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    v1.0.28
    OpenPayerPolicy UpdatesGastroenterologyBCBS Vermont Capsule Endoscopy Coverage | OpenPaye…
    Ask Trek AI about this page
    ModifiedBlue Cross Blue Shield of VermontPolicy 6.01.VT33

    Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders Corporate Medical Policy

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    This policy governs coverage and medical necessity for wireless capsule endoscopy, patency capsule use, and magnetic capsule endoscopy for gastrointestinal conditions. It applies to providers seeking reimbursement from Blue Cross Blue Shield of Vermont, subject to the member’s contract and required prior approval.

    Policy Summary
    PayerBlue Cross Blue Shield of Vermont
    PolicyWireless Capsule Endoscopy for Gastrointestinal (GI) Disorders
    Policy CodePolicy 6.01.VT33
    Change TypeModified
    Effective DateApr 1, 2025
    Last ReviewJan 1, 2025
    Next Review DateJan 1, 2026
    Key ActionPrior approval is required for services governed by this policy.
    SourceLink
    POLICY UPDATE CHANGES

    The policy added lower gastrointestinal bleeding with major risks for colonoscopy or moderate sedation and incomplete colonoscopy to the investigational indications.

    The policy added CPT code 0651T as requiring prior approval and later added CPT code 91113 as requiring prior approval.

    In January 2025, codes 91110, 91112, and 91113 were removed from the list of codes requiring prior approval.

    In February 2022, code 0651T was changed from requiring prior approval to investigational status.

    4Medically necessary indication categories
    2Investigational codes

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    RequiredPrior approval
    1Covered code without prior approval
    Recoupment riskAudit noncompliance

    Coverage Criteria

    Medically necessary wireless capsule endoscopy

    Wireless capsule endoscopy of the small bowel may be considered medically necessary when ANY of the following indications is met.

    Medically necessary indications

    • Suspected small bowel bleeding: The patient has suspected small bowel bleeding, evidenced by prior inconclusive upper and lower gastrointestinal endoscopic studies performed during the current episode of illness.Prior inconclusive upper and lower GI endoscopy during the current illness episode
    • Initial suspected Crohn disease diagnosis: The patient has suspected Crohn disease without evidence of disease on conventional diagnostic tests such as small bowel follow-through and upper and lower endoscopy.No evidence on conventional diagnostic testing
    • Established Crohn disease reassessment: The patient has an established diagnosis of Crohn disease and has unexpected changes in the course of disease or response to treatment suggesting that the initial diagnosis may be incorrect and reexamination may be indicated.Unexpected disease-course or treatment-response change
    • Hereditary gastrointestinal polyposis surveillance: The procedure is being performed for surveillance of the small bowel in a patient with a hereditary gastrointestinal polyposis syndrome, including familial adenomatous polyposis or Peutz-Jeghers syndrome.Hereditary GI polyposis syndrome

    Investigational services and indications

    Other indications of wireless capsule endoscopy are considered investigational, including but not limited to the following.

    Investigational indications

    • Crohn disease or ulcerative colitis extent: Evaluation of the extent of known Crohn disease or ulcerative colitis.
    • Esophageal evaluation: Evaluation of the esophagus in patients with gastroesophageal reflux disease or other esophageal pathologies.
    • Other non-bleeding GI conditions: Evaluation of celiac sprue, irritable bowel syndrome, Lynch syndrome, portal hypertensive enteropathy, small bowel neoplasm, unexplained chronic abdominal pain, or other gastrointestinal diseases and conditions not presenting with gastrointestinal bleeding.
    • Colon evaluation:

    Patency capsule use is considered investigational, including use to evaluate gastrointestinal tract patency before wireless capsule endoscopy.

    Magnetic capsule endoscopy is considered investigational for evaluation of patients with unexplained upper abdominal complaints and for all other indications.

    Magnetically controlled capsule endoscopy represented by CPT code 0651T is considered investigational and will be denied.

    Esophageal intraluminal gastrointestinal tract imaging represented by CPT code 91111 is considered investigational and will be denied.

    Coding and Code Status

    Codes requiring prior approvalCPT
    0651TCode requiring prior approval
    91113Code requiring prior approval
    Medically necessary when applicable criteria have been met; no prior approval requiredCPTCovered
    91110Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus through ileum, with interpretation and report.
    Prior approval requiredCPTCovered
    91112Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report.
    InvestigationalCPT
    0651TMagnetically controlled capsule endoscopy, esophagus through stomach, including intraprocedural positioning of capsule, with interpretation and report.
    91111Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus with interpretation and report.

    Provider and Authorization Requirements

    Prior Authorization

    Prior Approval and Contract Terms

    Prior approval is required for services addressed by this policy, and benefits remain subject to all terms, limitations, and conditions of the subscriber contract. Member contract language takes precedence over this medical policy when the two conflict.

    • Coverage varies by the member’s group or individual contract.
    • Not all groups are required to follow Vermont legislative mandates.
    Prior Authorization

    NEHP and ABNE Authorization

    Members enrolled in the New England Health Plan (NEHP) require an approved referral authorization. Access Blue New England (ABNE) members require prior approval, and benefits may differ for both products.

    • Confirm applicable benefits with the member’s health plan customer service department.
    • Member-specific authorization and benefit requirements apply.

    Background

    Wireless capsule endoscopy is a noninvasive gastrointestinal imaging procedure in which a patient swallows a capsule that records images of the gastrointestinal mucosa as it passes through the gastrointestinal tract. The capsule is later excreted, and the recorded images are interpreted.

    Definitions

    Wireless capsule endoscopy
    Procedure typeA noninvasive, device-based procedure
    How it is performedThe patient swallows a capsule that records images of the intestinal mucosa as it passes through the gastrointestinal tract.
    After the procedureThe capsule is collected after excretion, and the recorded images are interpreted.
    Suspected small bowel bleeding
    TermSuspected small bowel bleeding
    Former terminologyPreviously referred to as obscure gastrointestinal bleeding.
    Clinical context
    Policy Summary
    PayerBlue Cross Blue Shield of Vermont
    PolicyWireless Capsule Endoscopy for Gastrointestinal (GI) Disorders
    Policy CodePolicy 6.01.VT33
    Change TypeModified
    Effective DateApr 1, 2025
    Last ReviewJan 1, 2025
    Next Review DateJan 1, 2026
    Key ActionPrior approval is required for services governed by this policy.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Code StatusProvider and Authorization RequirementsBackgroundDefinitions
    Evaluation of the colon, including detection of colonic polyps or colon cancer.
  1. Acute upper GI bleeding: Initial evaluation of acute upper gastrointestinal bleeding.
  2. Lower GI bleeding with procedural risk: Evaluation of patients with evidence of lower gastrointestinal bleeding and major risks for colonoscopy or moderate sedation.
  3. Incomplete colonoscopy: Evaluation of patients following incomplete colonoscopy.
  4. Patency capsule: Use of a patency capsule, including to evaluate gastrointestinal tract patency before wireless capsule endoscopy.
  5. Magnetic capsule endoscopy for unexplained upper abdominal complaints and all other indications.
    6. Prior Authorization

    Specific CPT Codes Requiring Approval

    Prior approval is required for the specified CPT codes before providing the service.

    • CPT 0651T — prior approval required.
    • CPT 91113 — prior approval required.
    Prior Authorization

    Prior Approval for CPT 91112

    The current CPT code table lists CPT 91112 as requiring prior approval. Submit the authorization before the service is performed.

    • CPT 91112 — prior approval required.

    Unsupported block type: documentation пон:documentation

    Unsupported block type: documentation

    Unsupported block type: info

    Unsupported block type: denial_risk

    Unsupported block type: denial_risk

    Unsupported block type: denial_risk

    Denial Risk

    Audit Noncompliance May Trigger Recoupment

    BCBSVT may audit any provider or facility for compliance with this medical policy. If an audit identifies noncompliance, BCBSVT may recoup all noncompliant payments.

    • Maintain documentation demonstrating compliance with the policy guidelines.
    Denial Risk

    Investigational Capsule Endoscopy Codes

    Claims for the listed investigational capsule endoscopy codes will be denied as investigational.

    • CPT 0651T — magnetically controlled capsule endoscopy, esophagus through stomach, including intraprocedural positioning, interpretation, and report.
    • CPT 91111 — gastrointestinal tract imaging, intraluminal capsule endoscopy of the esophagus, with interpretation and report.
    The condition may involve a bleeding source that cannot be diagnosed by other methods, including after negative upper and lower endoscopy.