281.0 pernicious anemia does not meet medical necessity per LCD number L31800.
LCD Information
Document Information
LCD ID Number
L31800
LCD Title
Wireless Capsule Endoscopy
Contractor's Determination Number
L6330
AMA CPT/ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2010 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.
Primary Geographic Jurisdiction
North Carolina
South Carolina
Virginia
West Virginia
Oversight Region
Region IV
Original Determination Effective Date
For services performed on or after 03/19/2011
Original Determination Ending Date
Revision Effective Date
For services performed on or after 06/18/2011
Revision Ending Date
CMS National Coverage Policy
Indications and Limitations of Coverage and/or Medical Necessity
Wireless capsule endoscopy (WCE) is a non-invasive diagnostic imaging procedure utilizing a miniature digital video camera contained in a non-biodegradable capsule. The capsule is swallowed and images are transmitted by radio-telemetry to external sensors worn by the patient, where they are stored for later review and interpretation.
Indications
WCE is indicated for the evaluation of gastrointestinal blood loss of obscure origin, or anemia due to suspected occult blood loss, the origin of which is suspected to be in the small intestinal mucosa, based on documented negative or non-diagnostic prior evaluation of the esophagus, stomach, duodenum, (EGD), and colon (colonoscopy) by conventional instrumental endoscopy.
WCE is also indicated as a primary procedure in the evaluation of signs or symptoms suspected to be indicative of small bowel neoplasm or regional enteritis. As a primary procedure, prior EGD and colonoscopy are not a prerequisite for these indications.
Limitations
A physician trained in gastrointestinal endoscopic interpretation must interpret WCE.
WCE must be performed:
Under the general supervision of a physician trained in endoscopic interpretation.
With a device approved by the FDA.
WCE is not covered for the following:
Patients with blood loss who have not been properly evaluated prior to WCE with conventional endoscopic procedures.
Colorectal cancer screening or surveillance.
Evaluation of hematemesis.
Screening for esophageal disorders (Barrett's esophagus, varices) or portal hypertensive gastropathy.
Coding Information
Bill Type Codes:
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.
Revenue Codes:
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
CPT CODES
91110
GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE ENDOSCOPY), ESOPHAGUS THROUGH ILEUM, WITH PHYSICIAN INTERPRETATION AND REPORT
91111
GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE ENDOSCOPY), ESOPHAGUS WITH PHYSICIAN INTERPRETATION AND REPORT
ICD-9 Codes that Support Medical Necessity
Use of these codes does not guarantee reimbursement. The patient's medical record must document that the coverage criteria in this policy have been met.
CPT Code 91110
152.0 - 152.9
MALIGNANT NEOPLASM OF DUODENUM - MALIGNANT NEOPLASM OF SMALL INTESTINE UNSPECIFIED SITE
211.2
BENIGN NEOPLASM OF DUODENUM JEJUNUM AND ILEUM
230.7
CARCINOMA IN SITU OF OTHER AND UNSPECIFIED PARTS OF INTESTINE
235.2
NEOPLASM OF UNCERTAIN BEHAVIOR OF STOMACH INTESTINES AND RECTUM
280.0
IRON DEFICIENCY ANEMIA SECONDARY TO BLOOD LOSS (CHRONIC)
280.9
IRON DEFICIENCY ANEMIA UNSPECIFIED
285.1
ACUTE POSTHEMORRHAGIC ANEMIA
457.1
OTHER LYMPHEDEMA
537.82
ANGIODYSPLASIA OF STOMACH AND DUODENUM (WITHOUT HEMORRHAGE)
537.83
ANGIODYSPLASIA OF STOMACH AND DUODENUM WITH HEMORRHAGE
537.84
DIEULAFOY LESION (HEMORRHAGIC) OF STOMACH AND DUODENUM
555.0
REGIONAL ENTERITIS OF SMALL INTESTINE
555.2
REGIONAL ENTERITIS OF SMALL INTESTINE WITH LARGE INTESTINE
557.0 - 557.9
ACUTE VASCULAR INSUFFICIENCY OF INTESTINE - UNSPECIFIED VASCULAR INSUFFICIENCY OF INTESTINE
558.1
GASTROENTERITIS AND COLITIS DUE TO RADIATION
558.2
TOXIC GASTROENTERITIS AND COLITIS
558.9
OTHER AND UNSPECIFIED NONINFECTIOUS GASTROENTERITIS AND COLITIS
562.02
DIVERTICULOSIS OF SMALL INTESTINE WITH HEMORRHAGE
562.03
DIVERTICULITIS OF SMALL INTESTINE WITH HEMORRHAGE
569.82
ULCERATION OF INTESTINE
569.84
ANGIODYSPLASIA OF INTESTINE (WITHOUT HEMORRHAGE)
569.85
ANGIODYSPLASIA OF INTESTINE WITH HEMORRHAGE
569.86
DIEULAFOY LESION (HEMORRHAGIC) OF INTESTINE
578.1
BLOOD IN STOOL
578.9
HEMORRHAGE OF GASTROINTESTINAL TRACT UNSPECIFIED
579.8
OTHER SPECIFIED INTESTINAL MALABSORPTION
579.9
UNSPECIFIED INTESTINAL MALABSORPTION
759.6
OTHER CONGENITAL HAMARTOSES NOT ELSEWHERE CLASSIFIED
787.91
DIARRHEA
792.1
NONSPECIFIC ABNORMAL FINDINGS IN STOOL CONTENTS
793.4
NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF GASTROINTESTINAL TRACT
Diagnoses that Support Medical Necessity
ICD-9 Codes that DO NOT Support Medical Necessity
All other ICD-9 codes not listed under "ICD-9 Codes that Support Medical Necessity" will be denied as not medically necessary.
