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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-91000-05

Fecha de entrada en vigencia original: 11/15/2002

Revisado: 09/24/15

Editado: 11/01/15

Tema: Endoscopia capsular inalámbrica

ESTA GUÍA DE COBERTURA MÉDICA NO ES UNA AUTORIZACIÓN, CERTIFICACIÓN, EXPLICACIÓN DE LOS BENEFICIOS NI GARANTÍA DE PAGO Y NO CONSTITUYE NI SUSTITUYE EL CONSEJO DE UN MÉDICO. TODAS LAS DECISIONES MÉDICAS SON RESPONSABILIDAD EXCLUSIVA DEL PACIENTE Y DEL MÉDICO. LOS BENEFICIOS SE DETERMINAN POR EL CONTRATO DEL GRUPO, EL FOLLETO DE BENEFICIOS DEL ASEGURADO O EL CERTIFICADO DEL SUSCRIPTOR VIGENTE CUANDO SE PRESTARON LOS SERVICIOS. ESTA GUÍA DE COBERTURA MÉDICA SE APLICA A TODAS LAS LÍNEAS COMERCIALES A MENOS QUE SE INDIQUE LO CONTRARIO EN LA SECCIÓN EXCEPCIONES DEL PROGRAMA.

           
Declaración de posición Facturación/codificación Reembolso Excepciones del programa Definiciones Guías relacionadas
           
Otro Referencias Actualizaciones    
           

DESCRIPCIÓN:

La endoscopia capsular inalámbrica es un dispositivo diseñado para visualizar porciones del intestino que no son accesibles a través de una endoscopia superior o inferior, principalmente del intestino delgado. Los pacientes se tragan una cápsula, esta registra imágenes de la mucosa intestinal conforme pasa por el tracto gastrointestinal (GI). La cápsula se recupera después de ser excretada y las imágenes se interpretan.

Varios sistemas, dispositivos y componentes para la imagenología gastrointestinal han recibido la autorización 501(k) de la Administración de Alimentos y Medicamentos (FDA) de EE. UU. (por ejemplo, Sistema de diagnóstico por imágenes Given®, Sistema de diagnóstico Given® con la cápsula endoscópica PillCam™, Sistema de permeabilidad Given® AGILE, Sistema de cápsula endoscópica Olympus y el Sistema de cápsula endoscópica PillCam®COLON 2).

DECLARACIÓN DE POSICIÓN:

 

Certificado de Necesidad Médica

Enviar un Certificado de Necesidad Médica (Certificate of Medical Necessity, CMN) completado junto con su solicitud de endoscopia capsular inalámbrica para agilizar el proceso de revisión médica.

1. Haga clic en el enlace Endoscopia capsular inalámbrica - Certificado de Necesidad Médica (MS Word) para abrir el formulario.

2. Complete meticulosamente todos los campos.

3. Imprima y envíe una copia del formulario junto con su solicitud.

Nota: Florida Blue actualiza regularmente estos formularios. Asegúrese de usar la versión más reciente de un CMN antes de enviarlo a Florida Blue. Para obtener una lista completa de los certificados de necesidad médica (CMN, por sus siglas en inglés) disponibles, visite la página Certificados de necesidad médica.

La endoscopia capsular inalámbrica cumple con la definición de necesidad médica para cualquiera de las siguientes indicaciones:

La endoscopia capsular inalámbrica se considera como experimental o en fase de investigación para todas las otras indicaciones incluidas, pero sin limitarse a, las siguientes porque no existe suficiente evidencia científica en las publicaciones médicas arbitradas de que la endoscopia capsular inalámbrica mejore los resultados de salud:

El uso de la cápsula de permeabilidad (e.g., Given® AGILE Patency System) se considera como experimental o en fase de investigación para todas las indicaciones, incluido su uso para evaluar la permeabilidad del tracto gastrointestinal antes de la endoscopia capsular inalámbrica, ya que no hay evidencia suficiente en las publicaciones médicas arbitradas que respalde la seguridad, la eficacia y los resultados de salud netos.

INFORMACIÓN PARA FACTURACIÓN/CODIFICACIÓN:

Codificación CPT:

91110

Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus through ileum, with interpretation and report

91111

Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus with interpretation and report (investigational)

0355T

Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), colon with interpretation and report (investigational)

NOTA: 91110 tiene un componente técnico y profesional. 91110 incluye el suministro de la cápsula, el equipo de conexión y grabación, la descarga de los datos digitales con el procesamiento de las imágenes de vídeo, y la revisión e interpretación con informe del médico.

Códigos de diagnóstico ICD-10 que respaldan la necesidad médica de 91110: (Vigente a partir del 10/01/2015)

D13.2

Benign neoplasm of duodenum

D13.30

Benign neoplasm of unspecified part of small intestine

D13.39

Benign neoplasm of other parts of small intestine

K50.00

Crohn’s disease of small intestine without complications

K50.011 – K50.019

Crohn’s disease of small intestine with complications

K50.80

Crohn's disease of both small and large intestine without complications

K50.811 – K50.819

Crohn’s disease of both small and large intestine with complications

K50.90

Crohn's disease, unspecified, without complications

K50.911 – K50.919

Crohn’s disease, unspecified, with complications

K55.21

Angiodysplasia of colon with hemorrhage

K57.01

Diverticulitis of small intestine with perforation and abscess with bleeding

K57.11

Diverticulosis of small intestine without perforation or abscess with bleeding

K57.13

Diverticulitis of small intestine without perforation or abscess with bleeding

K57.41

Diverticulitis of both small and large intestine with perforation and abscess with bleeding

K57.51

Diverticulosis of both small and large intestine without perforation or abscess with bleeding

K57.53

Diverticulitis of both small and large intestine without perforation or abscess with bleeding

K92.0

Hematemesis

K92.1

Melena

K92.2

Gastrointestinal hemorrhage, unspecified

Q85.8

Other phakomatoses, not elsewhere classified

Q85.9

Phakomatosis, unspecified

INFORMACIÓN DE REEMBOLSOS:

Consulte la sección titulada DECLARACIÓN DE POSICIÓN.

EXCEPCIONES DEL PROGRAMA:

Programa para empleados federales (FEP, Federal Employee Program): seguir las pautas del FEP.

Organización de cuentas estatales (SAO, State Account Organization): seguir las pautas del SAO.

Productos Medicare Advantage:

La siguiente Determinación de cobertura local (LCD, Local Coverage Determination) se revisó en la fecha de edición más reciente de la guía: Endoscopia capsular inalámbrica, (L29310) ubicada en fcso.com.

DEFINICIONES:

Angiodisplasia: pequeñas anomalías de los vasos sanguíneos y linfáticos.

Enfermedad celíaca: trastorno intestinal crónico hereditario en el que la incapacidad de absorber la porción de gliadina del gluten causa que la gliadina dispare una respuesta inmunitaria que daña a la mucosa intestinal.

Enteritis: inflamación del intestino, especialmente del intestino delgado.

Poliposis adenomatosa familiar: es una enfermedad del intestino grueso que se caracteriza por la formación, especialmente en el colon y el recto, de numerosos pólipos adenomatosos que generalmente, en caso de no recibir tratamiento, se vuelven malignos. Puede ser asintomática o estar acompañada por diarrea o sangrado, y que es hereditaria como un rasgo autosómico dominante, su abreviatura en inglés es FAP.

Síndrome de Lynch: a menudo llamado cáncer colorrectal hereditario sin poliposis (HNPCC), es un trastorno hereditario que aumenta el riesgo de muchos tipos de cáncer, en particular cáncer de colon (intestino grueso) y el recto, que se conocen colectivamente como cáncer colorrectal.

Hemorragia en tracto digestivo superior: anemia ferropénica (por deficiencia de hierro) recurrente o perniciosa, prueba positiva de sangre oculta en heces, o sangrado visible sin que se detecte el origen de la hemorragia en la endoscopia original.

Síndrome de Peutz-Jeghers: poliposis familiar hereditaria como un rasgo autosómico dominante y que se caracteriza por numerosos pólipos en el estómago, intestino delgado y colon y por manchas con contenido de melanina en la piel y membranas mucosas, especialmente en los labios y encías.

GUÍAS RELACIONADAS:

Monitoreo del pH esofágico, 01-91000-01
Cápsula ingerible para registro de pH y presión, 01-91000-08

OTROS:

Otros nombres para informar la endoscopia capsular inalámbrica:

Endoscopia capsular
Endoscopia de cápsula Given
Sistema endoscópico de vídeo telemétrico ingerible
Sistema de diagnóstico por imágenes de vídeo telemétrico ingerible
Cápsula de motilidad inalámbrica (WMC, por sus siglas en inglés)

REFERENCIAS:

  1. American Society for Gastrointestinal Endoscopy Guidelines: Technology Status Evaluation Report; Wireless Capsule Endoscopy, (08/02).
  2. Apostolopoulos P, Liatsos C, Gralnek IM et al. The role of wireless capsule endoscopy in investigating unexplained iron deficiency anemia after negative endoscopic evaluation of the upper and lower gastrointestinal tract. Endoscopy 2006; 38(11): 1127-1132.
  3. Blue Cross Blue Shield Association Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus and Colon Medical Policy 6.01.33, 08/13.
  4. Blue Cross Blue Shield Association TEC Assessment Wireless Capsule Endoscopy in Obscure Digestive Tract Bleeding, Vol. 16, No. 18, 04/02.
  5. ECRI. Emerging Technology (TARGET) Evidence Report. Capsule endoscopy for diagnosis of obscure small-bowel bleeding. Plymouth Meeting, PA: ECRI. Feb 2008.
  6. ECRI. Health Technology Assessment Information Service. Windows on Medical Technology™. Capsule Endoscopy to Determine the Cause of Bleeding Suspected to Be of Small Bowel Origin. December 2006. Issue No. 143.
  7. ECRI. Target Database. Target Report 888. Capsule endoscopy of the esophagus. Plymouth Meeting, PA: ECRI. December 2007.
  8. Eisen GM, Eliakim R, Zaman A, Schwartz J, Faigel D, Rondonotti E, Villa F, Weizman E, Yassin K, deFranchis R. The accuracy of PillCam ESO capsule endoscopy versus conventional upper endoscopy for the diagnosis of esophageal varices: a prospective three-center pilot study. Endoscopy. 2006; (1): 31-5.
  9. Eliakim R, Sharma VK, Yassin K, Adler SN, Jacob H, Cave DR, Sachdev R, Mitty RD, Hartmann D, Schilling D, Riemann JF, Bar-Meir S, Bardan E, Fennerty B, Eisen G, Faigel D, Lewis BS, Fleischer DE. A prospective study of the diagnostic accuracy of PillCam ESO esophageal capsule endoscopy versus conventional upper endoscopy in patients with chronic gastroesophageal reflux diseases. J Clin Gastroenterol. 2005; (7): 572-8.
  10. Eliakim R, Yassin K, Shlomi I, Suissa A, Eisen GM. A novel diagnostic tool for detecting oesophageal pathology: the PillCam oesophageal video capsule. Aliment Pharmacol Ther. 2004 ; 20(10): 1083-9.
  11. First Coast Service Options, Inc. Wireless Capsule Endoscopy LCD L29310, 01/01/13.
  12. Giardiello FM, Allen JI, Axilbund JE et al. Guidelines on Genetic Evaluation and Management of Lynch Syndrome: A Consensus Statement by the US Multi-Society Task Force on Colorectal Cancer. American Journal of Gastroenterology 2014; 109(8): 1159-1179.
  13. Goldfarb NI, Pizzi LT, Fuhr JP, Salvador C, Sikirica V, Kornbluth A, Lewis Blair. Diagnosing Crohn’s Disease: An Economic Analysis Comparing Wireless Capsule Endoscopy with Traditional Diagnostic Procedures. Dis Manag. 2004 Winter; 7(4): 292-304.
  14. Hanauer SB,, Sandborn W, and The Practice Parameters Committee of the American College of Gastroenterology. Management of crohn’s disease in adults. American Journal of Gastroenterology 2001; 96(3): 635-643.
  15. Hartmann D, Schmidt H; Bolz G, Schilling D, Kinzel F, Eickhoff A, Huschner W, Moller K, Jakobs R, Reitzig P, Weickert U; Gellert K, Schultz H, Guenther K, Hollerbuhl H, Schoenleben K, Schulz HJ, Riemann JF. A prospective two-center study comparing wireless capsule endoscopy with intraoperative enteroscopy in patients with obscure GI bleeding. Gastrointest Endosc. 2005 ; 61(7): 826-32.
  16. Hayes, Inc. Hayes Medical Technology Directory. Wireless Capsule Endoscopy November 2003. Update performed January 2006.
  17. Hayes, Inc. Medical Technology Directory. Capsule Endoscopy for Diagnostic Imaging of the Small Bowel. Lansdale, PA: Hayes, Inc.; January 2008.
  18. Hayes, Inc. Medical Technology Directory. Capsule Endoscopy for Diagnostic Imaging of the Esophagus. Lansdale, PA: Hayes, Inc.; January 2008.
  19. Hayes, Inc. Health Technology Brief. Wireless Video Capsule Endoscopy (PillCam™ ESO) (Given Imaging Inc.) for Diagnosis of Esophageal Disease. Lansdale, PA: Hayes, Inc; January 2007.
  20. Kopylov U, Seidman EG. Role of capsule endoscopy in inflammatory bowel disease. World Journal of Gastroenterology 2014; 20(5): 1155-1164.
  21. Lapalus MG, Dumortier J, Fumex F, Roman S, Lot M, Prost B, Mion F, Ponchon T. Esophageal capsule endoscopy versus esophagogastroduodenoscopy for evaluating portal hypertension: a prospective comparative study of performance and tolerance. Endoscopy. 2006; 38(1): 36-41.
  22. Leighton JA, Legnani P, Seidman EG. Role of capsule endoscopy in inflammatory bowel disease: where we are and where we are going. Inflammatory Bowel Diseases 2007; 13(3): 331-7.
  23. Lichtenstein GR, Hanauer SB, Sandborn WJ. Management of crohn’s disease in adults. American Journal of Gastroenterology 2009.
  24. Mata A, Llach J, Castells A, Rovira JM, Pellise M, Gines A, Fernandez-Esparrach G, Andreu M, Bordas JM, Pique JM. A prospective trial comparing wireless capsule endoscopy and barium contrast series for small-bowel surveillance in hereditary GI polyposis syndromes. Gastrointest Endosc. 2005; 61(6): 721-5.
  25. Mekaroonkamol P, Cohn R, Chawla S. Portal hypertensive enteropathy. World Journal of Hepatology 2015; 7(2): 127-138
  26. Mishkin DS, Chuttani R, Croffie J, Disario J, Liu J, Shah R, Somogyi L, Tierney W, Song LM, Petersen BT; Technology Assessment Committee, American Society for Gastrointestinal Endoscopy. ASGE Technology Status Evaluation Report: wireless capsule endoscopy. Gastrointest Endosc. 2006; 63(4): 539-45.
  27. Mitselos IV, Christodoulou DK, Katsanos KH et al. Role of wireless capsule endoscopy in the follow-up of inflammatory bowel disease. World Journal of Gastroenterology 2015; 7(6): 643-651.
  28. Muhammad A, Pitchumoni CS. Newly detected celiac disease by wireless capsule endoscopy in older adults with iron deficiency anemia. Journal of Clinical Gastroenterology 2008; 42(9): 980-983.
  29. National Institute for Clinical Excellence (NICE). Interventional procedures overview of wireless capsule endoscopy, 06/04.
  30. Pennazio M, Rondonotti E, de Franchis R. Capsule endoscopy in neoplastic diseases. World Journal of Gastroenterology 2008; 14(34): 5245-5253.
  31. Qureshi W, Adler DG, Davila R, Egan J, Hirota W, Leighton J, Rajan E, Zuckerman MJ, Fanelli R, Wheeler-Harbaugh J, Baron TH, Faigel DO; Standards of Practice Committee. ASGE Guideline: the role of endoscopy in the management of variceal hemorrhage, updated July 2005. Gastrointest Endosc. 2005; 62(5): 651-5.
  32. Raju GS, Gerson L, Das A, Lewis B; American Gastroenterological Association. American Gastroenterological Association (AGA) Institute medical position statement on obscure gastrointestinal bleeding. Gastroenterology. 2007; 133(5): 1694-6.
  33. Ramirez FC, Shaukat MS, Young MA, Johnson DA, Akins R. Feasibility and safety of string, wireless capsule endoscopy in the diagnosis of Barrett’s esophagus. Gastrointest Endosc. 2005; 61(6): 741-6.
  34. Redondo-Cerezo E, Sanchez-Cepilla AD, De La Torre-Rubio P et al. Wireless capsule endoscopy: perspectives beyond gastrointestinal bleeding. World Journal of Gastroenterology 2014; 20(42): 15664-15673.
  35. Shen B, Remizi FH, Santisi J et al. Application of wireless capsule endoscopy for the evaluation of iron deficiency anemia in patients with ileal pouches. Journal of Clinical Gastroenterology 2008; 42(8): 897-902.
  36. Sieg A, Friedrich K, Sieg U. Is PillCam COLON capsule endoscopy ready for colorectal cancer screening? A prospective feasibility study in a community gastroenterology practice. American Journal of Gastroenterology 2009; 104(4): 848-854.
  37. Stein E, Berger Z, Hutfless S, et al. Wireless Motility Capsule versus Other Diagnostic Technologies for Evaluating Gastroparesis and Constipation: A Comparative Effectiveness Review. Comparative Effectiveness Review No. 110. (Prepared by Johns Hopkins Evidence-based Practice Center under Contract No. 290 2007 10061-I.) AHRQ Publication No. 13-EHC060-EF. Rockville, MD: Agency for Healthcare Research and Quality; May 2013.
  38. Triantafyllou K, Beintaris I, Dimitriadis GD. Is there a role for colon capsule endoscopy beyond colorectal cancer screening? A literature review. World Journal of Gastroenterology 2014; 20(36): 13006-13014.
  39. Trifan A, Singeap AM, Cojocariu C, et al. Small bowel tumors in patients undergoing capsule endoscopy: a single center experience. Journal of Gastrointestinal and Liver Diseases 2010; 19(1): 21-25.
  40. Van Gossum A, Munoz-Navas M, Fernandez-Urien I et al. Capsule endoscopy versus colonoscopy for the detection of polyps and cancer. New England Journal of Medicine 2000; 361: 264-270.
  41. Zuckerman GR, Prakash C, Askin MP, Lewis BS. AGA technical review on the evaluation and management of occult and obscure gastrointestinal bleeding. Gastroenterology. 2000; 118(1): 201-21.

APROBACIÓN DEL COMITÉ:

Esta Guía de cobertura médica (MCG, Medical Coverage Guideline) fue aprobada por el Comité de Normas y Coberturas Médicas de BCBSF el 26/06/2014.

INFORMACIÓN DE LAS ACTUALIZACIONES DE LA GUÍA:

11/15/02

New Medical Coverage Guideline.

05/15/03

Reviewed and revised; investigational status changed.

09/15/03

Added coding clarification note.

01/01/04

Annual HCPCS coding update.

05/15/04

Scheduled review and revision of guideline; consisting of updated references additional indication for coverage and deletion of G0262.

05/15/05

Scheduled review and revision of guideline; consisting of updated references.

10/15/05

Revision to guideline; consisting of the addition of an investigational statement for wireless capsule endoscopy of the esophagus and updated references.

06/15/06

Scheduled review and revision of guideline consisting of updated references.

10/30/06

Revision to guideline consisting of the addition of Program Exception verbiage for Medicare Advantage products.

01/01/07

HCPCS coding update consisting of the addition of 91111.

03/15/07

Scheduled review and revision of guideline consisting of updated references.

06/15/07

Reformatted guideline; updated references.

07/15/08

Review and revision of guideline consisting of updated references.

11/15/09

Annual review. Added experimental or investigational statement for the Given® Patency System. Added program exception for Medicare, ICD-9 codes that support medical necessity for 91110 and 91111. Updated references.

01/01/11

Revision; added related ICD-10 codes.

03/15/11

Added smart pill to section titled “Other”.

11/15/11

Annual review; maintain medical necessity position statement. Revised description; FDA statement. Updated experimental or investigational position statement, added evaluation of the colon including, but not limited to, detection of colonic polyps or colon cancer. Revised/updated definitions. Updated reference.

01/01/13

Annual HCPCS coding update; revised 91110 and 91111 code descriptor.

7/15/14

Annual review; Updated description section. Added “performed during the current episode of illness” to meets the definition of medical necessity statement; Obscure gastrointestinal (GI) bleeding suspected of being of small bowel origin, as evidenced by prior inconclusive upper and lower gastrointestinal endoscopic studies “performed during the current episode of illness”. Added “suspected small bowel tumor” to position statement. Added “ulcerative colitis” and “initial evaluation of patients with acute upper gastrointestinal bleeding (GI) bleeding to experimental or investigational statement. Added ICD-9 diagnoses codes: 211.2, 578.0, 578.1 and 759.6. Added Medicare Advantage products program exception. Updated references for 91110.

10/15/15

Review and revision; added evaluation of members with Crohn’s disease for unexpected change(s) in the course of disease or response to treatment to position statement, added Lynch syndrome, portal hypertensive enteropathy and unexplained chronic abdominal pain to the experimental or investigational position statement, revised experimental or investigational position statement, and updated references.

11/01/15

Revision: ICD-9 Codes deleted.

Date Printed: October 23, 2017: 02:15 AM