eosinophilic esophagitis or eosinophilic GI disease; Sequential/periodic EGD: Assessment of mucosal healing and screening for Barrett's esophagus in persons with severe erosive esophagitis; Sequential/periodic EGD: Surveillance of persons with gastric ulcers (with biopsies of the ulcer if still present) after 8 to 12 weeks when ANY ONE of the following: symptoms persist despite medical therapy; OR unclear etiology; OR giant ulcer (greater than 2 cm); OR biopsies not performed or inadequate sampling on the index upper endoscopy (minimum of four biopsies, at least one from each of the four quadrants; additional edge biopsies with jumbo forceps if endoscopic features of malignancy); OR ulcer appears suspicious for malignancy on index endoscopy (mass lesion, elevated irregular ulcer borders, or abnormal adjacent mucosal folds) — surveillance considered even if index biopsies benign, as false-negative results occur in 2-5% of malignant ulcers; OR persons with bleeding ulcers at initial presentation who show signs of continued bleeding; OR risk factors for gastric cancer (e.g., age greater than 50 years, H. pylori, immigrants from a high-prevalence region [e.g., Japan, Korea, Taiwan, Costa Rica], family history of gastric cancer, gastric atrophy, adenoma, dysplasia, intestinal metaplasia); Sequential/periodic EGD: Surveillance in persons with confirmed complete resection of dysplasia — Note: use of high-definition white light endoscopy (HDWLE) and image-enhanced endoscopy (IEE), with biopsies per systematic biopsy protocol in addition to targeted biopsies, is recommended; Sequential/periodic EGD: Surveillance in persons with gastric premalignant conditions (GPMC) who identify as a high-risk race or ethnicity (e.g., East Asian and Pacific Islander, Hispanic [Latino/a], Black, American Indian and Alaska Native) or who emigrated from a high-incidence region (e.g., East Asia, Eastern Europe including western Russia, Central/South America) — Note: recommended for 3-year endoscopic surveillance given the substantial increased GC risk; Sequential/periodic EGD: Surveillance in persons with autoimmune gastritis (AIG) — Note: use of HDWLE and IEE should be considered; Sequential/periodic EGD note: Surveillance in persons with multiple risk factors for GC may be considered for shorter than 3-year intervals (e.g., extensive gastric intestinal metaplasia [GIM] plus family history of GC may warrant 1- to 2-year interval). High-risk groups = non-neoplastic GIM with at least ONE of: high-risk GIM histology (incomplete GIM subtype vs complete subtype, OR corpus extension defined as corpus involvement with antrum or incisure involvement); OR any GIM histology with one high-risk factor (family history of GC in a first-degree relative; foreign-born with emigration from a high-incidence nation; high-risk race/ethnicity [East Asian and Pacific Islander, Hispanic (Latino/a), Black, American Indian and Alaska Native]); Sequential/periodic EGD note (GPMC management): All persons with GPMC should be tested for H. pylori using nonserologic methods, treated if positive, and confirmed eradicated irrespective of histology/severity/grade/visibility; eradication ideally confirmed at least several weeks before surveillance. Persons with indefinite dysplasia (IND) have elevated risk and warrant follow-up: IND diagnosis confirmed by a second GI pathologist; if confirmed, repeat high-quality endoscopy (HDWLE + IEE) with systematic protocol + targeted biopsies in 6-12 months; subsequent management parallels visible vs nonvisible low-grade dysplasia; if IND not confirmed on repeat, surveillance per systematic biopsy results; Sequential/periodic EGD note (gastric ulcers): Persons with gastric ulcers should undergo repeat endoscopic evaluation to assess for ulcer healing prior to discontinuing acid suppression therapy; Biopsy of upper GI tract: Gastroesophageal reflux disease (GERD) — biopsies directed to irregularities of the mucosa; Biopsy of upper GI tract: Barrett's esophagus — Seattle Protocol (4-quadrant biopsies every 1-2 cm and target biopsies from any visible lesion): without dysplasia = 4-quadrant biopsies each 2 cm; with low grade dysplasia = 4-quadrant biopsies each 1-2 cm; with high grade dysplasia = 4-quadrant biopsies each 1 cm; Biopsy of upper GI tract: Eosinophilic esophagitis — up to 8 biopsies of the esophagus, plus biopsies of the gastric antrum and duodenum if there is suspicion of eosinophilic gastroenteritis; Biopsy of upper GI tract: Infectious esophagitis — CMV infection: biopsies from the base of the ulcers; HSV infection: biopsies from the edges of the ulcers; esophageal candidiasis: biopsies from affected areas plus exfoliative cytology; Biopsy of upper GI tract: Helicobacter pylori — up to 5 biopsies (Sydney protocol). In suspected gastric atrophy with or without intestinal metaplasia, obtain biopsies per a systematic protocol (e.g., updated Sydney System): minimum of 5 total, with antrum/incisura and corpus samples placed in separately labeled jars (jar 1 'antrum/incisura', jar 2 'corpus'); Biopsy of upper GI tract: Metaplastic (chronic) atrophic gastritis — environmental metaplastic atrophic gastritis: up to 12 biopsies; autoimmune atrophic metaplastic gastritis (AMAG): biopsies of ulcers, nodules, polyps, and masses to rule out neoplasia; Biopsy of upper GI tract: Gastric polyps — number of medically necessary biopsies determined by the number of polyps — Note: all persons with hyperplastic or adenomatous gastric epithelial polyps [GEP] should have standard Sydney protocol biopsies and testing for H. pylori infection; Biopsy of upper GI tract: Peptic ulcer disease — 8 or more biopsies, from the base and edges if there is suspicion of malignancy; Biopsy of upper GI tract: Celiac disease — up to 2 biopsies of the duodenal bulb and 4 or more biopsies of the distal duodenum; Biopsy of upper GI tract: Inflammatory bowel disease, diagnosis — two or more biopsies from the esophagus, stomach and duodenum; Biopsy of upper GI tract: Acute graft versus host disease — in case of non-diagnostic flexible sigmoidoscopy, an upper endoscopy should be performed with four or more biopsies from the gastric body, antrum and duodenum; Endoscopic submucosal dissection (ESD) for treatment of BE when ANY of the following is met: Barrett's esophagus with high-grade dysplasia (HGD) with a visible lesion of greater than 1.5 cm; OR early esophageal cancer by endoscopic ultrasonography (EUS) with a negative PET scan; OR esophageal polyps unable to be removed by snare techniques; OR recurrent HGD (visible lesion(s)); OR submucosal esophageal adenocarcinoma (T1b) with low-risk features (less than 500-um invasion in the submucosa [sm1], good-to-moderate differentiation, and no lymphatic invasion); OR submucosal masses of greater than 2.0 cm. Applies to 25 codes: 43235, 43236, 43237, 43238, 43239, 43240, 43241, 43242, 43243, 43244, 43245, 43246, 43247, 43248, 43249, 43250, 43251, 43252, 43253, 43254, 43255, 43257, 43259, 43266, 43270. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Providers may be required to submit photographs of mucosal abnormalities seen on EGD and/or colonoscopy (note under sequential/periodic EGD surveillance section). Policy exclusions and limitations: Experimental, investigational, or unproven — EGD before bariatric surgery in asymptomatic persons; Experimental, investigational, or unproven — EGD for confirming placement of gastric band; Experimental, investigational, or unproven — EGD for diagnosing laryngopharyngeal reflux; Experimental, investigational, or unproven — EGD for routine screening; Experimental, investigational, or unproven — Evaluation of symptoms that are considered functional in origin (exceptions: an EGD may be done once to rule out organic disease, especially if symptoms are unresponsive to therapy); Experimental, investigational, or unproven — Evaluation of metastatic adenocarcinoma of unknown primary site when the results will not alter management; Experimental, investigational, or unproven — Repeat EGD for persons with a prior normal EGD if symptoms remain unchanged; Experimental, investigational, or unproven — Routine evaluation of abdominal pain in children (i.e., without other signs and symptoms suggestive of serious organic disease); Experimental, investigational, or unproven — Evaluation of radiographical findings of: asymptomatic or uncomplicated sliding hiatal hernia; deformed duodenal bulb when symptoms are absent or respond adequately to ulcer therapy; uncomplicated duodenal ulcer that has responded to therapy; Experimental, investigational, or unproven — Surveillance for malignancy in persons with gastric atrophy, pernicious anemia, or prior gastric operations for benign disease (e.g., partial gastrectomy for peptic ulcer disease); Experimental, investigational, or unproven — Surveillance of healed benign disease (e.g., esophagitis or duodenal/gastric ulcer); Experimental, investigational, or unproven — Surveillance during repeated dilations of benign strictures unless there is a change in status; Experimental, investigational, or unproven — Surveillance of persons with achalasia; Experimental, investigational, or unproven — Surveillance of persons with previous aerodigestive squamous cell cancer; Experimental, investigational, or unproven — Surveillance of persons following adequate sampling or removal of non-dysplastic gastric polyps; Experimental, investigational, or unproven — Endoscopic functional luminal imaging probe (EndoFLIP) (impedance planimetry) for management of achalasia; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for management of dysphagia; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for management of esophagitis; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for management of esophagogastric junction outflow obstruction; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for management of fecal incontinence; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for management of gastro-esophageal reflux disease (GERD); Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for management of gastroparesis; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for prediction of response to endoscopic therapy of pouch strictures; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for prediction of response to flexible endoscopy in Zenker's diverticulotomy; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for management of upper GI tract stenosis (including guiding therapy for esophageal stenosis); Experimental, investigational, or unproven — Screening upper endoscopy; no current guidelines of leading medical professional organizations or Federal public health agencies recommend routine upper endoscopy screening of asymptomatic persons; Experimental, investigational, or unproven — Drug-coated balloons for the treatment of esophageal strictures. 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 Upper Gastrointestinal Endoscopy?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Providers may be required to submit photographs of mucosal abnormalities seen on EGD and/or colonoscopy (note under sequential/periodic EGD surveillance section).
What does Aetna exclude for Upper Gastrointestinal Endoscopy?
Policy exclusions and limitations: Experimental, investigational, or unproven — EGD before bariatric surgery in asymptomatic persons; Experimental, investigational, or unproven — EGD for confirming placement of gastric band; Experimental, investigational, or unproven — EGD for diagnosing laryngopharyngeal reflux; Experimental, investigational, or unproven — EGD for routine screening; Experimental, investigational, or unproven — Evaluation of symptoms that are considered functional in origin (exceptions: an EGD may be done once to rule out organic disease, especially if symptoms are unresponsive to therapy); Experimental, investigational, or unproven — Evaluation of metastatic adenocarcinoma of unknown primary site when the results will not alter management; Experimental, investigational, or unproven — Repeat EGD for persons with a prior normal EGD if symptoms remain unchanged; Experimental, investigational, or unproven — Routine evaluation of abdominal pain in children (i.e., without other signs and symptoms suggestive of serious organic disease); Experimental, investigational, or unproven — Evaluation of radiographical findings of: asymptomatic or uncomplicated sliding hiatal hernia; deformed duodenal bulb when symptoms are absent or respond adequately to ulcer therapy; uncomplicated duodenal ulcer that has responded to therapy; Experimental, investigational, or unproven — Surveillance for malignancy in persons with gastric atrophy, pernicious anemia, or prior gastric operations for benign disease (e.g., partial gastrectomy for peptic ulcer disease); Experimental, investigational, or unproven — Surveillance of healed benign disease (e.g., esophagitis or duodenal/gastric ulcer); Experimental, investigational, or unproven — Surveillance during repeated dilations of benign strictures unless there is a change in status; Experimental, investigational, or unproven — Surveillance of persons with achalasia; Experimental, investigational, or unproven — Surveillance of persons with previous aerodigestive squamous cell cancer; Experimental, investigational, or unproven — Surveillance of persons following adequate sampling or removal of non-dysplastic gastric polyps; Experimental, investigational, or unproven — Endoscopic functional luminal imaging probe (EndoFLIP) (impedance planimetry) for management of achalasia; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for management of dysphagia; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for management of esophagitis; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for management of esophagogastric junction outflow obstruction; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for management of fecal incontinence; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for management of gastro-esophageal reflux disease (GERD); Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for management of gastroparesis; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for prediction of response to endoscopic therapy of pouch strictures; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for prediction of response to flexible endoscopy in Zenker's diverticulotomy; Experimental, investigational, or unproven — EndoFLIP (impedance planimetry) for management of upper GI tract stenosis (including guiding therapy for esophageal stenosis); Experimental, investigational, or unproven — Screening upper endoscopy; no current guidelines of leading medical professional organizations or Federal public health agencies recommend routine upper endoscopy screening of asymptomatic persons; Experimental, investigational, or unproven — Drug-coated balloons for the treatment of esophageal strictures. 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

Aetna CPB 0738 — Upper Gastrointestinal Endoscopy

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0738 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.