CG-MED-59 Upper Gastrointestinal Endoscopy in Adults

This document addresses indications for upper gastrointestinal (GI) endoscopy in adults. This document does not address upper gastrointestinal (GI) endoscopy in children, wireless capsule endoscopy, virtual endoscopy or in vivo analysis of gastrointestinal lesions via endoscopy.

Note: Please see the following related documents for additional information:

EGD for diagnostic purposes for adults aged 18 years or older is considered medically necessary for any of the following indications:

EGD for therapeutic purposes for adults aged 18 years or older is considered medically necessary for any of the following indications:

Screening EGD for adults aged 18 years or older is considered medically necessary for any of the following indications:

Sequential or periodic diagnostic EGD for adults aged 18 years or older is considered medically necessary for any of the following indications:

EGD for adults aged 18 years or older is considered not medically necessary when the above criteria are not met, and for all other indications, including but not limited to the following:

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.

Upper GI endoscopy, or EGD, is usually performed to evaluate symptoms of persistent upper abdominal pain, nausea, vomiting, and difficulty swallowing or bleeding from the upper GI tract. This procedure is more accurate than x-ray imaging for detecting inflammation, ulcers, or tumors of the esophagus, stomach and duodenum and can detect early cancer, as well as distinguish between benign and malignant conditions when biopsies of suspicious areas are obtained. EGD uses a flexible fiber-optic scope with a light and camera to examine the upper part of the GI system. The scope is inserted through the mouth into the upper GI tract allowing for direct visualization of the esophagus, stomach, and duodenum through the camera.

The quality of evidence concerning the safety and efficacy of EGD is lacking for the majority of the most common uses of the technology. In an effort to provide safe recommendations to guide clinical practice in the use of EGD, the American Society for Gastrointestinal Endoscopy (ASGE), the American Gastroenterological Association (AGA), and the American College of Gastroenterology (ACG) have established practice guidelines based largely on consensus within these respective specialty medical societies.

In 2012, the ASGE published a broad guideline entitled, Appropriate use of GI Endoscopy. The guideline contains several position statements based on a critical review of the available data as well as expert consensus. The ASGE has also published a number of indication-specific guidelines such as, The Role of Endoscopy in Barrett’s Esophagus and other Premalignant Conditions of the Esophagus (2012), The Role of Endoscopy in Gastroduodenal Obstruction and Gastroparesis (2011), The Role of Endoscopy in Dyspepsia (2015), The Role of Endoscopy in the Management of Benign and Malignant Gastroduodenal Obstruction (2021), and The Role of Endoscopy in the Diagnosis of Malignancy in Biliary Strictures of Undetermined Etiology (2023). The indication-specific guidelines also contain recommendations based on consensus and a review of the literature; each recommendation was graded on the quality of the supporting evidence in accordance with the definitions in Table 1. The ACG has also published indication-specific clinical practice guidelines on the use of endoscopy in commonly encountered clinical scenarios, such as Diagnosis and Management of Barrett's Esophagus: an Updated ACG Guideline (Shaheen 2022), Diagnosis and Management of Achalasia (Vaezi, 2020), and Gastroparesis (Camilleri, 2022). The ACG’s recommendations are graded in accordance with the same definitions as the ASGE, which appear in Table 1. The medically necessary indications in this clinical guideline are largely based on ASGE, ACG and AGA recommendations that are graded as ‘moderate’ to ‘high’ quality where the ACG has not considered the recommendation ‘conditional’ (“uncertainty about the tradeoffs”) or the AGA has not considered the recommendation ‘weak’ (“recommendation not suitable for quality or performance measure”). Where there was discordance, criteria are based on expert consensus.

An AGA guideline (Wang, 2021) provides advice regarding surveillance intervals using endoscopy after removal of dysplastic lesions and early GI cancers with endoscopic submucosal dissection. These criteria are also based on expert consensus, and the authors acknowledge that the level of evidence available to support much of the surveillance advice is generally low.

Major gastroenterological specialty societies recommend screening only for individuals at high risk for development of Barret’s esophagus or esophageal adenocarcinoma (abbreviated as BE and EAC, respectively in the guidelines).

The ACG guideline on diagnosis and management of Barrett’s esophagus (Shaheen, 2022) includes the following statement on screening:

We suggest a single screening endoscopy for patients with chronic GERD symptoms and 3 or more additional risk factors for BE, including male sex, age >50 years, White race, tobacco smoking, obesity, and family history of BE or EAC in a first-degree relative (strength of recommendation: conditional; quality of evidence: very low).

The ASGE (2012) guideline states, “Risk factors for BE and EAC include male sex, white race, age older than 50 years, family history of BE, increased duration of reflux symptoms, smoking, and obesity”.

Neither the ACG (Shaheen, 2022) nor the ASGE (2012) recommend screening the general population for Barrett’s esophagus.

GERD is defined as “symptoms or complications resulting from the reflux of gastric contents into the esophagus or beyond, into the oral cavity (including larynx) or lung” (Flores, 2019). Increased BMI, waist circumference and weight gain are associated with the presence of GERD (Katz, 2013; Flores, 2019). The typical symptoms of GERD include dyspepsia, epigastric pain, early satiety, belching, and bloating (Katz, 2013). As noted by Brethauer (2014) “treatment of GERD is initially medical with acid suppression but if symptoms are refractory to medical therapy or if there is an associated anatomic etiology for the GERD, surgical revision may be required”.

The ACG 2022 guideline on GERD (Katz, 2022) notes that “There is no gold standard for the diagnosis of GERD. Thus, the diagnosis is based on a combination of symptom presentation, endoscopic evaluation of esophageal mucosa, reflux monitoring, and response to therapeutic intervention.” For patients with classic GERD symptoms of heartburn and regurgitation who have no alarm symptoms, an 8-week trial of empiric proton pump inhibitors (PPIs) once daily before a meal is recommended. The AGA (Yadlapati, 2022) concurs and further finds that “if troublesome heartburn, regurgitation, and/or non-cardiac chest pain do not respond adequately to a PPI trial or when alarm symptoms exist, clinicians should investigate with endoscopy.” The ACG recommendation on upper endoscopy for diagnosing GERD is as follows:

Upper endoscopy is the most widely used objective test for evaluating the esophageal mucosa. For patients with GERD symptoms who also have alarm symptoms such as dysphagia, weight loss, bleeding, vomiting, and/or anemia, endoscopy should be performed as soon as feasible. The endoscopic findings of EE [erosive esophagitis] and Barrett’s esophagus are specific for the diagnosis of GERD.

Table 1. Quality of Evidence Grading of Recommendations Assessment, Development and Evaluation (GRADE) System (AGA, 2011; ASGE, 2015; ASGE, 2018).

Table 2. Spigelman Stage classification (0-IV) of duodenal polyposis (Brosens, 2005).

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Subject: Upper Gastrointestinal Endoscopy in Adults
Guideline #: CG-MED-59	Publish Date: 06/28/2024
Status: Revised	Last Review Date: 06/06/2024

CPT
43233	Esophagogastroduodenoscopy, flexible transoral; diagnostic, with dilation of esophagus with balloon (30 mm diameter or larger) (includes fluoroscopic guidance, when performed)
43235	Esophagogastroduodenoscopy, flexible transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
43236	Esophagogastroduodenoscopy, flexible transoral; with directed submucosal injection(s), any substance [other than injections related to gastroesophageal reflux or dysphagia]
43239	Esophagogastroduodenoscopy, flexible transoral; with biopsy, single or multiple
43241	Esophagogastroduodenoscopy, flexible transoral; with insertion of intraluminal tube or catheter
43243	Esophagogastroduodenoscopy, flexible transoral; with injection sclerosis of esophageal/gastric varices
43244	Esophagogastroduodenoscopy, flexible transoral; with band ligation of esophageal/gastric varices
43245	Esophagogastroduodenoscopy, flexible transoral; with dilation of gastric/duodenal stricture(s) (eg, balloon, bougie)
43246	Esophagogastroduodenoscopy, flexible transoral; with directed placement of percutaneous gastrostomy tube
43247	Esophagogastroduodenoscopy, flexible transoral; with removal of foreign body(s)
43248	Esophagogastroduodenoscopy, flexible transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire
43249	Esophagogastroduodenoscopy, flexible transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)
43250	Esophagogastroduodenoscopy, flexible transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
43251	Esophagogastroduodenoscopy, flexible transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
43254	Esophagogastroduodenoscopy, flexible transoral; with endoscopic mucosal resection
43255	Esophagogastroduodenoscopy, flexible transoral; with control of bleeding, any method
43266	Esophagogastroduodenoscopy, flexible transoral; with placement of endoscopic stent (includes pre- and post-dilation and guide wire passage, when performed)
43270	Esophagogastroduodenoscopy, flexible transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre-and post-dilation and guide wire passage, when performed) [other than ablation related to Barrett’s esophagus]
0652T	Esophagogastroduodenoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
0653T	Esophagogastroduodenoscopy, flexible, transnasal; with biopsy, single or multiple
0654T	Esophagogastroduodenoscopy, flexible, transnasal; with insertion of intraluminal tube or catheter

ICD-10 Diagnosis
	All diagnoses

‘High’	Further research is very unlikely to change our confidence in the estimate of effect.
‘Moderate’	Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
‘Low’	Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
‘Very Low’	Any estimate of effect is very uncertain.

Spigelman classification	Endoscopic frequency
Stage 0	4 years
Stage I	2-3 years
Stage II	1-3 years
Stage III	6-12 months
Stage IV	Surgical evaluation

Status	Date	Action
Revised	06/06/2024	Medical Policy & Technology Assessment Committee (MPTAC) review. Revised clinical indications in MN statement on screening EGD in adults at risk for Barrett’s esophagus and removed male sex.
Revised	05/09/2024	MPTAC review. Added proton pump inhibitors as an example of appropriate trial of therapy to MN statement on diagnostic EGD in adults in Clinical Indications section. Revised Discussion/General Information and References sections.
Revised	05/11/2023	MPTAC review. Revised Clinical Indications section to remove references to “life-limiting comorbidities.”
		Corrected spelling error in MN criteria.
Reviewed	11/10/2022	MPTAC review. Updated Discussion/General Information and References sections.
Reviewed	11/11/2021	MPTAC review. Updated Discussion/General Information and References sections.
	07/01/2021	Updated Coding section with 07/01/2021 CPT changes; added 0652T, 0653T, 0654T.
Revised	11/05/2020	MPTAC review. Removed list of risk factors related to screening for Barrett’s esophagus from clinical indications in MN statement on screening EGD in adults. Updated Discussion/General Information section. Reformatted Coding section.
Revised	05/14/2020	Medical Policy & Technology Assessment Committee (MPTAC) review. In Clinical Indications section, updated “SURG.00106 Ablative Techniques as a Treatment for Barrett's Esophagus” to new guideline number “CG-SURG-101 Ablative Techniques as a Treatment for Barrett's Esophagus.” Updated Discussion/General Information, and References sections.
Revised	06/06/2019	MPTAC review. In Sequential or Periodic Diagnostic EGD in Adults section of Clinical Indications, changed “and” to “or” in criterion A.1. Updated Description, Discussion/General Information, and References sections. Updated Coding section; removed CPT 43238, 43242, 43253.
Revised	09/13/2018	Medical Policy & Technology Assessment Committee (MPTAC) review. Title changed to Upper Gastrointestinal Endoscopy in Adults. Revised MN criteria in Diagnostic Esophagogastroduodenoscopy (EGD) in Adults section. Added MN criteria for age requirement in all indications. Removed MN criteria for screening EGD in pediatric individuals. Added NMN criteria for age requirement in all indications. Updated Description, Discussion/General Information, and References sections.
Revised	11/02/2017	MPTAC review. Updated header language from “Current Effective Date” to “Publish Date.” Added therapeutic indications to the document. Revised Title, Position Statement and Coding sections. Updated Rationale and References.
New	09/13/2017	MPTAC review. Initial document development.