Upper Gastrointestinal (UGI) Endoscopy for Adults

MEDICAL POLICY 2.01.533 Upper Gastrointestinal (UGI) Endoscopy for Adults Effective Date: Aug. 1, 2016 Last Revised: July 12, 2016 Replaces: N/A RELATED MEDICAL POLICIES: 2.01.38 Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease Introduction Upper gastrointestinal (UGI) endoscopy is a procedure that looks at the esophagus, stomach and the first part of the small intestine using a flexible tube-like tool containing glass fibers that transmit light and magnify the image. The scope is inserted through the mouth to view the esophagus, stomach, and first part of the small intestine. It is usually performed with light anesthesia through an intravenous administration. The scope is used to search for cause(s) of severe heartburn, difficulty swallowing, reflux, persistent vomiting, and bleeding. This tool can also be used to remove polyps or stones from the bile duct. Note: The Introduction section is for your general knowledge and is not to be construed as policy coverage criteria. The rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered. Quick Links: Select a link below to be redirected to that section. POLICY CRITERIA CODING RELATED INFORMATION EVIDENCE REVIEW REFERENCES HISTORY PRIOR AUTHORIZATION REQUIREMENTS Selecting the icon in the document returns you to this Quick Links menu. Carrier Status of Genetic Diseases Policy Coverage Criteria

Condition Any other Coverage Criteria Upper gastrointestinal endoscopy (UGI) is considered not medically necessary for individuals without a documented clinical indication that meets medical necessity criteria described in this policy. Upper gastrointestinal endoscopy (UGI) is considered not medically necessary when: Performed for evaluation of UGI symptoms that are chronic, non-progressive, atypical for known organic disease, and is considered functional in origin (infrequent exceptions exist when a one-time endoscopic examination may be done to rule out organic disease, in cases where symptoms are unresponsive to therapy) Performed for evaluation of uncomplicated heartburn that responds to conservative medical management Performed for evaluation of UGI conditions/diagnoses when the endoscopy results will not alter management Performed for evaluation of x-ray findings showing any of the following: o Deformed duodenal bulb that is asymptomatic or has responded to ulcer therapy o Duodenal bulb ulcer that is uncomplicated and has responded to therapy o Sliding hiatal hernia that is asymptomatic or uncomplicated Performed as routine screening of the upper gastrointestinal (UGI) tract in the absence of a clinical indication Condition Malignant Indications Coverage Criteria Upper gastrointestinal endoscopy (UGI) may be considered medically necessary for patients 19 years of age and older for any of the following indications: Dysplasia Page 2 of 24

Condition Coverage Criteria Esophageal cancer Familial adenomatous polyposis Gastric cancer History of Lynch Syndrome (HNPCC or hereditary nonpolyposis colorectal cancer) Head/neck cancer In situations where clinical features are highly suspicious for UGI malignancy (e.g., epigastric mass found on x-ray, abnormal Barium study, and others) Metaplastic columnar or glandular epithelium Patients with prior adenomatous gastric polyps or sessile polyps (rare) Strong family history of gastrointestinal cancer Tylosis Non-Malignant Indications Alarm Symptoms Upper gastrointestinal endoscopy (UGI) may be considered medically necessary for patients 19 years of age and older when: Performed for evaluation of any of the following alarm symptoms that may be associated with reflux symptoms or dyspepsia (heartburn): o Anemia or gastrointestinal bleeding (see GI Bleeding below) o Epigastric mass (found on examination) o Persistent vomiting of unknown cause, including vomiting blood o Swallowing that is difficult (dysphagia) o Unintentional weight loss of 3 kg (approx. 6.6 lbs.) or more since symptoms started Follow-up of Known Upper gastrointestinal endoscopy (UGI) may be Conditions considered medically necessary for patients 19 years of age and older when: Performed for evaluation of any of the following indications that may be associated with reflux symptoms Page 3 of 24

Condition Coverage Criteria or dyspepsia (heartburn): o Anorexia of unknown cause o Chest pain that is unusual, and that persists after heart disease is ruled out (see Evidence Review) o Erosive esophagitis o Esophageal varices, with or without bleeding o History of gastric surgery o NSAID use is stopped yet symptoms continue o Swallowing that is difficult (dysphagia) o Swallowing that is painful (odynophagia) Note: Medical records may be requested to review the services for medical necessity. Documentation in the medical record must clearly support the medical necessity of the UGI services and include the following information: The patient s symptoms and duration Prior treatment trial, failure, or contraindication to proton pump inhibitors or other conservative medical management such as NSAID cessation (if applicable) Reports of previous diagnostic and/or ancillary testing Lifestyle modification(s) that was tried and failed (e.g. diet change, weight loss, elevating head of bed, etc.) Gastrointestinal (GI) Bleeding Symptoms Upper gastrointestinal endoscopy (UGI) may be considered medically necessary for patients 19 years of age and older when: Performed for evaluation of gastrointestinal (GI) bleeding when one or more of the following are present: o Blood in stools when a colonoscopy is negative or inconclusive o Chronic GI bleeding o History of long term use of anticoagulation therapy o History of long term use of NSAIDs for arthritis o Iron deficiency anemia o Persistent blood tinged vomitus Page 4 of 24

Condition Coverage Criteria Note: Medical records may be requested to review the services for medical necessity. Documentation in the medical record must clearly support the medical necessity of the UGI services and include the following information: The patient s symptoms and duration Gastroesophageal Reflux (GERD) or Dyspepsia Symptoms Upper gastrointestinal endoscopy (UGI) may be considered medically necessary for patients 19 years of age and older when: Performed for evaluation of GERD symptoms that are present for at least 3 months and persist after 4 weeks of treatment with daily proton pump inhibitor therapy Note: Medical records may be requested to review the services for medical necessity. Documentation in the medical record must clearly support the medical necessity of the UGI services and include the following information: The patient s symptoms and duration Prior treatment trial, failure, or contraindication to proton pump inhibitors or other conservative medical management such as NSAID cessation (if applicable) Reports of previous diagnostic and/or ancillary testing Patients who refuse PPI therapy should have tried and failed H2 blocker treatment for 6 weeks Other Upper Gastrointestinal (UGI) Indications Upper gastrointestinal endoscopy (UGI) may be considered medically necessary for patients 19 years of age and older for any of the following indications: Achalasia Barrett s esophagus (BE) surveillance based on the pathology: o High-grade dysplasia: repeat EGD every 3 months after initial biopsy for 1 year, then annually o Low grade dysplasia: repeat EGD twice within 12 months after initial biopsy, then annually if pathology Page 5 of 24

Condition Coverage Criteria unchanged o No dysplasia: repeat EGD one time within 12 months after initial biopsy; then every 3 years if pathology unchanged Celiac disease (Duodenal disease) and all of the following: o GI symptoms are consistent with chronic malabsorption AND o Serology tests are positive for celiac disease Cirrhosis upon initial diagnosis, one UGI endoscopy to screen for esophageal varices Crohn disease that involves the esophagus, stomach or duodenum Gastric, peptic, esophageal ulcer confirmation when: o Conservative medical management was tried and failed to relieve symptoms (e.g. cessation of NSAIDs, trial of appropriate medication) OR o Conservative medical management is contraindicated Ingestion of a caustic agent Ingested foreign body, known or suspected Male patient, aged 50 years or older with 5 years or more of GERD symptoms and 1 or more of the following: o Elevated body mass index (BMI) o Excess abdominal fat (intra-abdominal fat distribution) o Hiatal hernia o Night-time symptoms of reflux o Tobacco use Patients scheduled for a gastric bypass surgery Patients scheduled for organ transplantation Pernicious anemia symptoms (when other testing is inconclusive) UGI tract stricture or obstruction Page 6 of 24

Condition Coverage Criteria Note: Medical records may be requested to review the services for medical necessity. Documentation in the medical record must clearly support the medical necessity of the UGI services. Coding Place of Service Upper gastrointestinal endoscopy is a diagnostic or therapeutic procedure that is performed in an ambulatory surgery center, or an inpatient or outpatient hospital setting. CPT 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 43238 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasoundguided intramural or transmural fine needle aspiration/biopsy(s), (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures) 43239 Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple 43242 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasoundguided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis) Related Information Page 7 of 24

Definitions of Terms Achalasia: An esophageal motility disorder involving the smooth muscle of the esophagus and the lower esophageal sphincter (LES). Barrett esophagus: The replacement of the normal squamous epithelium of the esophagus that is damaged by gastroesophageal reflux disease with metaplastic columnar or glandular epithelium that is predisposed to esophageal adenocarcinoma. Crohn's or Crohn disease: Also known as Crohn syndrome and regional enteritis, this is a type of inflammatory bowel disease (IBD) that may affect any part of the gastrointestinal tract from mouth to anus. Celiac disease (also known as celiac sprue or gluten-sensitive enteropathy): An autoimmune digestive disorder. When foods with gluten are eaten the body s reaction causes damage to the intestinal lining. Cirrhosis: Scarring of the liver because of injury or long-term disease. The most common causes in the U.S. are chronic alcoholism and hepatitis. A small number of people with cirrhosis get liver cancer (see esophageal varices). Dyspepsia: A chronic or recurrent pain or discomfort centered in the upper abdomen; patients with predominant or frequent (more than once a week) heartburn or acid regurgitation (see GERD). Dysphagia: Difficulty or inability to swallow. Esophageal varices: Abnormally enlarged veins in the lower part of the esophagus, usually formed in the presence of a clot or when scar tissue in the liver obstructs blood flow Gastrointestinal: Abroad term relating to the organs and muscles of the digestive system (e.g. esophagus, stomach, small/large intestine). GERD: The acronym for gastroesophageal reflux disease, a digestive disorder affecting the lower esophageal sphincter (LES) (see dyspepsia). Odynophagia: The sensation of burning, squeezing pain when swallowing. Pernicious anemia: A vitamin B12 deficiency which reduces the body s ability to make healthy red blood cells. (Symptoms include but are not limited to anemia, extreme fatigue, pallor, red tongue, shortness of breath, tingling/numbness/coldness of hands and feet). Page 8 of 24

Medical management: Includes non-invasive interventions such as acid suppressive medications, nutritional counseling for dietary changes, weight loss counseling, environmental changes (e.g., elevating the head of bed) and others. Tylosis: A rare autosomal dominant syndrome that causes thickened skin on the palms of the hands and soles of the feet, associated with increased risk of esophageal squamous cell carcinoma. Varices: See esophageal varices. Histamine 2 Receptor Antagonists (H2RA) Use These have not been shown to heal esophagitis. A trial of full adult strength H2 may be used as a substitute for a trial of PPI only if the member cannot tolerate PPI or has a contraindication to their use are shown in Table 1. Table 1. Treatment of Erosive and Nonerosive Gastroesophageal Reflux Disease Medication Histamine 2 Receptor Antagonists* Low Dose (adult, oral) Standard Dose (adult, oral) Famotidine 10 mg twice daily 20 mg twice daily Δ Ranitidine 75 mg twice daily 150 mg twice daily Δ Nizatidine 75 mg twice daily 150 mg twice daily Cimetidine 200 mg twice daily 400 mg twice daily Δ Proton Pump Inhibitors Omeprazole 20 mg daily 40 mg daily Lansoprazole 15 mg daily 30 mg daily Esomeprazole 20 mg daily 40 mg daily Pantoprazole 20 mg daily 40 mg daily Dexlansoprazole Not available 30 mg daily, 60 mg daily Rabeprazole 10 mg daily 20 mg daily GERD: gastroesophageal reflux disease; US: United States. Page 9 of 24

* Histamine 2 receptor antagonists require dose adjustment in the setting of renal insufficiency. Available without a prescription (over the counter) in the US. Δ The daily dose for initial healing of esophagitis with erosions and symptoms of GERD in the US prescribing information is up to twice the standard dose shown in this table. Strength not available in US. Available elsewhere. Prepared with data from: Kahrilas PJ, et al. American Gastroenterological Association Medical Position Statement on the management of gastroesophageal reflux disease. Gastroenterology 2008; 135:1383. Anon. American Gastroenterological Association Institute Technical Review on the Management of Gastroesophageal Reflux Disease. Gastroenterology 2008; 135:1392. Source: 2016 UpToDate Evidence Review In the absence of a clear cancer diagnosis, professional societies indicate that conservative medical management of gastrointestinal symptoms should be the first intervention before an 2, 3, 6 invasive diagnostic test such as an upper gastrointestinal endoscopy. Non-cardiac Chest Pain (NCCP) NCCP describes pain in the chest area that is similar to heart muscle pain (also called angina) in patients who do not have heart disease confirmed by a cardiac work-up. NCCP occurs in men and women of all ages as well as children. Because of the anatomy of the chest cavity with the heart and esophagus resting near each other, pain from either organ may be similar, which makes it hard to differentiate the pain source. Patients, who continue to have chest pain after a cardiac work up fails to provide evidence of heart disease, may need a GI work up. The American College of Gastroenterology makes a strong recommendation stating that a cardiac cause should be excluded in patients with chest pain before the commencement of a gastrointestinal evaluation. 4 Page 10 of 24

Practice Guidelines and Position Statements American College of Physicians (ACP) In December of 2012 the American College of Physicians (ACP) published clinical guidelines for upper endoscopy. 6 The best practice recommendations from the professional organization follow. Best Practice Advice 1 Upper endoscopy is indicated in men and women with heartburn and alarm symptoms: Anemia Bleeding Dysphagia Recurrent vomiting Weight loss Best Practice Advice 2 Upper endoscopy is indicated in men and women with: Typical gastroesophageal reflux disease (GERD) symptoms that persist despite a therapeutic trial of 4 to 8 weeks of twice-daily proton-pump inhibitor therapy. Severe erosive esophagitis after a 2-month course of proton-pump inhibitor therapy to assess healing and rule out Barrett esophagus. Recurrent endoscopy after this follow-up examination is not indicated in the absence of Barrett esophagus. History of esophageal stricture that have recurrent symptoms of dysphagia Best Practice Advice 3 Upper endoscopy may be indicated: In men older than 50 years with chronic GERD symptoms (symptoms for more than 5 years) and additional risk factors (nocturnal reflux symptoms, hiatal hernia, elevated body mass Page 11 of 24

index, tobacco use, and intra-abdominal distribution of fat) to detect esophageal adenocarcinoma and Barrett esophagus. For surveillance evaluation in men and women with a history of Barrett esophagus. In men and women with Barrett esophagus and no dysplasia, surveillance examinations should occur at intervals no more frequently than 3 to 5 years. More frequent intervals are indicated in patients with Barrett esophagus and dysplasia American College of Gastroenterology (ACG) The American College of Gastroenterology (ACG) developed guidelines 7 for the diagnosis and management of GERD. The relevant guideline information follows: Establishing the Diagnosis of Gastroesophageal Reflux Disease (GERD) from the ACG Recommendations The diagnosis of GERD is made using some combination of symptom presentation, objective testing with endoscopy, ambulatory reflux monitoring, and response to antisecretory therapy. 1. A presumptive diagnosis of GERD can be established in the setting of typical symptoms of heartburn and regurgitation. Empiric medical therapy with a PPI is recommended in this setting. (Strong recommendation, moderate level of evidence). 2. Patients with non-cardiac chest pain suspected due to GERD should have diagnostic evaluation before institution of therapy. (Conditional recommendation, moderate level of evidence) A cardiac cause should be excluded in patients with chest pain before the commencement of a gastrointestinal evaluation (Strong recommendation, low level of evidence) 3. Barium radiographs should not be performed to diagnose GERD (Strong recommendation, high level of evidence) 4. Upper endoscopy is not required in the presence of typical GERD symptoms. Endoscopy is recommended in the presence of alarm symptoms and for screening of patients at high risk for complications. Repeat endoscopy is not indicated in patients without Barrett s esophagus in the absence of new symptoms. (Strong recommendation, moderate level of evidence) 5. Routine biopsies from the distal esophagus are not recommended specifically to diagnose GERD. (Strong recommendation, moderate level of evidence) 6. Esophageal manometry is recommended for preoperative evaluation, but has no role in the diagnosis of GERD. (Strong recommendation, low level of evidence) Page 12 of 24

7. Ambulatory esophageal reflux monitoring is indicated before consideration of endoscopic or surgical therapy in patients with GERD, as part of the evaluation of patients refractory to PPI therapy, and in situations when the diagnosis of GERD is in question. (Strong recommendation, low level evidence). Ambulatory reflux monitoring is the only test that can assess reflux symptom association (Strong recommendation, low level of evidence). 8. Ambulatory reflux monitoring is not required in the presence of short or long-segment Barrett s esophagus to establish a diagnosis of GERD. (Strong recommendation, moderate level of evidence). 9. Screening for Helicobacter pylori infection is not recommended in GERD. Eradication of H. pylori infection is not routinely required as part of antireflux therapy (Strong recommendation, low level of evidence) Table 2. Diagnostic Testing for GERD and Utility of Tests Diagnostic Test Indication Highest Level of Evidence PPI trial Classic symptoms, no Meta-analysis warning signs Recommendation Negative trial does not rule out GERD Barium swallow Not for GERD diagnosis. Use of evaluation of Case-control Do not use unless evaluating for complication (stricture, dysphagia. ring) Endoscopy Alarm symptoms, screening of high-risk Randomized control trial Consider early for elderly, those at risk for Barrett s, patients, chest pain non-cardiac chest pain, patients unresponsive to PPI Esophageal biopsy Exclude non-gerd causes for symptoms Case-Control Not indicated for diagnosis of GERD Esophageal manometry Preoperative evaluation for surgery Observational Not recommended for GERD diagnosis. Rule out achalasia /scleroderma-like esophagus pre-op Ambulatory reflux monitoring Preoperatively for nonerosive disease. Refractory GERD symptoms, GERD diagnosis in question Observational Correlate symptoms with reflux, document abnormal acid exposure or reflux frequency GERD=gastroesophageal reflux disease; PPI=proton pump inhibitor Page 13 of 24

American Society for Gastrointestinal Endoscopy (ASGE) In 2012, the ASGE 8 published updated SOP recommendations for esophagogastroduodenoscopy (EGD) with specific indications. Esophagogastroduodenoscopy is generally indicated for evaluating: A. Upper abdominal symptoms that persist despite an appropriate trial of therapy. B. Upper abdominal symptoms associated with other symptoms or signs suggesting structural disease (e.g., anorexia and weight loss) or new-onset symptoms in patients older than 50 years of age. C. Dysphagia or odynophagia. D. Esophageal reflux symptoms that persist or recur despite appropriate therapy. E. Persistent vomiting of unknown cause. F. Other diseases in which the presence of upper GI pathology might modify other planned management. Examples include patients who have a history of ulcer or GI bleeding who are scheduled for organ transplantation, long-term anti-coagulation, or non-steroidal anti-inflammatory drug therapy for arthritis, and those with cancer of the head and neck. G. Familial adenomatous polyposis syndromes. H. For confirmation and specific histological diagnosis of radiologically demonstrated lesions: 1. Suspected neoplastic lesion 2. Gastric or esophageal ulcer 3. Upper tract stricture or obstruction I. Gastrointestinal bleeding: 1. In patients with active or recent bleeding 2. For presumed chronic blood loss and for iron deficiency anemia when the clinical situation suggests an upper GI source or when colonoscopy does not provide an explanation J. When sampling of tissue or fluid is indicated. K. Selected patients with suspected portal hypertension to document or treat esophageal varices. L. To assess acute injury after caustic ingestion. M. To assess diarrhea in patient suspected of having small-bowel disease (e.g. celiac disease) Page 14 of 24

N. Treatment of bleeding lesions such as ulcers, tumors, vascular abnormalities (e.g., electrocoagulation, heater probe, laser photocoagulation, or injection therapy). O. Removal of foreign bodies. P. Removal of selected lesions. Q. Placement of feeding or drainage tubes (peroral, percutaneous endoscopic gastrostomy, percutaneous endoscopic jejunostomy). R. Dilation and stenting of stenotic lesions (e.g., with transendoscopic balloon dilators or dilation systems using guide wires). S. Management of achalasia (e.g., botulinum toxin, balloon dilation). T. Palliative treatment of stenosing neoplasms (e.g., laser, multi-polar electrocoagulation, stent placement). U. Endoscopic therapy of intestinal metaplasia. V. Intraoperative evaluation of anatomic reconstructions typical of modern foregut surgery (e.g., evaluation of anastomotic leak and patency, fundoplication formation, pouch configuration during bariatric surgery). W. Management of operative complications (e.g., dilation of anastomotic strictures, stenting of anastomotic disruption, fistula, or leak in selected circumstances). Esophagogastroduodenoscopy is generally not indicated for evaluating: A. Symptoms that are considered functional in origin (there are exceptions in which an endoscopic examination may be done once to rule out organic disease, especially if symptoms are unresponsive to therapy or symptoms recur that are different in nature from the original symptoms). B. Metastatic adenocarcinoma of unknown primary site when the results will not alter management. C. Radiographical findings of: 1. Asymptomatic or uncomplicated sliding hiatal hernia 2. Uncomplicated duodenal ulcer that has responded to therapy 3. Deformed duodenal bulb when symptoms are absent or respond adequately to ulcer therapy Sequential or periodic EGD may be indicated for: Page 15 of 24

A. Surveillance for malignancy in patients with pre-malignant conditions (e.g. Barrett's esophagus, polyposis syndromes, gastric adenomas, tylosis or previous caustic ingestion). Sequential or periodic EGD is generally not indicated for: A. Surveillance for malignancy in patients with gastric atrophy, pernicious anemia, or fundic gland or hyperplastic polyps, gastric intestinal metaplasia, or prior gastric operations for benign disease. B. Surveillance of healed benign disease such as esophagitis or gastric or duodenal ulcer. American Association for the Study of Liver Diseases (AASLD) In 2007 the AASLD published the following recommendations 9 for Prevention and Management of Gastroesophageal Varices and Variceal Hemorrhage in Cirrhosis: 1. Screening esophagogastroduodenoscopy (EGD) for the diagnosis of esophageal and gastric varices is recommended when the diagnosis of cirrhosis is made (Class IIa, Level C). 2. On EGD, esophageal varices should be graded as small or large (>5 mm) with the latter classification encompassing medium-sized varices when 3 grades are used (small, medium, large). The presence or absence of red signs (red wale marks or red spots) on varices should be noted (Class IIa, Level C). 3. In patients with cirrhosis who do not have varices, nonselective beta-blockers cannot be recommended to prevent their development (Class III, Level B). 4. In patients who have compensated cirrhosis and no varices on the initial EGD, it should be repeated in 3 years (Class I, Level C). If there is evidence of hepatic decompensation, EGD should be done at that time and repeated annually (Class I, Level C). 5. In patients with cirrhosis and small varices that have not bled but have criteria for increased risk of hemorrhage (Child B/C or presence of red wale marks on varices), nonselective beta-blockers should be used for the prevention of first variceal hemorrhage (Class IIa, Level C). 6. In patients with cirrhosis and small varices that have not bled and have no criteria for increased risk of bleeding, beta-blockers can be used, although their long-term benefit has not been established (Class III, Level B). 7. In patients with small varices that have not bled and who are not receiving beta-blockers, EGD should be repeated in 2 years (Class I, Level C). If there is evidence of hepatic decompensation, EGD should be done at that time and repeated annually (Class I, Level C). In patients with small varices who receive beta-blockers, a follow-up EGD is not necessary. Page 16 of 24

8. In patients with medium/large varices that have not bled but have a high risk of hemorrhage (Child B/C or variceal red wale markings on endoscopy), nonselective beta-blockers (propranolol or nadolol) or EVL may be recommended for the prevention of first variceal hemorrhage (Class I, Level A). 9. In patients with medium/large varices that have not bled and are not at the highest risk of hemorrhage (Child A patients and no red signs), nonselective beta-blockers (propranolol, nadolol) are preferred and EVL should be considered in patients with contraindications or intolerance or noncompliance to beta-blockers (Class I, Level A). 10. If a patient is placed on a nonselective beta-blocker, it should be adjusted to the maximal tolerated dose; follow-up surveillance EGD is unnecessary. If a patient is treated with EVL, it should be repeated every 1-2 weeks until obliteration with the first surveillance EGD performed 1-3 months after obliteration and then every 6-12 months to check for variceal recurrence (Class I, Level C). 11. Nitrates (either alone or in combination with beta-blockers), shunt therapy, or sclerotherapy should not be used in the primary prophylaxis of variceal hemorrhage (Class III, Level A). 12. Acute GI hemorrhage in a patient with cirrhosis is an emergency that requires prompt attention with intravascular volume support and blood transfusions, being careful to maintain a hemoglobin of 8g/dL (Class I, Level B). 13. Short-term (maximum 7 days) antibiotic prophylaxis should be instituted in any patient with cirrhosis and GI hemorrhage (Class I, Level A). Oral norfloxacin (400 mg BID) or intravenous ciprofloxacin (in patients in whom oral administration is not possible) is the recommended antibiotic (Class I, Level A). In patients with advanced cirrhosis intravenous ceftriaxone (1 g/day) may be preferable particularly in centers with a high prevalence of quinolone-resistant organisms (Class I, Level B). 14. Pharmacological therapy (somatostatin or its analogues octreotide and vapreotide; terlipressin) should be initiated as soon as variceal hemorrhage is suspected and continued for 3-5 days after diagnosis is confirmed (Class I, Level A). 15. EGD, performed within 12 hours, should be used to make the diagnosis and to treat variceal hemorrhage, either with EVL or sclerotherapy (Class I, Level A). 16. TIPS is indicated in patients in whom hemorrhage from esophageal varices cannot be controlled or in whom bleeding recurs despite combined pharmacological and endoscopic therapy (Class I, Level C). 17. Balloon tamponade should be used as a temporizing measure (maximum 24 hours) in patients with uncontrollable bleeding for whom a more definitive therapy (e.g., TIPS or endoscopic therapy) is planned (Class I, Level B). 18. In patients who bleed from gastric fundal varices, endoscopic variceal obturation using tissue adhesives such as cyanoacrylate is preferred, where available. Otherwise, EVL is an option (Class I, Level B). Page 17 of 24

19. A TIPS should be considered in patients in whom hemorrhage from fundal varices cannot be controlled or in whom bleeding recurs despite combined pharmacological and endoscopic therapy (Class I, Level B). 20. Patients with cirrhosis who survive an episode of active variceal hemorrhage should receive therapy to prevent recurrence of variceal hemorrhage (secondary prophylaxis) (Class I, Level A). 21. Combination of nonselective beta-blockers plus EVL is the best option for secondary prophylaxis of variceal hemorrhage (Class I, Level A). 22. The nonselective beta-blocker should be adjusted to the maximal tolerated dose. EVL should be repeated every 1-2 weeks until obliteration with the first surveillance EGD performed 1-3 months after obliteration and then every 6-12 months to check for variceal recurrence (Class I, Level C). 23. TIPS should be considered in patients who are Child A or B who experience recurrent variceal hemorrhage despite combination pharmacological and endoscopic therapy. In centers where the expertise is available, surgical shunt can be considered in Child A patients (Class I, Level A). 24. Patients who are otherwise transplant candidates should be referred to a transplant center for evaluation (Class I, Level C). Medicare National Coverage The coverage statement is that Endoscopic procedures are covered when reasonable and necessary for the individual patient. 5 References 1. Chan WW ed. Endoscopy. The Merck Manual Online. Merck Research Laboratories; revised February 2013. Available at: http://www.merck.com/mmpe/sec02/ch009/ch009c.html. Accessed July 2016. 2. Katz PO, Gerson LB, Vila MF. Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. The American College of Gastroenterology. Am J Gastroenterol 2013; 108:308-328. PMID 23419381. Available at URL address: http://gi.org/guideline/diagnosis-and-managemen-of-gastroesophageal-reflux-disease/. Accessed July 2016. 3. Choosing Wisely Campaign. American Gastroenterological Association: Five things physician and patients should question. The ABIM Foundation 2012. Available at: http://www.choosingwisely.org/wpcontent/uploads/2013/01/5things_12_factsheet_aga.pdf. Accessed July 2016. 4. Achem SR. American College of Gastroenterology. Non-cardiac chest pain. Patient education and resource center updated July 2013 [online]. Available online at URL address: http://patients.gi.org/topics/non-cardiac-chest-pain/. Accessed July 2016. Page 18 of 24

5. Medicare National Coverage Determination, Endoscopy (100.2). Available at URL address: http://www.cms.gov/medicarecoverage-database/details/ncddetails.aspx?ncdid=81&ncdver=1&coverageselection=both&articletype=all&policytype=final&s=washington&key Word=Endoscopy&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAABAAAAAAAA%3d%3d&. Accessed July 2016. 6. Shaheen NJ, Weinberg DS, et al. Upper Endoscopy for Gastroesophageal Reflux Disease: Best Practice Advice from the Clinical Guidelines Committee of the American College of Physicians. Annals of Internal Medicine. Vol 157, number 11, pgs. 806-816. PMID 23208168. Available at URL address: http://annals.org/article.aspx?articleid=1470281. Accessed July 2016. 7. Katz PO, Gerson LB, Vila MF. Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. The American College of Gastroenterology. Am J Gastroenterol 2013; 108:308-328. PMID 15184824. Available at URL address: http://gi.org/guideline/diagnosis-and-managemen-of-gastroesophageal-reflux-disease/. Accessed July 2016. 8. ASGE Standards of Practice Committee, Early DS, Ben-Menachem T, et al. Appropriate use of GI endoscopy. Specific indications statements from the SOP committee. Gastrointest Endosc 2012; 75(6):1127-1131. PMID 22624807. Available online at: http://www.asge.org/clinicalpractice/clinical-practice.aspx?id=352. Accessed July 2016. 9. Garcia-Tsao G, Sanyal AJ, Grace ND, et al. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 2007 Sep, 46(3):922-938. AASLD practice guidelines. PMID 17879356. Available at http://www.aasld.org/publications/practice-guidelines-0. Accessed July 2016. 10. Cerulli MA. Upper gastrointestinal bleeding. emedicine Medicine Topic 3565.eMedicine.com; updated May 2014. Available at: http://www.emedicine.com/med/topic3565.htm. Accessed July 2016. 11. Liu, R., Kriz, H., Thielke, A., Vandegriff, S., & King, V. (2012). Upper Endoscopy for Gastroesophageal Reflux Disease (GERD) and Upper Gastrointestinal (GI) Symptoms. Portland, OR: Center for Evidence-based Policy, Oregon Health and Science University. Available at: http://www.hca.wa.gov/hta/documents/upper_endoscopy_final_published_041812.pdf. Accessed January 2016. 12. American Society for Gastrointestinal Endoscopy, Hwang JH, Shergill AK, et al. The role of endoscopy in the management of variceal hemorrhage. Gastrointest Endosc 2014 Aug; 80(2): 221-227. PMID 25034836. Available online at: http://www.asge.org/clinicalpractice/clinical-practice.aspx?id=352. Accessed July 2016. 13. Kahrilas, PJ. Medical management of gastoresophageal reflux disease in adults. In: UpToDate, Grover, S(Ed), UpToDate, Waltham, MA, 2016. History Date Comments 06/10/13 New policy. Add to Utilization Management section. Policy approved with 90-day hold for provider notification. The policy effective date is October 01, 2013. 08/15/13 Update Related Policies. Remove 2.01.520 and add 2.01.20. 09/05/13 Coding update. CPT code 43252 removed from policy as it pertains to another policy (2.01.87). 08/11/14 Annual Review. Changed the title to Upper Gastrointestingal (UGI) Endoscopy for Adults, for ease of finding the document. Policy extensively re-written. Policy Page 19 of 24

statements reorganized but intent is unchanged. Revised adult to patients of 19 years old and older. Policy updated with literature search through June, 2014. Reference to using MCG as a tool to guide determinations is removed. References 6-10 added; others renumbered/removed. New CPT codes 43233, 43253, 43254, 43266, 43270 added for 2014. Policy statements changed as noted. 10/13/14 Interim Update. Removed Policy statement under UGI Tract Symptoms header that states interferes with activities of daily living on 3 or more days a week. Extensive editorial changes to consolidate and simplify criteria in the policy statements. Clarification for non-cardiac chest pain (NCCP) added to the rationale section. Reference 5 added; others renumbered. Policy statements revised, intent is unchanged. 12/22/14 Interim Update. Policy reclassified, renumbered from 11.01.504 to 2.01.533 and moved from UM section to Medicine section. Reference 1 removed; others renumbered and broken hyperlinks repaired. Policy statements unchanged. 05/12/15 Annual Review. Policy updated with literature search through April, 2015. Added esophageal varices with or without bleeding to the Follow Up of Known Conditions list. Added new cirrhosis diagnosis to the Other Indications list. Cirrhosis added to Definition of Terms. Added AASLD recommendations to Practice Guidelines and Position Statements section. References 10,13 added; others renumbered. Policy statements changed as noted. Remove informational CPT codes: 43233-34, 43237, 43240-41, 43243-43256; 43258-59; 43270; remove ICD-9 diagnosis codes, as they do not affect policy adjudication. 06/02/15 Update Related Policies. Remove 2.01.81 as it was archived. 12/07/15 Update Related Policies. Remove 6.01.33 and 7.02.500 as they were archived. 02/09/16 Annual Review. No change in coverage statements. Removed reference 6, Medicare LCD no longer available. 07/12/16 Interim Update. Added information on histatmine 2 receptor antagonists and table to Related Information section; reference 13 added. Policy moved into new format; no change to policy statements. Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). 2016 Premera All Rights Reserved. Scope: Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member Page 20 of 24

benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage. PRIOR AUTHORIZATION REQUIREMENTS Clinical Information Requirements Please submit your patient s information and clinical records listed below for a prior authorization request upper gastrointestinal (UGI) endoscopy for adults to this fax number: 800-843-1114. All information must be submitted for prior authorization review to be completed. NOTE: Patient must be 19 years of age or older and meet at least one of the criteria below. No review is required for patients 18 years of age or younger. Coding Please indicate the codes to be reviewed with this request: CPT 43235 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 43236 with directed submucosal injection(s) any substance 43238 with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), esophagus (includes endoscopic ultrasound examination limited to the esophagus) 43239 with biopsy, single or multiple 43242 with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum and/or jejunum as appropriate) Page 21 of 24

Condition Clinical Information Required Malignant Indications For requests for UGI, please submit history and treatment supporting one of the following conditions: Dysplasia Esophageal cancer Familial adenomatous polyposis Gastric cancer History of Lynch syndrome (HNPCC or hereditary nonpolyposis colorectal cancer) Head/neck cancer In situations where clinical features are highly suspicious for UGI malignancy (e.g., epigastric mass found on x-ray, abnormal Barium study, and others) Patients with prior adenomatous gastric polyps or sessile polyps (rare) Strong family history of gastrointestinal cancer Tylosis Condition Clinical Information Required Non-malignant Indications Alarm Symptoms For requests for UGI, please submit documentation supporting an indication of one of the following: Anemia or gastrointestinal bleeding (see GI bleeding section) Epigastric mass (on examination) Persistent vomiting of unknown cause, including vomiting blood Swallowing that is difficult (dysphagia) Unintentional weight loss of 3 kg or more since symptoms started Follow-up of Known For requests for UGI, please submit documentation Conditions supporting an indication of one of the following: Anorexia of unknown cause Chest pain that is unusual, and that persists after heart disease is ruled out Erosive esophagitis Page 22 of 24

Gastrointestinal Bleeding Symptoms Gastroesophageal Reflux GERD Symptoms Upper Gastrointestinal Tract (UGI) Dyspepsia Symptoms Other Upper Gastrointestinal Tract Indications History of gastric surgery NSAID use is stopped yet symptoms continue Swallowing that is difficult (dysphagia) Swallowing that is painful (odynophagia) For requests for UGI, please submit documentation supporting an indication of one of the following: Blood in stools when a colonoscopy is negative or inconclusive Chronic GI bleeding History of long-term use of anticoagulation therapy History of long-term use of NSAIDs for arthritis Iron deficiency anemia Persistent blood-tinged vomitus For requests for UGI, please submit documentation of the following: Symptoms present for at least 3 months AND Failure of daily proton pump inhibitory therapy after 4 weeks of treatment For requests for UGI, please submit documentation of the following: Symptoms present for at least 3 months AND Failure of daily proton pump inhibitory therapy after 4 weeks of treatment For requests for UGI, please submit documentation supporting one of the following and all criteria listed under that condition: Achalasia Barrett s esophagus (BE) surveillance-based on pathology: o High-grade dysplasia: Repeat EGD every 3 months after initial biopsy for 1 year, then annually o Low-grade dysplasia: Repeat EGD twice within 12 months after initial biopsy, then annually if pathology is unchanged Page 23 of 24

o No dysplasia: Repeat EGD one time within 12 months after initial biopsy, then every 3 years if pathology is unchanged Celiac disease (Duodenal disease) and ALL of the following: o GI symptoms are consistent with chronic malabsorption AND o Serology tests are positive for celiac disease Crohn s disease that involves the esophagus, stomach or duodenum Gastric, peptic, esophageal ulcer confirmation when conservative medical management was tried and failed to relieve symptoms (e.g., cessation of NSAIDs, trial of appropriate medication) or was contraindicated Ingestion of a caustic agent Ingested foreign body, known or suspected Male patient, 50 years old or older with 5 years or more of GERD symptoms with one or more of the following: o Elevated body mass index (BMI) o Excess abdominal fat (intra-abdominal fat distribution) o Hiatal hernia o Night-time symptoms of reflux o Tobacco use Patient is scheduled for gastric bypass surgery Patient is scheduled for organ transplantation Pernicious anemia symptoms (when other testing is inconclusive) Upper GI tract stricture or obstruction Page 24 of 24