Upper Endoscopy for Gastroesophogeal Reflux Disease (GERD) and Gastrointestinal (GI) Symptoms

Coverage decision: Covered with conditions

Conditions of Coverage

  • Adults with initial presenting complaints of upper GI symptoms or symptoms consistent with GERD
  • Failure of adequate trial of medical treatment to improve or resolve symptoms (recurrence of symptoms after initial treatment indicates treatment failure), or;
  • Presence of alarm symptoms:
    • Persistent dysphagia or odynophagia;
    • Persistent vomiting of unknown etiology;
    • Evaluation of epigastric mass;
    • Confirmation and specific histological diagnosis of radiologically demonstrated lesions;
    • Evaluation for chronic blood loss and iron deficiency anemia when an upper gastrointestinal source is suspected or when colonoscopy results are negative;
    • Progressive unintentional weight loss.

Background Policy Information

The State Health Technology Clinical Committee (HTCC) reviewed upper endoscopy for GERD and GI symptoms on May 18, 2012. The committee’s determination, based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, is that upper endoscopy for GERD and GI symptoms is a covered benefit with conditions.  Complete information on this HTCC determination is available here: http://www.hca.wa.gov/about-hca/health-technology-assessment/health-technology-reviews.

Implementation of the Determination

Upper endoscopy may be used only for care of a condition accepted on the claim. Upper endoscopy is an invasive procedure.  GERD and GI symptoms are unlikely to be related to any occupational injury or disease and are therefore not expected to be accepted conditions on an L&I claim. All requests require prior authorization.

For State Fund Claims

All requests will be reviewed by L&I’s occupational nurse consultant and claims manager.

  • Complete the Preauthorization Form and fax to:(360) 902-4567
  • For additional information contact the claims manager
    • To obtain the claims manager’s phone number call 1-800-831-5227
    • Attending provider, concurrent care provider or IME log into the Claims & Account Center (CAC)
For Self-Insured Claims

Please contact the self-insured employer (SIE) or their third party administrator (TPA). For a list of SIE/TPAs, go to:
http://www.Lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/Default.asp

Billing Codes

CPT ® Codes: 43191, 43193, 43197, 43198, 43200, 43202, 43206, 43235, 43239 and 43252


For more information:
Contact information.

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