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LCD
ID Number
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L1831
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LCD
Title
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Wireless Capsule Endoscopy
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Contractor's
Determination Number
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L1831
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AMA
CPT / ADA
CDT Copyright Statement
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CPT codes,
descriptions and other data only are copyright 2007 American Medical
Association (or such other date of publication of CPT). All Rights
Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology,
(CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. © 2002,
2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
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CMS
National Coverage Policy
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Title XVIII of the
Social Security Act, Section 1862 (a)(1)(A). This
section excludes coverage of items or services that are not reasonable and
necessary for the diagnosis or treatment of illness or injury or to improve
the functioning of a malformed body member.
Title XVIII of the Social Security Act, Section 1862 (a)(7).
This section prohibits Medicare payment for any expenses on items and
services incurred for routine physical examinations.
Title XVIII of the Social Security Act, Section 1833 (e). This section
prohibits Medicare payment for any claim that lacks the necessary
information to process the claim.
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Primary Geographic
Jurisdiction
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New
Jersey
Tennessee
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Secondary Geographic
Jurisdiction
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Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
North Dakota
Nebraska
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
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Oversight
Region
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Region IV
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Original
Determination Effective Date
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For services performed
on or after 09/29/2002
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Original
Determination Ending Date
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Revision
Effective Date
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For services performed
on or after 12/09/2005
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Revision
Ending Date
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Indications
and Limitations of Coverage and/or Medical Necessity
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Indications Summary
Wireless Capsule Endoscopy is covered for
the investigation of occult GI bleeding which has eluded localization by
conventional means (including upper and lower endoscopy),
and which is therefore felt to originate in the small intestine. All
other uses for this device are Investigational and therefore non-covered.
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Wireless Capsule Endoscopy, approved by the FDA
August 2001, is a non-invasive diagnostic imaging system that uses a
disposable miniature video digital camera contained in a non-biodegradable
capsule. The capsule is swallowed to allow painless endoscopic
imaging of the entire small bowel to assess patients with intractable
gastrointestinal bleeding where the source has not been identified by
conventional means.
The diagnostic imaging system is comprised of three components:
- Ingestible Capsule containing a miniature color video camera,
a light source, batteries, a miniature radio transmitter, and an
antenna. The capsule is propelled by peristalsis, and can provide more
than 5 hours of images cross-referenced with localization data.
- Data Recorder, carried on the belt, receives and stores
signals transmitted by the capsule. This allows users to continue
about their daily activities during the examination.
- A computer workstation is needed to
perform image and data processing, creating a video that may be viewed
by the physician offline.
Indications:
Wireless Capsule Endoscopy is indicated for the
diagnosis of occult gastrointestinal bleeding, the site of which has not
previously been identified by standard endoscopic
exams such as upper gastrointestinal endoscopy,
colonoscopy, push enteroscopy or radiologic
procedures. It may be especially helpful in the diagnosis of angiodysplasias of the GI tract.
Limitations:
1. This test is payable only for those beneficiaries with documented
continuing GI blood loss and anemia secondary to bleeding.
2. Wireless Capsule Endoscopy is not payable
unless the patient has undergone upper GI endoscopy
and colonoscopy within the same spell of illness and they have failed to
reveal a source of bleeding.
3. This test is not reimbursable for the confirmation of lesions or
pathology normally within the reach of upper or lower endoscopes (lesions
proximal to the ligament of Treitz or distal to
the ileum).
4. This test is not payable for patients with hematemesis.
5. This test is not reimbursable for colorectal cancer screening.
6. The test is payable only for services using FDA approved devices.
7. The test is reimbursable only when ordered, performed and interpreted by
a gastroenterologist.
8. Wireless capsule endoscopy is contraindicated
to anyone known or suspected of having intestinal obstructions, including
problems with fistulas or strictures, due to the possibility of pill
entrapment.
9. Wireless Capsule Endoscopy used to evaluate a
possible diagnosis of Crohn's disease, celiac
disease, intestinal tumors, or any other GI diagnosis will be non-covered
as E&I in the absence of occult GI bleeding.
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Coverage
Topic
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Diagnostic Tests and
X-Rays
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