ModifiedCapital BluecrossPolicy MP 5.033

Wireless Capsule Endoscopy for Gastrointestinal Disorders

Defines medical necessity and investigational indications for wireless capsule endoscopy and variant devices for Capital BlueCross products; applies to clinicians ordering or performing CE and utilization reviewers.

Policy Summary

PayerCapital Bluecross

PolicyWireless Capsule Endoscopy for Gastrointestinal Disorders

Policy CodePolicy MP 5.033

Change TypeMaterial updates to investigational indications and coding

Effective DateAug 1, 2025

Next Review Date

Key ActionFor suspected small bowel bleeding, obtain documentation of prior inconclusive upper and lower endoscopies during the current episode before requesting capsule endoscopy.

SourceLink

POLICY UPDATE CHANGES

Changed iron deficiency anemia, celiac disease and suspected small bowel tumors when not associated with GI bleeding from medically necessary to investigational.

Changed patency capsule to investigational.

Added CPT/HCPCS code 0977T.

Added new ICD-10 codes Z83.72, Z86.0100, Z86.0101, Z86.0102, Z86.0109.

Patency capsule position changed multiple times historically (medically necessary then investigational).

4+Medically necessary categories

Jan 31, 2025Key indications moved to investigational

Multiple

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FDA-cleared devices summarized

2Procedure codes covered when necessary

4+Procedure codes investigational

multiplePolicy history entries

Coverage Criteria for Capsule Endoscopy

Prior Authorization

Provider action: Coverage tied to product and documented indication

Wireless capsule endoscopy (CE) coverage is product- and indication-specific. Prior to performing CE, providers must verify the member's benefit coverage and medical necessity for the specific indication. Documentation supporting the clinical indication must be available in the medical record and submitted with any prior authorization or claim as required by the payer.

Confirm member benefit for capsule endoscopy under the member's specific product prior to scheduling.
Obtain and document the clinical indication that meets the medically necessary criteria in the member's chart.
Submit required clinical documentation with prior authorization requests and with claims to support medical necessity.
Verify coding and billing requirements; ensure the procedure and any associated codes (including modifiers) reflect the service provided and the clinical indication.

Denial Risk

Provider action: Investigational indications trigger denials

Use of wireless capsule endoscopy for indications listed as investigational or not medically necessary may be denied. When CE is performed for an indication categorized as investigational, expect claim denial and potential member liability if the service is not covered by the member's benefit.

Services coded with investigational procedure codes (e.g., 0651T, 91111, 91113, 0977T) or billed for investigational indications may be denied.
Patency capsule and magnetic capsule endoscopy are considered investigational per the policy update (01/31/2025) and are not covered.
If an investigational indication is documented, include rationale and attempt prior authorization only if the member's benefit allows case-by-case review.

Documentation Required

Provider action: Clinical indication documentation

Clinical documentation must demonstrate the specific medical indication that meets the policy's medically necessary criteria. Examples of required documentation include prior endoscopy reports, radiographic studies, laboratory results (e.g., evidence of GI bleeding), symptom history, and prior treatment response. For cases of suspected small bowel bleeding, documentation must show prior inconclusive upper and lower GI endoscopic evaluations during the current episode of illness.

Attach relevant endoscopy and imaging reports to prior authorization requests and to the medical record.
Document symptom chronology, prior diagnostic workup, and why alternative standard procedures (eg, conventional endoscopy or radiography) were not diagnostic or feasible.
For surveillance in hereditary GI polyposis syndromes, include genetic diagnosis and prior surveillance findings or rationale for CE.
For established Crohn's disease, document change in clinical course or treatment response prompting re-evaluation.

Prior Authorization

Provider action: Benefit and medical necessity verification

Prior authorization and benefit verification are required when specified by the member's product. Providers should confirm whether CE requires prior authorization and follow payer-specific submission processes. Failure to obtain required benefit verification or authorization may result in denial or member responsibility.

Perform benefit verification at scheduling to confirm coverage, prior authorization requirements, and any patient cost-sharing.
When prior authorization is required, submit complete clinical documentation supporting the indication and any required forms.
Retain payer responses (authorization numbers, scope, and dates) in the patient's chart and include authorization references on claims if required.

Billing Rule

Provider action: Coding and claim documentation

Accurate coding and claim documentation are required to support coverage decisions. Use covered procedure codes for CE when medically necessary and avoid codes reserved for investigational procedures. When applicable, include diagnosis codes that substantiate the medical necessity of the service.

Submit covered CE procedure codes only when the indication meets medical necessity (e.g., 91110, 91299 when applicable).
Do not use investigational procedure codes (0651T, 91111, 91113, 0977T) for medically necessary services — these codes are listed as investigational and may trigger denials.
Include the primary diagnosis code that best reflects the clinical indication (eg, documented GI bleeding, established Crohn's disease with change in course).
When submitting claims for services preceded by a patency capsule, note that the patency capsule is considered investigational per the 01/31/2025 update and 91299 is only covered when used for patency capsule per previous coding table guidance; verify current allowed codes and payer policy before billing.
Maintain contemporaneous clinical records to support coding choices and be prepared to provide records upon request.

Coding and Device Information

FDA-cleared devices / 510(k) numbersmixed

K211684	Pillcam SB 3 Capsule Endoscopy System clearance 8/27/2021
K203192	NaviCam Stomach Capsule System clearance 5/22/2020
K183192	CapsoCam Plus (SV-3) clearance 4/19/2019
K183053	Olympus Small Intestinal Capsule Endoscope System clearance 3/5/2019
K180732	MiroCam Capsule Endoscope System clearance 11/8/2018
K180171	PillCam Patency System clearance 3/8/2018
K170438	MiroCam Capsule Endoscope clearance 1/30/2018
K170210	PillCam SBC capsule endoscopy system clearance 9/1/2017
K170839	RAPID Web clearance 5/26/2017
K163495	AdvanCE capsule delivery device clearance 3/10/2017

1–10 of 16

1/2

Investigational; therefore, not covered (Procedure Codes)CPTNot Covered

0651T
91111
91113
0977T

Covered when medically necessary (Procedure Codes)CPTCovered

91110
91299	Covered when used for patency capsule

Investigational; therefore, not covered (Diagnosis Codes)ICD-10Not Covered

D13.91	Familial adenomatous polyposis
D50.0	Iron deficiency anemia secondary to blood loss (chronic)
D50.8	Other iron deficiency anemias
K50.00	Crohn's disease of small intestine without complications
K50.011	Crohn's disease of small intestine with rectal bleeding
K50.012	Crohn's disease of small intestine with intestinal obstruction
K50.013	Crohn's disease of small intestine with fistula
K50.014	Crohn's disease of small intestine with abscess
K50.018	Crohn's disease of small intestine with other complication
K50.10	Crohn's disease of large intestine without complications

1–10 of 31

1/4

Procedure code history and current additionsHCPCS

0355T	Replaced by 91113 per administrative update
91113	Capsule endoscopy code (noted as replacement for 0355T; later policy history indicates status changed)
0977T	New code added effective 07/01/2025

ICD-10 codes added administrativelyICD-10

Z83.72	Added code (policy history)
Z86.0100	Added code (policy history)
Z86.0101	Added code (policy history)
Z86.0102	Added code (policy history)
Z86.0109	Added code (policy history)

Device-specific constraints — Magnetic capsule endoscopy (NaviCam™) and similar systems

Age requirementAdults 22 years of age or older

BMI constraintBody mass index less than 38

Device contraindications (excerpt)Contraindicated in patients with gastrointestinal obstruction, stenosis, fistula, or dysphagia

Implantable device cautionContraindicated for patients with cardiac pacemakers or other implantable electronic medical devices

PregnancyNot for use in pregnant women

Provider Actions, Billing, and Documentation

Prior Authorization

Verify product coverage and documented indication

Medical necessity for capsule endoscopy must match the covered indications in this policy and the policy applies only to certain Capital BlueCross programs and products; benefit variations may affect coverage (see FEP PPO reference).

Confirm the indication aligns with the listed medically necessary criteria (e.g., suspected small bowel bleeding with prior inconclusive upper and lower endoscopy).
Check product-specific benefit variations prior to ordering or billing (FEP PPO uses a separate manual).

Billing Rule

Use covered procedure codes when medically necessary

Coverage is limited to procedure codes 91110 and 91299 (91299 only when used for patency capsule) when medically necessary; listed investigational procedure codes (0651T, 91111, 91113, 0977T) are not covered.

Bill only 91110 or 91299 (per policy guidance) for covered capsule endoscopy services when criteria are met.
Do not submit investigational procedure codes for reimbursement expecting coverage.

Background

Wireless capsule endoscopy (CE) is a noninvasive, single-use ingestible camera that transits the gastrointestinal tract and wirelessly transmits images to an external recorder for review; evacuation typically occurs in about 24 hours, though transit can be longer and some systems report battery life constraints. Magnetic capsule endoscopy systems (eg, NaviCam) couple a disposable imaging capsule with an external magnet and physician-operated console to actively maneuver the capsule—primarily for stomach visualization—without sedation. Magnetic CE has device-specific contraindications including gastrointestinal obstruction or stenosis, implanted electronic devices (eg, pacemakers), pregnancy, age under 22 years, and a body mass index of 38 or greater.

Definitions

Capsule endoscopy (CE)

DefinitionAn ingestible, single-use disposable imaging capsule that captures video images as it passes through the gastrointestinal tract and wirelessly transmits them to a wearable recorder for later review

Typical size and featuresExample system measures ~11 x 30 mm, contains camera, self-illumination, image transmission modules, and an internal battery (up to ~8 hours)

Transit and recordingAverage transit to evacuation ~24 hours; images recorded to a wearable receiver and downloaded to a workstation for review

Magnetic capsule endoscopy

DefinitionA capsule endoscopy system comprising a single-use ingestible capsule and an external magnet linked to a physician-operated console that enables magnetic guidance and directed visualization (primarily the stomach)

Intended use

Policy Revision History

2025-06-10administrative_update

Added HCPCS/CPT code 0977T effective 07/01/2025.

2025-01-31minor_review_substantive_changeLatest

Changed iron deficiency anemia, celiac disease, and suspected small bowel tumors (when not associated with GI bleeding) from medically necessary to investigational; changed patency capsule to investigational; revised rationale and definitions.

2024-08-16

Policy Summary

PayerCapital Bluecross

PolicyWireless Capsule Endoscopy for Gastrointestinal Disorders

Policy CodePolicy MP 5.033

Change TypeMaterial updates to investigational indications and coding

Effective DateAug 1, 2025

Next Review Date

Key ActionFor suspected small bowel bleeding, obtain documentation of prior inconclusive upper and lower endoscopies during the current episode before requesting capsule endoscopy.

SourceLink

On This Page

Billing Rule

Use current procedure codes and meet medical necessity

Providers must use the current procedure codes in effect on the date of the claim and ensure coding reflects the policy status and effective dates for coverage determination.

Historical changes include replacement of 0355T by 91113 (01/01/2022) and later additions such as 0977T (effective 07/01/2025).
Ensure submitted codes correspond to the policy’s coding table and claim date to avoid misprocessing.

Step Therapy

Require prior inconclusive upper and lower endoscopy for obscure GI bleeding

For suspected small bowel bleeding, wireless capsule endoscopy is indicated only after prior inconclusive upper and lower endoscopic studies performed during the same episode of illness.

Document that both upper and lower endoscopy were nondiagnostic in the current episode before CE.
CE may identify bleeding sources when standard workup is nondiagnostic and is indicated in this context per policy.

Documentation Required

Document clinical indication and prior endoscopy

Documentation must support that small bowel bleeding is suspected and that prior upper and lower endoscopic studies during the current episode were inconclusive, or that another listed medically necessary indication is present.

Include procedural reports or documentation showing nondiagnostic upper and lower endoscopies in the same episode of illness.
For other indications (eg, suspected Crohn disease, surveillance for hereditary polyposis), include relevant diagnostic findings and prior testing.

Prior Authorization

Confirm benefits and medical necessity prior to billing

Verify member benefit information and that the specific service billed is eligible for reimbursement; inclusion of a code in the coding section does not guarantee coverage and final payment depends on member benefits and medical necessity.

Check the member’s plan for applicable benefit variations before scheduling or billing.
Confirm that the service meets both policy medical necessity criteria and plan benefit rules.

Billing Rule

Align claims with current coding and policy history

Ensure coding and claim documentation reflect coding updates and additions (for example, replacement of 0355T with 91113; subsequent coding status changes and later additions such as 0977T and new ICD-10 codes) so claims correspond to the policy position and effective dates.

Update claim submissions to use codes effective on the service date and include supporting documentation tying the code to the medically necessary indication.
Be aware of code status changes recorded in policy history (91113, 0355T, 0977T and added ICD-10 codes).

Denial Risk

Investigational items may be denied if billed

Procedures and diagnoses explicitly listed as 'Investigational; therefore, not covered' are excluded from coverage and may be denied when billed using the listed procedure and diagnosis codes.

Do not bill covered benefits for procedures or diagnoses that the policy labels investigational.
Review the policy’s not-covered procedure and diagnosis code lists before claim submission.

Denial Risk

Recent investigational reclassifications can trigger denials

Procedures or indications changed to investigational in recent policy history (for example, iron deficiency anemia, celiac disease, suspected small bowel tumors when not associated with GI bleeding; patency capsule) may be denied if submitted for those indications.

Policy history (01/31/2025) moved these indications to investigational—confirm current policy status before billing.
Patency capsule is listed as investigational as of the 01/31/2025 update.

Intended primarily for stomach visualization without sedation, with procedural time ~15–20 minutes

Operational notesCapsule motion and direction are controlled by the operator via the console; capsule images are wirelessly transmitted to capture desired anatomy

Patency capsule

DefinitionA capsule designed to verify adequate patency of the gastrointestinal tract prior to administration of a video capsule in patients with known or suspected strictures

PurposeUsed to reduce risk of video capsule retention by testing intestinal patency before CE

Associated device examplePillCam Patency System (K180171) is an FDA-cleared patency capsule referenced in the policy

ENDOSCOPY

DefinitionInspection of body organs or cavities by use of an endoscope

ContextIncludes conventional upper and lower endoscopy used as comparators or prerequisites in this policy (eg, prior inconclusive studies for suspected small bowel bleeding)

Role in CE pathwayPrior endoscopy (upper and lower) is required before CE for suspected small bowel bleeding in the current episode of illness

PERISTALSIS

DefinitionThe progressive wavelike movement that occurs involuntarily in hollow tubes of the body, especially the alimentary canal

Relevance to CEPeristalsis carries the capsule through the gastrointestinal tract and determines image capture as the device transits

Clinical notePeristaltic activity influences capsule transit time (average ~24 hours) and image acquisition rate

510(k)

DefinitionA 510(k) is a premarketing submission to the FDA demonstrating that a device is substantially equivalent to a legally marketed device not subject to premarket approval (PMA)

PurposeUsed to obtain clearance for FDA marketing of many capsule endoscopy systems described in this policy

ImplicationDevices listed in the policy have 510(k) clearances with specific K numbers (see coding section)

Patency capsule — dissolvable test device (alternate note)

DefinitionA dissolvable (biodegradable) capsule used to test intestinal patency before performing capsule endoscopy to reduce the risk of capsule retention

Clinical use noteAlthough previously considered for verifying patency, the policy changed the patency capsule status to investigational as of 01/31/2025

Device examplePillCam Patency System (K180171) is referenced as a patency capsule in the policy history and device listings

administrative_update

Added new ICD-10 codes Z83.72, Z86.0100, Z86.0101, Z86.0102, Z86.0109 effective 10/01/2024.

2023-02-13minor_review

Title changed to 'Wireless Capsule Endoscopy for Gastrointestinal Disorders'; added iron deficiency anemia as medically necessary with criteria; clarified diagnostic testing for suspected Crohn disease; moved evaluation of the esophagus for GERD from E/I to not medically necessary; added policy guidelines and references.

2021-12-01administrative_update

Code update: replaced 0355T with 91113 effective 01/01/2022.

2021-02-24major_review

Added to list of medically necessary indications (including celiac disease in certain patients) and revised position on patency capsule from investigational to medically necessary with criteria.

2020-02-26consensus_review

Policy updated with literature review and references; policy statements unchanged.

Administrative coding updates and policy effective dates noted in the history include: replacement of HCPCS/CPT code 0355T by 91113 (administrative change effective 01/01/2022), subsequent coding status revisions documented in policy history, addition of ICD-10 codes Z83.72, Z86.0100, Z86.0101, Z86.0102, Z86.0109 effective 10/01/2024, and addition of CPT/HCPCS code 0977T effective 07/01/2025. Providers should use the codes current on the date of claim submission and follow the policy’s coverage criteria.