Capsule endoscopy (esophagus, small bowel, colon) — Coverage and prior authorization
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Defines Fallon Health coverage, prior authorization, and medical necessity criteria for capsule endoscopy of the esophagus (CPT 91111), small bowel/esophagus through ileum (CPT 91110), and colon (CPT 91113) for specified Fallon products.
Effective 12/01/2024 Fallon Health will use InterQual® Criteria for medical necessity determinations for small bowel capsule endoscopy (CPT 91110).
Capsule endoscopy (CPT 91110, 91111, 91113) require prior authorization for listed Fallon products.
Coverage and Medical Necessity Criteria
Small bowel capsule endoscopy (CPT 91110) — InterQual
Covered when InterQual criteria are met (for CPT 91110):
InterQual criteria available via Fallon transparency tool
Esophageal capsule endoscopy — Medical necessity for variceal evaluation
Esophageal capsule endoscopy (CPT 91111) may be considered medically necessary when ALL of the following are met:
EGD is the widely accepted gold standard; capsule CE reserved when EGD cannot/ will not be performed
Colon capsule endoscopy — Primary and secondary indications
Colon capsule endoscopy (CPT 91113) considered medically necessary when either PRIMARY or SECONDARY criteria are met:
Adopts National Government Services LCD L38571
Applies to MassHealth ACO and Community Care members
General coverage determination
Overall determination
From Analysis of Evidence section
Coverage criteria (history summary)
Policy history notes changes affecting coverage criteria
See policy history for dates of changes
Exclude capsule endoscopy for patients with known or suspected gastrointestinal obstruction, stricture, or fistula; those with a cardiac pacemaker or other implanted electro‑medical device that emits radiofrequency or other interfering signals; patients with a swallowing disorder; and patients with a known contraindication or allergy to any medication or preparation agent used before or during the procedure. Capsule endoscopy may not be performed in conjunction with CT colonography and may not be performed for colorectal cancer screening (regardless of family history or other risk factors).
Use of magnetically controlled capsule endoscopy (CPT 0651T; e.g., NaviCam®) is considered experimental/investigational and not medically necessary and is excluded from coverage.
Note planned policy history entry for the 09/23/2025 review: an explicit exclusion for magnetically controlled capsule endoscopy will be added and the Summary of Evidence and Analysis of Evidence will be updated; this change does not alter the existing coverage criteria.
Patency capsule testing is not covered. The patency capsule was developed to assess luminal patency before capsule endoscopy, but published studies do not demonstrate clinical utility. There is no specific CPT code for patency capsule testing; the appropriate unlisted code is CPT 91299, and no part of this service may be reported as a covered service. Imaging such as an X‑ray or other technique to confirm passage or detect a retained patency capsule is not covered.
Current evidence does not establish magnetically controlled capsule endoscopy as a validated substitute for conventional modalities nor as an effective triage tool to allocate patients to other diagnostic procedures. The diagnostic characteristics are insufficient to support routine substitution or triage, and direct evidence of improved clinical outcomes is lacking.
CPT / Informational Codes and Surveillance Guidance
| 91112 | Wireless Gastrointestinal Motility Monitoring System (SmartPill®) — listed as excluded |
| 0651T | Magnetically controlled capsule endoscopy — considered experimental/investigational and not medically necessary |
| 91299 | Unlisted procedure code noted as appropriate code for patency capsule testing; service not covered |
| 91110 | Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy); esophagus through ileum, with physician interpretation and report. |
| 91111 | Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), esophagus with interpretation and report. |
| 91112 | Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report. |
| 91113 | Gastrointestinal tract imaging, intraluminal (e.g., capsule endoscopy), colon, with interpretation and report. |
| 0651T | Magnetically controlled capsule endoscopy, esophagus through stomach, including intraprocedural positioning of capsule, with interpretation and ... |
Prior Authorization, Documentation, and Denial Risks
Prior authorization required for CPT 91110, 91111, 91113 and InterQual use for 91110 effective date
Capsule endoscopy procedures CPT 91110 (small bowel), 91111 (esophagus), and 91113 (colon) require prior authorization from Fallon Health. For CPT 91110, Fallon Health will use InterQual® Criteria to determine medical necessity effective for dates of service on or after 12/01/2024; InterQual criteria are available via Fallon’s transparency tool.
Prior authorization / coding note — codes listed for informational purposes
Codes listed in the coding section (e.g., 91110, 91111, 91112, 91113, 0651T) are provided for informational purposes only; their presence does not constitute or imply coverage or reimbursement.
- Do not assume a listed code is covered—check member benefit plan and prior authorization requirements.
- CPT 91110–91113 should not be reported for the same patient on the same date of service.
Prior authorization per Fallon criteria and benefit plan; history notes on InterQual adoption and criteria additions
Prior authorization and medical necessity determinations are governed by Fallon Health criteria and the member’s benefit plan; policy history documents adoption of InterQual® for small bowel CE and addition of esophageal and colon CE coverage criteria.
- Fallon’s prior authorization requirements are applied according to Fallon criteria and the member’s specific benefit plan.
- InterQual adoption and addition of coverage criteria for esophageal and colon capsule endoscopy are recorded in the policy history.
Use as alternative to EGD — conditions when esophageal capsule endoscopy may be appropriate
Esophageal capsule endoscopy (CPT 91111) may be used as an alternative to EGD only when the patient has cirrhosis with portal hypertension, no prior variceal bleeding, and the treating physician documents that the patient cannot or will not undergo EGD.
- EGD remains the gold standard; capsule CE is reserved when EGD cannot or will not be performed at the treating physician's request.
- Indication requires diagnosis of cirrhosis and portal hypertension with no prior variceal bleeding.
Step therapy (none specified)
No step therapy requirements are specified in the policy.
- The policy does not state any required step therapy prior to authorization of capsule endoscopy.
Required clinical justification and documentation for colon capsule endoscopy (primary vs secondary indications; risk documentation)
For colon capsule endoscopy (CPT 91113), documentation must show either: (1) a primary indication with evaluation by a qualified endoscopist demonstrating major risks for optical colonoscopy or moderate sedation and one of the listed diagnostic/surveillance indications, or (2) a secondary indication after an incomplete optical colonoscopy with adequate preparation and one of the listed diagnostic/surveillance indications.
- Primary: documentation of major risks for optical colonoscopy/moderate sedation by a board-certified/eligible gastroenterologist, surgeon trained in endoscopy, or equivalent.
- Secondary: documentation of incomplete optical colonoscopy with adequate preparation.
- Applicable diagnostic/surveillance triggers include surveillance of prior colon polyps, positive FOBT, positive sDNA, or other evidence of lower GI bleeding in hemodynamically stable patients.
Coding guidance (informational) — inclusion of code does not imply coverage; CPT 91110 note
Coding in the policy is informational; inclusion of a code does not imply coverage. Note that CPT 91110–91113 may not be reported for the same patient on the same date of service.
- Presence of a code in the coding table is informational only and does not guarantee coverage or reimbursement.
- Do not report CPT 91110–91113 for the same patient on the same date of service.
Authority and documentation expectations — Medicare Advantage follows CMS NCDs/LCDs; Fallon internal criteria when absent
For Medicare Advantage members Fallon follows CMS NCDs and LCDs when making determinations; when those do not fully establish coverage, Fallon may create internal criteria. Fallon generally follows MassHealth Medical Necessity Guidelines for MassHealth members and requires PACE interdisciplinary team authorization for PACE members.
- Medicare Advantage: follow applicable NCDs/LCDs and Medicare statutes/regulations; fallback to Fallon internal criteria if needed.
- MassHealth/NaviCare: follow MassHealth Medical Necessity Guidelines when applicable.
- PACE: services must be authorized by the interdisciplinary team except for emergency/urgent out-of-area care.
Exclusion-based denial triggers — obstruction/stricture/fistula, implanted electro-medical devices, etc.
Requests may be denied when the patient has known or suspected gastrointestinal obstruction, stricture, or fistula; an implanted cardiac pacemaker or other electro-medical device that emits an interfering signal; a swallowing disorder; a known contraindication or allergy to procedure medications/prep agents; when performed with CT colonography; or when performed for colorectal cancer screening.
- Do not perform capsule endoscopy in patients with suspected or known obstruction/stricture/fistula.
- Do not perform in patients with implanted electro-medical devices that may interfere or in those with swallowing disorders.
- Not permitted in conjunction with CT colonography or for colorectal cancer screening.
Experimental / Investigational stance — magnetically controlled wireless capsule (e.g., NaviCam®) considered experimental/investigational
Magnetically controlled wireless capsule endoscopy systems (for example, NaviCam® / CPT 0651T) are considered experimental and investigational and are not medically necessary per the policy.
- MCE is considered experimental/investigational due to inadequate evidence to substitute for other modalities or demonstrate improved outcomes.
- CPT 0651T (magnetically controlled capsule endoscopy) is listed as experimental/investigational and not medically necessary.
Benefit-plan coverage limitation — not covered for all products; governed by member benefit plan and contract
Coverage of services in this policy is not universal across all Fallon products or employer groups; coverage is governed by the member’s benefit plan and Evidence of Coverage and may be denied if the service is not included in the member’s plan.
- Always verify the member’s benefit plan and Evidence of Coverage for coverage and exclusions for the requested service.
- If the benefit plan provisions conflict with this policy, the benefit plan governs (subject to applicable state and federal mandates).
Clinical Background and Evidence Summary
Capsule endoscopy is a swallowed miniature camera used primarily to visualize the small intestine and increasingly portions of the entire gastrointestinal tract. The device is propelled by normal peristalsis and provides direct intraluminal imaging but is limited by its inability to be steered (except for magnetically controlled systems), obtain biopsies, or provide therapy. Esophagogastroduodenoscopy (EGD) remains the diagnostic and therapeutic gold standard for evaluation of esophageal varices because it allows direct visualization, biopsy, and intervention; magnetically controlled systems aim to enable active control in the stomach but currently lack sufficient evidence to replace or triage away from conventional endoscopic modalities.
Definitions and Device Names
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