Refer to Cigna CPT list for eviCore‑reviewed procedures

These guidelines include procedures that eviCore does not review for Cigna; providers must refer to the Cigna CPT code list to determine which high‑tech imaging/procedures are reviewed by eviCore for Cigna.

Prior authorization not specified in this excerpt

This extract contains only the table of contents and does not specify prior authorization requirements or affected billing codes for EGD procedures.

No prior‑auth code lists in this window

No prior authorization code lists or explicit prior‑auth requirements are included in the provided document window; the extract lists guideline sections only.

Prior authorization not specified in section headings

The fragments shown are section headings and do not state prior authorization requirements for the referenced topics.

Authorize against guideline criteria and require pertinent clinical evaluation

Requests for EGD are evaluated against the guideline criteria and require submission of a pertinent clinical evaluation documenting new onset or change in symptoms.

• Pertinent clinical evaluation should include detailed history & physical, appropriate labs, imaging, pathology and procedure reports, and reports from other treating providers.
• For established individuals, a recent meaningful technological contact may suffice as the pertinent clinical evaluation.

Document failed therapy or qualifying alarm features on prior‑auth

Prior authorization should indicate failure of recommended empiric therapy durations or presence of qualifying indications such as alarm features when applicable.

• Document failure of empiric anti‑secretory therapy per guideline durations (e.g., 4‑week daily PPI for dyspepsia; 8‑12 week PPI regimens for GERD/ulcer scenarios).
• Document alarm features (dysphagia, odynophagia, significant weight loss, GI bleeding, iron‑deficiency anemia) when present.

Ensure indication matches listed medically‑necessary reasons

Prior authorization requests should document that the clinical indication matches a listed medically‑necessary indication for EGD (for example dysphagia, odynophagia, persistent vomiting ≥7 days, presumed upper GI bleeding, iron‑deficiency anemia with supportive labs).

Reference specific clinical evidence when requesting authorization

Clinical justification for authorization should reference meeting the specific listed criteria, such as diagnostic laboratory markers for pernicious anemia or negative/inconclusive breath testing with persistent high suspicion for SIBO.

• For pernicious anemia: reference vitamin B12 <300 pg/mL or elevated MMA and supporting antibody/lab findings.
• For SIBO: document breath test results (negative or inconclusive) and ongoing clinical suspicion.

Prior‑auth recommended for initial or repeat EGD in EoE

Prior authorization is recommended/required when seeking coverage for initial or repeat EGD to diagnose or surveil eosinophilic esophagitis (EoE) according to the policy's diagnostic and timing criteria.

• Initial EGD indicated for PPI‑refractory GERD, dysphagia/food bolus obstruction, atopic history, or absolute eosinophil count >1500.
• Repeat EGD indicated after 8 weeks of dietary/pharmacologic therapy or per surveillance intervals (including annual surveillance in established EoE).

Document cirrhosis/portal‑hypertension evidence for varices screening

EGD is medically necessary to screen for esophageal varices in individuals with cirrhosis and decompensation, imaging evidence of portal hypertension, or cACLD with noninvasive markers of clinically significant portal hypertension; providers should document these findings when requesting EGD.

• Document decompensation features (ascites, encephalopathy, variceal bleeding) or imaging evidence of portal hypertension (portosystemic collaterals, splenomegaly).
• Noninvasive CSPH markers include TE LSM ≥25 kPa or LSM ≥20 kPa with platelets <150,000/µL.

No prior‑auth codes listed in these reference pages

No prior authorization codes or requirements are specified in the reference pages included in this extract.

Prior‑auth criteria not included in references

No prior authorization criteria are included in the references fragment provided here.

No step therapy rules in these chunks

No step therapy requirements are included in the provided document chunks.

No step therapy in these fragments

No step therapy rules are present in these reference fragments.

Require 4‑week PPI (or PCAB) trial before EGD for <60 dyspepsia

For dyspepsia in individuals under age 60 without red flag features, EGD is appropriate only after failure of a 4‑week trial of daily PPI (or appropriately dosed PCAB) or after failure of a 'test and treat' H. pylori strategy with confirmation of eradication when applicable.

• PPI should be taken daily unless there is documented allergy or intolerance.
• H. pylori eradication should be confirmed 4 weeks after therapy completion by non‑invasive testing when applicable.

Document anti‑secretory therapy trial duration before EGD for GERD

Many GERD indications require documentation of a trial of anti‑secretory therapy of specified duration (e.g., 8‑week once‑daily PPI, 4‑week twice‑daily PPI, or appropriately dosed PCAB) prior to approving EGD.

• Return of typical GERD symptoms after discontinuation of appropriately directed anti‑secretory therapy of these durations also supports medical necessity.

Expect 8–12 week medical therapy trial before ulcer surveillance EGD

For surveillance of gastric or duodenal ulcers, a trial of daily PPI and H. pylori therapy when applicable for 8–12 weeks is expected prior to surveillance EGD to document persistent symptoms or nonhealing ulcers.

• Giant or refractory ulcers may require repeat EGD every 8–12 weeks until healing is documented.

Require non‑endoscopic SIBO testing before EGD aspirate collection

For suspected small intestinal bacterial overgrowth (SIBO), perform non‑endoscopic testing (breath testing or dietary trials) first; EGD with duodenal fluid collection is indicated only when breath testing is negative or inconclusive and clinical suspicion remains high.

PPI trial and timed repeat EGD considerations for suspected EoE

For suspected EoE, initial management with a PPI may be relevant because more than one‑third of patients respond; repeat EGD timing for assessment of treatment response is specified (e.g., after 8 weeks of therapy) and annual surveillance is described for established disease.

• Repeat EGD is medically necessary after 8 weeks of dietary or pharmacologic treatment to assess response.
• Annual EGD surveillance is medically necessary for evaluation of disease stability or progression in established EoE.

Document rationale when opting for endoscopy rather than non‑endoscopic EoE management

When choosing EGD for EoE, consider non‑endoscopic management and balance procedural risks; document the rationale for selecting endoscopy over alternative pathways.

No step therapy rules in these references

No step therapy rules are provided in the reference pages included in this extract.

No step therapy in references

No step therapy requirements are included in the references section of this extract.

Coverage policy is guidance — verify member benefit plan

Use this coverage policy as an interpretive guide, but verify the member's specific benefit plan documents and any applicable laws/regulations because coverage determinations depend on those terms.

No documentation rules in TOC fragments

No documentation submission requirements are present in the table‑of‑contents fragments shown.

No documentation requirements in this excerpt

No documentation requirements are present in the provided excerpt; the content is limited to section headings and page references.

Include complete H&P, labs, imaging, pathology and procedure reports

Submit pertinent medical records with authorization requests, including a detailed history & physical, relevant laboratory studies, imaging, pathology and prior procedure reports, and reports from other treating providers.

• For established individuals, a recent meaningful technological contact (telehealth, telephone, electronic message) since symptom onset/change may suffice.
• If records lack sufficient detail to understand current clinical status, requests may be denied.

Document prior empiric therapy, alarm features, and specialty evaluations

Document trials of empiric medical therapy (agent and duration), presence of alarm features (dysphagia, odynophagia, weight loss, GI bleeding, iron‑deficiency anemia), specialty evaluations for extra‑esophageal symptoms, and prior anti‑reflux procedural history when requesting EGD.

Include pathology confirmation and dysplasia grade (second review if indefinite)

Provide pathology confirmation and documentation of dysplasia grade for Barrett's esophagus and GIM; for pathology that is suggestive or indefinite for dysplasia, include second pathologist confirmation when suggested.

• Document risk factors (family history, race/ethnicity, country of birth) when submitting for GIM surveillance.

Document index biopsy status or reason biopsy not performed

For surveillance after gastric ulcer, document the initial biopsy status or the clinical reason a biopsy was not performed (e.g., active bleeding, coagulopathy) to justify surveillance timing.

Document breath test results and persistent symptoms for SIBO EGD

When using EGD for SIBO workup or persistent small‑bowel symptoms, document non‑invasive breath test results (negative or inconclusive) and persistent clinical symptoms to support endoscopic duodenal fluid collection.

• Document rationale that non‑endoscopic testing was negative/inconclusive and clinical suspicion remains high.

Document B12 <300 pg/mL or elevated MMA and supporting antibodies for PA

For newly diagnosed pernicious anemia, document diagnostic laboratory evidence including vitamin B12 <300 pg/mL or elevated methylmalonic acid (MMA) and supporting anti‑intrinsic factor or anti‑parietal cell antibodies or other consistent laboratory findings.

• Evidence of pernicious anemia and timing (EGD within 6 months of diagnosis) should be included in the request.

Specify pre‑op vs symptom‑driven post‑op indication and list symptoms for bariatric patients

For bariatric surgery patients, document whether the EGD is pre‑operative evaluation or post‑operative symptom‑driven, and list the specific symptoms prompting EGD (e.g., nausea/vomiting, abdominal pain, post‑op GERD, dumping syndrome, bleeding/anemia, failure to lose weight).

Document duodenal biopsy adequacy or prior inadequate biopsies for repeat EGD

Document initial duodenal biopsy adequacy (at least four post‑bulbar biopsies and 1–2 from the bulb) and, if requesting a repeat EGD for celiac evaluation, include documentation of prior inadequate biopsies to justify one‑time repeat scope.

• Adequate sampling details support medical necessity for repeat biopsy when prior sampling was insufficient.

References section — no submission rules

This section of the document contains the bibliographic references and does not include operational documentation or submission rules.

Coverage depends on benefit plan terms and applicable laws

Coverage determinations are governed by the member's applicable benefit plan document, laws/regulations, and collateral materials; the coverage policy is interpretive and may be superseded by the plan terms.

No denial triggers in TOC pages

The provided pages are a table of contents and do not include explicit denial triggers or authorization steps.

No explicit authorization or denial criteria here

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Denial risk for insufficient documentation

Requests may be denied if submitted medical records do not provide sufficiently detailed information to understand the individual's current clinical status and establish medical necessity.

Denial risk if prior medical therapy trials not documented

Failure to document prior trials of specified empiric medical therapy (for example 8‑week once‑daily PPI, 4‑week twice‑daily PPI, or appropriately dosed PCAB when indicated for GERD) may lead to denial.

Denial risk for Barrett's screening without required GERD duration and risk factors

Screening EGD for Barrett's esophagus may be denied if chronic GERD symptoms for ≥5 years plus at least three listed risk factors are not documented.

• Required risk factors include age ≥50, Caucasian race, male sex, obesity, tobacco history, or family history of Barrett's/EAC in a first‑degree relative.

Denial risk for missing 8–12 week PPI trial documentation

Failure to document an appropriate trial of daily PPI therapy for 8–12 weeks (or documented allergy/intolerance and alternative therapy) when indicated for ulcer surveillance or refractory reflux may affect approval.

Denial risk for missing duodenal ulcer therapy trial documentation

Lack of documentation of persistent symptoms after 8–12 weeks of PPI and/or H. pylori therapy when claiming surveillance for duodenal ulceration may trigger denial.

Denial risk: EGD not indicated for asymptomatic/uncomplicated radiologic findings

EGD is not medically necessary to evaluate radiologic findings for asymptomatic or uncomplicated sliding hiatal hernia, uncomplicated duodenal ulcer that has responded to therapy, or deformed duodenal bulb when symptoms are absent or respond to therapy.

Denial risk if pernicious anemia labs not provided

Failure to document pernicious anemia diagnosis with supporting laboratory evidence (e.g., vitamin B12 <300 pg/mL or elevated MMA with supporting antibody or laboratory findings) may lead to denial of EGD for this indication.

Denial risk for celiac‑related EGD without supporting biomarkers

EGD is not indicated for chronic abdominal pain or diarrhea (>30 days) as sole symptoms without elevated biomarkers associated with celiac disease; lacking such biomarkers when claiming celiac‑related EGD may lead to denial.

References only — no authorization/denial instructions

These reference pages are bibliography and do not include authorization or denial instructions.