INDICATIONS

OF UPPER

GI ENDOSCOPY

Diagnostic EGD

Therapeutic EGD

Screening EGD

Sequential or Periodic Diagnostic EGD

Diagnostic EGD

According to the ASGE Consensus Statement

Guidelines (2000-2006), esophago-gastroduodenoscopy

(EGD) for diagnostic purpose(s) is considered medically

necessary for any of the following:

1. Upper abdominal symptoms which persist

despite an appropriate trial of therapy

1. Upper abdominal symptoms which persist

despite an appropriate trial of therapy

2. Upper abdominal symptoms associated with other

signs/symptoms suggesting serious organic disease (e.g.,

anorexia and weight loss) or in patients over 45 years of age

2. Upper abdominal symptoms associated with other

signs/symptoms suggesting serious organic disease (e.g.,

anorexia and weight loss) or in patients over 45 years of age

3. Dysphagia or odynophagia 3. Dysphagia or odynophagia

4. Esophageal reflux symptoms that are persistent

or recurrent despite appropriate therapy

4. Esophageal reflux symptoms that are persistent

or recurrent despite appropriate therapy

5. Persistent vomiting of unknown origin 5. Persistent vomiting of unknown origin

6. Other disease in which the presence of upper GI

pathology might modify other planned management

6. Other disease in which the presence of upper GI

pathology might modify other planned management

7. Familial adenomatous polyposis syndromes 7. Familial adenomatous polyposis syndromes

8. For confirmation and specific histological diagnosis of radiographically demonstrated lesions:

a. Suspected neoplastic lesion

b. Gastric or esophageal ulcer

c. Upper GI stricture or obstruction

8. For confirmation and specific histological diagnosis of radiographically demonstrated lesions:

a. Suspected neoplastic lesion

b. Gastric or esophageal ulcer

c. Upper GI stricture or obstruction

9. Gastrointestinal bleeding:

a. In patients with active or recent bleeding

b. For presumed chronic blood loss and for iron deficiency anemia

when the clinical situation suggests an upper GI source or when

colonoscopy is negative

c. When surgical therapy is contemplated

d. When portal hypertension or aorto-enteric fistula is suspected

e. When re-bleeding occurs after acute self-limited blood loss

9. Gastrointestinal bleeding:

a. In patients with active or recent bleeding

b. For presumed chronic blood loss and for iron deficiency anemia

when the clinical situation suggests an upper GI source or when

colonoscopy is negative

c. When surgical therapy is contemplated

d. When portal hypertension or aorto-enteric fistula is suspected

e. When re-bleeding occurs after acute self-limited blood loss

10. When sampling of upper GI tissue or fluid is indicated 10. When sampling of upper GI tissue or fluid is indicated

11. To assess acute injury after caustic ingestion 11. To assess acute injury after caustic ingestion

12. Intraoperative EGD when necessary to clarify

location or pathology of a lesion

12. Intraoperative EGD when necessary to clarify

location or pathology of a lesion

13. Documentation of esophageal varices in patients with suspected portal hypertension 13. Documentation of esophageal varices in patients with suspected portal hypertension

14. Refusal to eat or failure to thrive in very young or uncommunicative child

(Rudolph [North American Society for Pediatric Gastroenterology and

Nutrition] [NASPGHAN], 2001; Squires [NASPGHAN], 1996)

14. Refusal to eat or failure to thrive in very young or uncommunicative child

(Rudolph [North American Society for Pediatric Gastroenterology and

Nutrition] [NASPGHAN], 2001; Squires [NASPGHAN], 1996)

Therapeutic EGD

According to the ASGE Consensus Statement

Guidelines (2000-2006), esophago-gastroduodenoscopy

(EGD) for therapeutic purpose(s) is considered medically

necessary for any of the following:

1. Treatment of bleeding from lesions such as ulcers, tumors, vascular malformations (e.g.,

electrocoagulation or injection therapy)

1. Treatment of bleeding from lesions such as ulcers, tumors, vascular malformations (e.g.,

electrocoagulation or injection therapy)

2. Sclerotherapy and/or band ligation for bleeding from esophageal or proximal

gastric varices

(For esophageal varices, procedure may be repeated every two to four weeks

until varices are eradicated) (Qureshi [ASGE], 2005)

2. Sclerotherapy and/or band ligation for bleeding from esophageal or proximal

gastric varices

(For esophageal varices, procedure may be repeated every two to four weeks

until varices are eradicated) (Qureshi [ASGE], 2005)

3. Foreign body removal 3. Foreign body removal

4. Removal of selected polypoid lesions 4. Removal of selected polypoid lesions

5. Placement of feeding tubes (per oral, percutaneous

endoscopic gastrostomy, percutaneous endoscopic

jejunostomy)

5. Placement of feeding tubes (per oral, percutaneous

endoscopic gastrostomy, percutaneous endoscopic

jejunostomy)

6. Dilation of stenotic lesions of the esophagus, pylorus or duodenum (e.g., with transendoscopic balloon dilators or dilating systems employing guidewires)

6. Dilation of stenotic lesions of the esophagus, pylorus or duodenum (e.g., with transendoscopic balloon dilators or dilating systems employing guidewires)

7. Management of achalasia (dilatation, Botulinum toxin)

7. Management of achalasia (dilatation, Botulinum toxin)

8. Palliative therapy of stenosing neoplasms 8. Palliative therapy of stenosing neoplasms

Screening EGD

According to the ASGE Consensus

Statement Guidelines (2000-2006), esophago-

gastroduodenoscopy (EGD) for screening

purpose(s) is considered medically necessary

for any of the following:

1. Patients who have longstanding (5 years or more) gastroesophageal reflux

disease (GERD) to rule out Barrett’s esophagus (Hirota [ASGE)], 2006)

1. Patients who have longstanding (5 years or more) gastroesophageal reflux

disease (GERD) to rule out Barrett’s esophagus (Hirota [ASGE)], 2006)

2. Patients at high risk for squamous cell cancer of the esophagus including, but not limited to:

A. Patients with tylosis (surveillance should begin at age 30 years)

B. Fanconi’s anemia

C. Patients with caustic injury (surveillance should begin 15 to 20 years after caustic ingestion)

(Hirota [ASGE], 2006; Wang [American Gastrointestinal Association], 2005)

2. Patients at high risk for squamous cell cancer of the esophagus including, but not limited to:

A. Patients with tylosis (surveillance should begin at age 30 years)

B. Fanconi’s anemia

C. Patients with caustic injury (surveillance should begin 15 to 20 years after caustic ingestion)

(Hirota [ASGE], 2006; Wang [American Gastrointestinal Association], 2005)

Sequential or Periodic Diagnostic EGD

According to the ASGE Consensus

Statement Guidelines (2000-2006), Sequential

or periodic diagnostic esophagogastro-

duodenoscopy (EGD) is considered medically

necessary for the following :

1. Pre-malignant conditions including, but not limited to:

a. Follow-up of patients with prior adenomatous gastric polyps

b. Follow-up of patients with Familial Adenomatous Polyposis (FAP)

c. Follow-up of patients with established Barrett’s esophagus

d. Follow up of patients with tylosis

e. Follow up of patients with caustic injury

1. Pre-malignant conditions including, but not limited to:

a. Follow-up of patients with prior adenomatous gastric polyps

b. Follow-up of patients with Familial Adenomatous Polyposis (FAP)

c. Follow-up of patients with established Barrett’s esophagus

d. Follow up of patients with tylosis

e. Follow up of patients with caustic injury

2. Follow up of selected esophageal, gastric or stomal ulcers if likely

to alter clinical management

2. Follow up of selected esophageal, gastric or stomal ulcers if likely

to alter clinical management

3. Follow up for adequacy of prior sclerotherapy and/or band ligation of esophageal varices (could be every 6-24 months depending on clinical status)

3. Follow up for adequacy of prior sclerotherapy and/or band ligation of esophageal varices (could be every 6-24 months depending on clinical status)

4. For surveillance for patients with portal

hypertension or cirrhosis

4. For surveillance for patients with portal

hypertension or cirrhosis

5. For surveillance for rejection or other complications

following intestinal transplantation.

5. For surveillance for rejection or other complications

following intestinal transplantation.

Not Medically Necessary EGD

According to the ASGE Consensus

Statement Guidelines (2000-2006),

esophagogastro-duodenoscopy (EGD)

is considered not medically necessary

for the following :

1. Distress that is chronic, non-progressive and atypical for known

organic disease, and is considered functional in origin

1. Distress that is chronic, non-progressive and atypical for known

organic disease, and is considered functional in origin

2.2. Uncomplicated heartburn responding to medical Uncomplicated heartburn responding to medical therapy therapy

2.2. Uncomplicated heartburn responding to medical Uncomplicated heartburn responding to medical therapy therapy

3.3. Metastatic adenocarcinoma of unknown primary Metastatic adenocarcinoma of unknown primary

site when the results will not alter management site when the results will not alter management

3.3. Metastatic adenocarcinoma of unknown primary Metastatic adenocarcinoma of unknown primary

site when the results will not alter management site when the results will not alter management

4. X-ray findings of: – Asymptomatic or uncomplicated sliding hiatal hernia, or – Uncomplicated duodenal ulcer that is responding to therapy, or – Deformed duodenal bulb seen on upper GI when symptoms are absent or responding adequately to ulcer therapy.

4. X-ray findings of: – Asymptomatic or uncomplicated sliding hiatal hernia, or – Uncomplicated duodenal ulcer that is responding to therapy, or – Deformed duodenal bulb seen on upper GI when symptoms are absent or responding adequately to ulcer therapy.

5.5. Routine screening of the upper gastrointestinal Routine screening of the upper gastrointestinal tract tract

5.5. Routine screening of the upper gastrointestinal Routine screening of the upper gastrointestinal tract tract

6. Patients without current gastrointestinal symptoms about to undergo

elective surgery for non-upper gastrointestinal disease

6. Patients without current gastrointestinal symptoms about to undergo

elective surgery for non-upper gastrointestinal disease

7.7. Confirming Helicobacter pylori (H. pylori) eradication Confirming Helicobacter pylori (H. pylori) eradication 7.7. Confirming Helicobacter pylori (H. pylori) eradication Confirming Helicobacter pylori (H. pylori) eradication

9. For surveillance for patients with portal hypertension or

cirrhosis Surveillance for malignancy in patients with gastric Surveillance for malignancy in patients with gastric

atrophy, pernicious anemia or treated achalasia atrophy, pernicious anemia or treated achalasia

9. For surveillance for patients with portal hypertension or

cirrhosis Surveillance for malignancy in patients with gastric Surveillance for malignancy in patients with gastric

atrophy, pernicious anemia or treated achalasia atrophy, pernicious anemia or treated achalasia

8.8. Surveillance of healed benign disease such as Surveillance of healed benign disease such as esophagitis, gastric or duodenal ulcer esophagitis, gastric or duodenal ulcer

8.8. Surveillance of healed benign disease such as Surveillance of healed benign disease such as esophagitis, gastric or duodenal ulcer esophagitis, gastric or duodenal ulcer

10. Routine surveillance after prior gastric operation for benign disease

(including non dysplastic gastric polyps)

10. Routine surveillance after prior gastric operation for benign disease

(including non dysplastic gastric polyps)

11.11. Surveillance during repeated dilatations of benign Surveillance during repeated dilatations of benign strictures unless there is a change in status strictures unless there is a change in status

11.11. Surveillance during repeated dilatations of benign Surveillance during repeated dilatations of benign strictures unless there is a change in status strictures unless there is a change in status

12. For surveillance for patients with portal hypertension or cirrhosis Isolated Isolated

pylorospasm, known congenital hypertrophic pyloric stenosis, constipation pylorospasm, known congenital hypertrophic pyloric stenosis, constipation

and encopresis, or inflammatory bowel disease responding to therapy. and encopresis, or inflammatory bowel disease responding to therapy.

12. For surveillance for patients with portal hypertension or cirrhosis Isolated Isolated

pylorospasm, known congenital hypertrophic pyloric stenosis, constipation pylorospasm, known congenital hypertrophic pyloric stenosis, constipation

and encopresis, or inflammatory bowel disease responding to therapy. and encopresis, or inflammatory bowel disease responding to therapy.

Indication

1 Upper abdominal symptoms in patients with age >45 y

2 Upper abdominal symptoms persistent despite therapy

3 Esophageal reflux symptoms persistent despite therapy

4 Upper abdominal symptoms associated with sign/symptoms suggesting serious organic disease

5 Follow-up of gastric/esophageal ulcer

6 Presumed chronic blood loss/iron deficiency anemia

7 Patients with active or recent GI bleeding

8 Sampling of tissue or fluid

9 Dysphagia/odynophagia

10 Periodic surveillance of Barrett's esophagus

11 To document or treat esophageal varices

12 Placement of feeding or drainage tubes

13 Dilation of stenotic lesions

14 Other system disease with upper GI pathology

15 Other ASGE indications