Upper Gastrointestinal Endoscopy and Gastrointestinal Biopsy
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Defines Aetna's medical necessity, experimental/investigational determinations, indications for diagnostic, therapeutic, surveillance (sequential/periodic) EGD and indications/technique recommendations for upper GI biopsy; includes extensive CPT/HCPCS/ICD-10 code lists for covered and not-covered indications. This is Part 1 of 4.
No material clinical or coverage changes in this update.
Coverage Summary
Scope: This Aetna Clinical Policy Bulletin (Number 0738) defines medical necessity, experimental/investigational determinations, and selection criteria for upper gastrointestinal endoscopy (EGD) and gastrointestinal biopsy—covering diagnostic, therapeutic, surveillance (sequential/periodic) uses, biopsy technique guidance (e.g., Seattle Protocol), and extensive CPT/HCPCS/ICD-10 code lists. Effective: 2007-11-09; Last review: 2023-10-04. High-level stance: multiple EGD indications are covered when criteria are met (diagnostic, therapeutic, surveillance, biopsy); a range of uses (including routine screening EGDs and many EndoFLIP applications) are designated experimental/investigational or not covered. This document is Part 1 of 4.
Medical-Necessity Criteria (Initial / Diagnostic / Therapeutic / Surveillance)
Medical Necessity - High-risk screening EGD (EGD/upper endoscopy)
Covered when ANY of the following are met:
ANY of the following
- 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.>= 5 years
- Persons with symptomatic pernicious anemia to identify prevalent lesions (e.g., carcinoid tumors, gastric cancer).
symptoms example: anemia, fatigue, pallor, red tongue, shortness of breath, tingling and numbness in hands and feet
- 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.platelets < 140,000/mm3
Medical Necessity - Diagnostic EGD
Covered when ANY of the following are met:
ANY of the following
- 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., PPI, with/without prokinetic, antidepressant).
- Evaluation of dyspepsia in persons who are H. pylori negative and who have undergone an appropriate trial of PPI therapy (defined as 2-4 week course of standard dose, once daily PPI).2-4 weeks PPI
- 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.age < 60 with alarm signs
- Evaluation of dyspepsia in persons over 60 years of age.age >= 60
- Evaluation of dysphagia or odynophagia.
- Evaluation of esophageal reflux symptoms that are persistent or recurrent despite appropriate therapy (appropriate therapy consists of an 8 week trial of standard dose once daily PPI; in patients with partial response, the dose may be increased to twice daily).8 weeks PPI (may increase to BID)
- Evaluation of esophageal masses and for directing biopsies for diagnosing esophageal cancer.
- Evaluation of persons with signs or symptoms of loco-regional recurrence after resection of esophageal cancer.
- Evaluation of persistent vomiting of unknown cause.
- Evaluation of other diseases in which the presence of upper GI pathological conditions might modify other planned management (e.g., persons scheduled for organ transplantation, long-term anticoagulation, long-term NSAID therapy for arthritis, and those with head and neck cancer).
- Evaluation of familial adenomatous polyposis syndromes.
Confirmation and specific histological diagnosis of radiologically demonstrated lesions
- Gastric or esophageal ulcer.
- Suspected neoplastic lesion.
- Upper GI tract stricture or obstruction.
- Evaluation of GI bleeding: for persons with active or recent bleeding; for presumed chronic blood loss and for iron deficiency anemia when clinical situation suggests an upper GI source or colonoscopy is negative.
- Sampling of upper GI tissue or fluid.
- Evaluation of persons with suspected portal hypertension to document or treat esophageal varices.
- Evaluation of acute injury after caustic ingestion.
- 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).
- Diagnosis of irritable bowel syndrome when other studies (colonoscopy, enteroscopy, ileoscopy, flexible sigmoidoscopy) have negative results.
- Differentiation of Crohn's disease from ulcerative colitis in indeterminate colitis.
Medical Necessity - Therapeutic EGD
Covered when ANY of the following therapeutic interventions are performed:
ANY of the following
- Banding or sclerotherapy of varices.
- Dilation of stenotic lesions (e.g., with trans-endoscopic balloon dilators or dilation systems using guide wires).
- Management of achalasia by means of botulinum toxin, balloon dilation.
- Palliative treatment of stenosing neoplasms by laser, multi-polar electrocoagulation, stent placement.
- Per-oral endoscopic myotomy (POEM) for treatment of type III (spastic) achalasia.
- Placement of feeding or drainage tubes (peroral, trans-nasal, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy).
- Removal of foreign bodies or selected polypoid lesions.
- Treatment of bleeding lesions such as ulcers, tumors, and vascular abnormalities by electrocoagulation, heater probe, laser photocoagulation, or injection therapy.
Medical Necessity - Sequential or periodic EGD (surveillance)
Covered when ANY of the following surveillance circumstances are met and intervals described:
ANY of the following
- Surveillance of persons with Barrett's esophagus (BE) without dysplasia: after 2 consecutive examinations within 1 year, acceptable interval for additional surveillance is every 3 years.after 2 N within 1 year then q3y
- 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.6 months then 12 months then yearly
- Surveillance of persons with BE and high-grade dysplasia: every 3 months for at least 1 year - after 1 year of no cancer detection, interval may be lengthened if no dysplasia on 2 subsequent 3-month interval endoscopies.q3 months x >=1 year then may lengthen after 2 negative q3m exams
- Surveillance of persons with severe caustic esophageal injury: every 1 to 3 years beginning 15 to 20 years after the injury.every 1-3 years starting 15-20 years post-injury
- Surveillance of persons with tylosis: every 1 to 3 years beginning at 30 years of age.every 1-3 years from age 30
- Surveillance of recurrence of adenomatous polyps in synchronous and metachronous sites at 3- to 5-year intervals.q3-5 years
- Surveillance of persons with familial adenomatous polyposis starting around time of colectomy or after age 30 years.around colectomy or age >=30
- Surveillance of persons with hereditary non-polyposis colorectal cancer.consider in high-risk individuals
Medical Necessity - Biopsy indications and technique recommendations
Biopsy of the upper GI tract is medically necessary for the following indications and sampling guidance:
ANY of the following
- GERD: biopsies directed to irregularities of the mucosa.
Barrett's esophagus - Seattle Protocol
- Without dysplasia - 4 quadrant biopsies each 2 cm.every 2 cm
- With low-grade dysplasia - 4 quadrant biopsies each 1-2 cm.every 1-2 cm
- With high-grade dysplasia - 4 quadrant biopsies each 1 cm.every 1 cm
- Eosinophilic esophagitis - up to 8 biopsies of the esophagus, plus gastric antrum and duodenum biopsies if suspicion of eosinophilic gastroenteritis.up to 8 esophageal biopsies
Infectious esophagitis
- CMV infection - biopsies from base of ulcers.
- HSV infection - biopsies from edges of ulcers.
- Esophageal candidiasis - biopsies from affected areas plus exfoliative cytology.
- Helicobacter pylori - up to 5 biopsies (Sydney protocol).up to 5 biopsies
Metaplastic (chronic) atrophic gastritis
- Environmental metaplastic atrophic gastritis - up to 12 biopsies.up to 12 biopsies
- Autoimmune atrophic metaplastic gastritis (AMAG) - biopsies of ulcers, nodules, polyps, and masses to rule out neoplasia.
- Gastric polyps - number of medically necessary biopsies determined by number of polyps.
- Peptic ulcer disease - 8 or more biopsies, from base and edges if suspicion of malignancy.>=8 biopsies
- Celiac disease - up to 2 biopsies of duodenal bulb and 4 or more biopsies of distal duodenum.2 bulb + >=4 distal
- Inflammatory bowel disease, diagnosis - two or more biopsies from esophagus, stomach and duodenum.>=2 biopsies per site
- Acute graft versus host disease - when flexible sigmoidoscopy non-diagnostic, perform upper endoscopy with four or more biopsies from gastric body, antrum and duodenum.>=4 biopsies per region
Medical Necessity - Endoscopic Submucosal Dissection (ESD) for Barrett's esophagus or early esophageal lesions
ESD is medically necessary when ANY of the following criteria are met:
ANY of the following
- Barrett's esophagus with high-grade dysplasia (HGD) with a visible lesion > 1.5 cm.> 1.5 cm
- Early esophageal cancer by endoscopic ultrasonography (EUS) with a negative PET scan.EUS suggesting early cancer + negative PET
- Esophageal polyps unable to be removed by snare techniques.
- Recurrent HGD (visible lesion(s)).
- Submucosal esophageal adenocarcinoma (T1b) with low-risk features (less than 500-μm invasion in submucosa [sm1], good-to-moderate differentiation, and no lymphatic invasion).submucosal invasion < 500 μm
- Submucosal masses of > 2.0 cm.> 2.0 cm
Not Covered / Experimental and Investigational
Experimental and Investigational - EGD and related technologies
Considered experimental and investigational (not established) for ANY of the following uses:
ANY of the following
- EGD (screening, diagnostic, therapeutic, or sequential/periodic) for: EGD before bariatric surgery in asymptomatic individuals; EGD for confirming placement of gastric band; EGD for diagnosing laryngopharyngeal reflux; EGD for routine screening; evaluation of symptoms considered functional in origin (except single EGD to rule out organic disease when unresponsive to therapy); evaluation of metastatic adenocarcinoma of unknown primary when results will not alter management; repeat EGD after a prior normal EGD if symptoms unchanged; routine evaluation of abdominal pain in children without other signs; evaluation of asymptomatic or uncomplicated sliding hiatal hernia; deformed duodenal bulb when asymptomatic or responsive to therapy; uncomplicated duodenal ulcer that has responded to therapy; surveillance for malignancy in gastric atrophy, pernicious anemia, or prior gastric operations for benign disease; surveillance of healed benign disease (e.g., esophagitis or duodenal/gastric ulcer); surveillance during repeated dilations of benign strictures unless change in status; surveillance of achalasia; surveillance of prior aerodigestive squamous cell cancer; surveillance of gastric intestinal metaplasia; surveillance after adequate sampling or removal of non-dysplastic gastric polyps.
- Endoscopic functional luminal imaging probe (EndoFLIP / impedance planimetry) for management of listed conditions (achalasia, dysphagia, esophagitis, EGJ outflow obstruction, fecal incontinence, GERD, gastroparesis, prediction of response in Zenker's diverticulotomy, upper GI tract stenosis).
- Screening upper endoscopy (routine screening) is considered experimental and investigational; no current guidelines recommend routine upper endoscopy screening of asymptomatic persons.
Coverage — General Indications, Not Generally Indicated, Surveillance, Biopsy, and Contraindications
Coverage — General clinical indications for EGD
Covered when ALL of the following general indications or specific diagnostic/treatment needs are met:
ALL of the following
- Evaluation of dyspepsia in individuals <60 only after noninvasive H. pylori testing and treatment if positive; or when dyspepsia persists despite appropriate trial of therapy.age < 60: H. pylori test required then treat if positive; PPI trial as defined
- Evaluation of dysphagia or odynophagia.
- Progressive or significant (>20 lbs) weight loss.> 20 lbs
- Esophageal reflux symptoms persistent or recurrent despite appropriate therapy.8 week PPI trial initial
- Persistent vomiting of unknown cause.
- Suspected neoplastic lesion, gastric or esophageal ulcer, upper tract stricture or obstruction.
- Gastrointestinal bleeding: active/recent bleeding or presumed chronic blood loss/IDA when upper source suspected or colonoscopy negative.
- Sampling of tissue or fluid is indicated (biopsy).
- Patients with suspected portal hypertension to document or treat esophageal varices.
- Assessment of acute injury after caustic ingestion.
- Treatment of bleeding lesions, banding/sclerotherapy of varices, removal of foreign bodies, removal of selected polypoid lesions, placement of feeding or drainage tubes, dilation of stenotic lesions, management of achalasia, palliative treatment of stenosing neoplasms.
Not generally indicated
EGD is generally not indicated when ANY of the following apply:
ANY of the following
- Symptoms considered functional in origin (except limited situations to rule out organic disease).
- Metastatic adenocarcinoma of unknown primary when results will not alter management.
- Radiographic findings of asymptomatic or uncomplicated sliding hiatal hernia.
- Uncomplicated duodenal ulcer that responded to therapy.
- Deformed duodenal bulb when symptoms absent or respond to therapy.
Surveillance/Sequential EGD — Indications
Sequential or periodic EGD may be covered when surveillance for malignancy or specific high-risk conditions is indicated:
ANY of the following
- Surveillance for malignancy in patients with pre-malignant conditions such as Barrett's esophagus.
- Patients with confirmed gastric high-grade dysplasia (consider gastrectomy or local resection or aggressive endoscopic therapy).
- Severe caustic esophageal injury surveillance every 1 to 3 years beginning 15 to 20 years after injury.every 1-3 years starting 15-20 years
- Tylosis surveillance every 1 to 3 years beginning at age 30.every 1-3 years from age 30
- Patients with familial adenomatous polyposis regular surveillance endoscopy starting around time of colectomy or after age 30.around colectomy or age >=30
- Consider surveillance for certain hereditary non-polyposis colorectal cancer patients (high risk).
Endoscopic biopsy coverage
Biopsy of the upper GI tract is covered when selection criteria/indications are met (e.g., suspected infection, neoplasm, gastritis, ulcers, celiac disease, IBD, suspected H. pylori, dysphagia, unexplained symptoms warranting tissue diagnosis).
ANY of the following
- Biopsy indicated to confirm histological diagnosis of radiologically demonstrated lesions.
- Biopsy indicated for suspected infectious esophagitis (e.g., herpesviral, CMV, candidal).
- Biopsy indicated for evaluation of celiac disease, gastritis/duodenitis, inflammatory bowel disease when EGD indicated.
- AGA recommends against routine biopsies of normal-appearing esophagus or GE junction when dyspepsia is sole indication.
Procedural contraindications
Absolute and relative contraindications to EGD:
ANY of the following
- Absolute contraindications: Shock, peritonitis, fulminant colitis, perforated viscus, severe cardiac decompensation, acute myocardial infarction (unless active life-threatening hemorrhage present)
- Relative contraindications: Obtunded or uncooperative subject, coma (unless intubated), cardiac arrhythmias or recent myocardial ischemia
Coding
Provider Actions
Document medical indication and prior therapy
Document the specific clinical indication and prior treatments (e.g., prior noninvasive H. pylori testing and eradication status, and prior adequate trials of PPI or other therapy) in the medical record when requesting or performing EGD/biopsy to support medical necessity.
Document Barrett's esophagus biopsy sampling
When performing biopsies for Barrett's esophagus, record the number and spacing of four-quadrant biopsies per the Seattle Protocol (no dysplasia: every 2 cm; low-grade dysplasia: every 1–2 cm; high-grade dysplasia: every 1 cm) and document biopsy results in the chart.
Prior authorization may be required for therapeutic/complex procedures
Prior authorization may be required for complex or advanced therapeutic procedures (for example, ESD, POEM, advanced EUS-guided interventions); follow applicable payer prior authorization processes and verify requirements prior to scheduling.
H. pylori testing before endoscopy in patients <60 with dyspepsia
For patients younger than 60 with dyspepsia, document noninvasive H. pylori testing and treatment if positive, and persistent symptoms despite eradication, before proceeding with endoscopy; include H. pylori test type and eradication status in the record.
Indication documentation for biopsy and surveillance
Document the specific clinical indication when performing biopsy or surveillance EGD (examples: suspected neoplasm, active or recent GI bleeding, iron deficiency anemia with suspected upper source, Barrett's esophagus surveillance, severe caustic injury follow-up) so that procedure selection and frequency align with policy criteria.
Code selection per procedure type
Select and report procedure codes that match the service rendered; for example, use 0653T for transnasal EGD with biopsy and C9779 for endoscopic submucosal dissection when criteria are met. Ensure diagnosis codes on the claim support the medical necessity for the selected procedure.
Routine biopsies of normal-appearing esophagus not supported for dyspepsia-only indication
Routine biopsies of a normal-appearing esophagus or gastroesophageal junction for dyspepsia as the sole indication are not supported and may be denied; if such biopsies are performed, document a clear clinical justification tied to policy exceptions.
Consider selective pre-operative EGD before bariatric surgery
Selective pre-operative EGD before bariatric surgery should be based on symptoms, risk factors, and planned procedure type; document symptom status and rationale when obtaining pre-op EGD in asymptomatic or average-risk patients.
EndoFLIP is investigational/experimental in many applications
EndoFLIP (impedance planimetry) is considered investigational/experimental for many clinical applications listed in the policy (eg, achalasia, dysphagia, GERD, gastroparesis, prediction of outcome for Zenker's diverticulotomy, upper GI stenosis); document if used and recognize it may not establish coverage.
Use guideline-based indications for ESD vs EMR
When selecting endoscopic resection technique for Barrett's esophagus, document lesion size, morphology, suspicion for submucosal invasion, prior EMR findings (eg, positive margins), and other features to justify ESD versus EMR per guideline recommendations (EMR appropriate ≤1.0 cm; EMR or ESD 1.1–2.0 cm; ESD preferred >2.0 cm or for suspected submucosal invasion).
Document EndoFLIP procedural parameters
If EndoFLIP is used intra-procedurally, document the distension volume (eg, 30-ml or 40-ml as used in studies), pre- and post-intervention metrics (eg, distensibility index, narrowest CSA, balloon pressure), and presence of hiatal hernia to support interpretation of measurements.
Background and Evidence Summaries
Background summary: The policy reviews the role of standardized biopsy protocols and advanced tools in upper GI practice. The Seattle Protocol (four-quadrant biopsies at spacing adjusted by dysplasia status) and the Sydney protocol for H. pylori sampling are included as sampling guidance. Studies of EndoFLIP (impedance planimetry) report its capability to measure cross-sectional area, pressure, and distensibility intra-procedurally (used in POEM, tailored fundoplication, pyloric assessment, Zenker's diverticulum), with promising but preliminary results and calls for larger standardized studies.
Guideline and study points: major guideline and evidence excerpts note that ESD may be appropriate for Barrett's lesions with features suspicious for submucosal invasion, large/bulky nodularity, recurrent visible dysplasia, or lesions > 2.0 cm, while EMR is appropriate for smaller lesions (≤ 1.0 cm), and that ESD provides higher en bloc, R0 and curative rates but longer procedure time and higher perforation risk; a multicenter retrospective series showed markedly lower recurrence with ESD versus EMR (recurrence ~ 3.5% ESD vs 31.4% EMR).
Limitations: the policy emphasizes study limitations — small sample sizes, single-operator/center series, variability in EndoFLIP measurement volumes (30- vs 40-ml), confounding factors such as hiatal hernia, inconsistent case definitions (ERD vs NERD), and the need for standardized metrics and larger multicenter trials to validate EndoFLIP and some procedural innovations. Additionally, an RCT of fibrin glue after gastric ESD in high-risk patients found no reduction in overall bleeding (though acute bleeding was lower), illustrating mixed or limited high-quality evidence for some adjunctive interventions.
Definitions
Appropriate trial of PPI therapy (for dyspepsia): a 2–4 week course of standard dose, once-daily proton pump inhibitor.
Appropriate therapy for reflux: an 8-week trial of standard dose once-daily PPI; dose may be increased to twice daily for partial responders.
Seattle Protocol (Barrett's esophagus biopsy): four-quadrant biopsies spaced by dysplasia status — without dysplasia every 2 cm; low-grade dysplasia every 1–2 cm; high-grade dysplasia every 1 cm.
Occult GI bleeding: initial presentation of positive FOBT and/or iron-deficiency anemia without visible fecal blood.
Obscure GI bleeding: bleeding of unknown origin that persists or recurs after negative initial primary endoscopy (colonoscopy and/or upper endoscopy).
EndoFLIP (FLIP, impedance planimetry): a catheter-mounted balloon device measuring cross-sectional area and intra-luminal pressure to calculate distensibility index and other luminal geometry metrics during endoscopy.
EGD / EGD (esophagogastroduodenoscopy): upper endoscopic examination of the esophagus, stomach, and duodenum.
DI (Distensibility index): distensibility index measured by FLIP (e.g., mm2/mmHg); nCSA: narrowest cross-sectional area measured by FLIP (mm2).
Revision History
Policy number 0738 became effective.
Policy number 0738 last reviewed.
Planned next review date for policy number 0738.
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