CurrentAmbetter NevadaPolicy WA.CP.MP.509

Upper GI Endoscopy for GERD

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This policy governs medical necessity for diagnostic upper gastrointestinal endoscopy in patients with gastroesophageal reflux disease. Coverage is supported when symptoms fail to improve with an adequate trial of medical treatment or when specified alarm symptoms are present.

Policy Summary

PayerAmbetter Nevada

PolicyUpper GI Endoscopy for GERD

Policy CodePolicy WA.CP.MP.509

Change TypeAnnual reviewadministrative update

Effective DateSep 1, 2026

Last ReviewJun 1, 2026

Next Review DateNot specified

Key ActionDiagnostic UGI endoscopy for GERD may not meet medical-necessity criteria when the patient has neither failure of an adequate trial of medical treatment nor an applicable alarm symptom.

SourceLink

POLICY UPDATE CHANGES

The 2026 annual review updated the references and made administrative branding updates.

2qualifying medical-necessity pathways

6specified GERD alarm symptoms

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CurrentAmbetter NevadaPolicy WA.CP.MP.509

Upper GI Endoscopy for GERD

Customize your policy alerts

Sign up for Ambetter Nevada Policy WA.CP.MP.509 alerts

Get alerted when Policy WA.CP.MP.509 changes without checking for updates manually.

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Policy Summary

PayerAmbetter Nevada

PolicyUpper GI Endoscopy for GERD

Policy CodePolicy WA.CP.MP.509

Change TypeAnnual reviewadministrative update

Effective DateSep 1, 2026

Last ReviewJun 1, 2026

Next Review DateNot specified

Key ActionDiagnostic UGI endoscopy for GERD may not meet medical-necessity criteria when the patient has neither failure of an adequate trial of medical treatment nor an applicable alarm symptom.

SourceLink

POLICY UPDATE CHANGES

The 2026 annual review updated the references and made administrative branding updates.

2qualifying medical-necessity pathways

6specified GERD alarm symptoms

Medical Necessity for Diagnostic UGI Endoscopy

Diagnostic UGI Endoscopy for GERD

Diagnostic UGI endoscopy for GERD is medically necessary when at least one of the following conditions is met:

Qualifying medical-necessity pathway

Failed medical treatment: Failure of an adequate trial of medical treatment to improve or resolve symptoms.
Alarm symptoms
- Persistent dysphagia or odynophagia.
- Persistent vomiting of unknown origin.
- Epigastric mass: Evaluation of an epigastric mass.
- Radiologically demonstrated lesion: Confirmation and specific histological diagnosis of radiologically demonstrated lesions.
- Chronic blood loss or iron deficiency anemia: Evaluation of chronic blood loss and iron deficiency anemia when an upper gastrointestinal source is suspected or when colonoscopy results are negative.UGI source suspected or colonoscopy results negative
- Progressive unintentional weight loss.

CPT Codes

CPT CodesCPT

43200	Esophagoscopy, flexible, transoral; diagnostic, incl collection of specimen.
43202	Esophagoscopy, flexible, transoral; w biopsy.
43235	EGD, flexible, transoral; diagnostic, incl collection of specimen.
43237	EGD, flexible, transoral; w/ endoscopic ultrasound exam limited to the esophagus, stomach or duodenum and adjacent structures.
43238	EGD, flexible, transoral; w/ transendoscopic ultrasound-guided intramural or transmural fine need aspiration/biopsy (includes endoscopic ultrasound of esophagus, stomach or duodenum).
43239	EGD, flexible, transoral; w biopsy.
43242	EGD, flexible, transoral; w/ transendoscopic ultrasound-guided intramural or transmural fine need aspiration/biopsy (includes endoscopic ultrasound of esophagus, stomach and duodenum)

When Criteria Are Not Met

Denial Risk

Confirm a qualifying medical-necessity pathway

Diagnostic UGI endoscopy for GERD may not meet medical-necessity criteria unless the patient has either failed an adequate trial of medical treatment to improve or resolve symptoms or has at least one specified alarm symptom.

Document failure of an adequate medical-treatment trial, or
Document an applicable alarm symptom: persistent dysphagia or odynophagia; persistent vomiting of unknown origin; epigastric mass; radiologically demonstrated lesion requiring confirmation and specific histological diagnosis; chronic blood loss and iron deficiency anemia when an UGI source is suspected or colonoscopy results are negative; or progressive unintentional weight loss.

Policy Background

This policy addresses the medical necessity of diagnostic upper gastrointestinal (UGI) endoscopy for gastroesophageal reflux disease (GERD). Endoscopy is considered medically necessary when an adequate trial of medical treatment fails to improve or resolve symptoms, or when specified alarm symptoms warrant evaluation.

The coverage standard is based on the Washington State Health Care Authority (HCA) Health Technology Assessment and Health Care Authority Billing Guidelines.