Clinical Medical Policy Department Clinical Affairs Division

Endoscopic Ultrasonography (EUS) [For the list of services and procedures that need preauthorization, please refer to http://www.mcs.com.pr. Go to “Proveedores”, and clic “Políticas Médicas”.]

Medical Policy: MP-SU-03-08 Original Effective Date: June 12, 2008 Revised: May 3, 2021 Next Revision: April, 2022

This policy applies to products subscribed by the following corporations, MCS Life Insurance Company (Commercial), and MCS Advantage, Inc. (Classicare) and Medical Card System, Inc., provider’s contract; unless specific contract limitations, exclusions or exceptions apply. Please refer to the member’s benefit certification language for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply subject to the aforementioned exceptions. DESCRIPTION

Endoscopy Ultrasonography (EUS) combines and in order to obtain images and information about the digestive tract and the surrounding tissue and . Endoscopy procedure is the insertion of a long flexible tube via the mouth or the to visualize the digestive tract. Whereas ultrasound uses high frequency sound waves to produce images of the organs and structures inside the body such as ovaries, uterus, liver, gallbladder, and aorta, etc. Traditional ultrasound sends sound waves to the organ(s) and back with a transducer placed on the skin overlying the organs(s) of interest. Images obtained by traditional ultrasound are not always on high quality. In EUS a small ultrasound transducer is installed on the tip of the endoscope which is inserted into the upper or the lower digestive tract and one can obtain high quality ultrasound images of the organs inside the body (MedicineNet, Inc., 2021).

Endoscopic Ultrasound (EUS) originally was developed as a diagnostic modality but rapidly gained a role for a variety of therapeutic applications. EUS has been used increasingly for drainage of pancreatic fluid collections, treatment of cystic lesions of the pancreas, EUS-guided cholangiopancreatography, localized therapy for pancreatic tumors, and treatment of subepithelial lesions and gastric varices (UpToDate®, 2021).

COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate member certificate and subscriber agreement contract for applicable diagnostic imaging, DME, laboratory, machine tests, benefits and coverage.

INDICATIONS

Medical Card System, Inc. (MCS) considers the use of Endoscopic Ultrasonography (EUS) medically reasonable and necessary, for Both Commercial and Classicare (Advantage) Lines of Business (LOB), for Any of the following indications:

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 1 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 1 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division

1. Staging tumors of the , pancreas, and bile ducts.

2. Evaluation and tissue sampling of abnormalities of the gastrointestinal (GI) tract wall or adjacent structures.

3. Evaluation of abnormalities of the pancreas, including masses, , cysts and chronic pancreatitis.

4. Evaluation of abnormalities of the biliary tree.

5. Providing endoscopic therapy of the gastrointestinal tract under ultrasonographic guidance.

6. Staging tumors shown to be metastatic only when the results are the basis for therapeutic decision.

7. Evaluation of adenopathy and masses of the posterior mediastinum, or in the inferior mediastinum, with Endoscopic Ultrasonography-Fine Needle Aspiration (EUS-FNA).

8. Staging of patients with Non-Small Cell (NSCLC), with Endoscopic Ultrasonography- Fine Needle Aspiration (EUS-FNA).

9. Placement of fiducials into tumors within or adjacent to the wall of the Gastrointestinal (GI) tract.

10. Treatment of symptomatic pseudocysts by creating an enteral-cyst communication.

11. To perform Celiac Plexus Blockade (CPB) or Celiac Plexus Neurolysis (CPN) as a means of achieving analgesia (i.e., Drug Delivery).

12. Providing access into the bile ducts or , either independently or as an adjunct to Endoscopic Retrograde Cholangiopancreatography (ERCP).

13. Evaluation for chronic pancreatitis.

14. Evaluation of acute pancreatitis of unknown etiology.

15. Evaluation for perianal and perirectal disorders (anal sphincter injuries, fistulae, abscesses).

16. Evaluation of patients at increased risk of .

CONTRAINDICATIONS/LIMITATIONS

1. To be performed at elderly patients with unstable cardiac or pulmonary conditions.

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Clinical Medical Policy Department Clinical Affairs Division

2. For staging of tumors, (e.g., of the GI tract, pulmonary, etc.) when prior imaging methods have confirmed metastasis (unless the results are the basis for therapeutic decisions).

3. When the risks to patient health or life are judged to outweigh the most favorable benefits of the procedure.

4. When adequate patient cooperation or consent cannot be obtained.

5. When the results will not contribute to a management choice.

6. For periodic follow-up of healed benign disease unless surveillance of a premalignant condition is warranted.

7. Contraindications to EUS-FNA include situations in which the FNA result would not affect management, inability to clearly visualize a lesion, a tumor mass or vessel interposed in the path between the needle and target, bleeding diathesis, and risk of tumor seeding.

8. When a perforated viscus is known or suspected.

CODING INFORMATION FOR BOTH THE COMMERCIAL AND CLASSICARE (ADVANTAGE) LOB

CPT® Codes (List may not be all inclusive) CPT® Codes Description 43231 Esophagoscopy, rigid or flexible; with endoscopic ultrasound examination

43232 Esophagoscopy, rigid or flexible; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s)

43237 Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination limited to the , or , and adjacent structures

Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of 43238 specimen(s) by brushing or washing, with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), esophagus (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures) 43240 Esophagogastroduodenoscopy, flexible, transoral; with transmural drainage of (includes placement of transmural drainage catheter[s]/stent[s], when performed, and endoscopic ultrasound, when performed) 43242 Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 3 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 3 All Rights Reserved®

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ultrasound examination of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to anastomosis) 43247 Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s) 43252 Esophagogastroduodenoscopy, flexible, transoral; with optical 43253 Esophagogastroduodenoscopy, flexible, transoral; diagnostic, with transendoscopic ultrasound-guided transmural injection, of diagnostic or therapeutic substance (s) (e.g., anesthetic, neurolytic agent) or fiducial marker(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) 43259 Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to anastomosis 44406 Colonoscopy through stoma; with endoscopic ultrasound examination, limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures 44407 Colonoscopy through stoma; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures 45341 Sigmoidoscopy, flexible; diagnostic with endoscopic ultrasound examination

45342 Sigmoidoscopy, flexible; diagnostic with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) Colonoscopy, flexible, proximal to splenic flexure; with endoscopic ultrasound 45391 examination Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic ultrasound 45392 guided intramural or transmural fine needle aspiration/biopsy(s) 76975 Gastrointestinal endoscopic ultrasound, supervision and interpretation

Current Procedural Terminology (CPT®) 2021 American Medical Association: Chicago, IL.

ICD-10 Codes (List may not be all inclusive) ICD-10-Codes DESCRIPTION B37.81 Candidal esophagitis C12 Malignant neoplasm of pyriform sinus C13.0 Malignant neoplasm of postcricoid region C13.1 Malignant neoplasm of aryepiglottic fold, hypopharyngeal aspect C13.2 Malignant neoplasm of posterior wall of hypopharynx C13.8 Malignant neoplasm of overlapping sites of hypopharynx C13.9 Malignant neoplasm of hypopharynx, unspecified

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C15.3 Malignant neoplasm of upper third of esophagus C15.4 Malignant neoplasm of middle third of esophagus C15.5 Malignant neoplasm of lower third of esophagus C15.8 Malignant neoplasm of overlapping sites of esophagus C15.9 Malignant neoplasm of esophagus, unspecified C16.0 Malignant neoplasm of cardia C16.1 Malignant neoplasm of fundus of stomach C16.2 Malignant neoplasm of body of stomach C16.3 Malignant neoplasm of pyloric antrum C16.4 Malignant neoplasm of pylorus C16.5 Malignant neoplasm of lesser curvature of stomach, unspecified C16.6 Malignant neoplasm of greater curvature of stomach, unspecified C16.8 Malignant neoplasm of overlapping sites of stomach C16.9 Malignant neoplasm of stomach, unspecified C17.0 Malignant neoplasm of duodenum C17.1 Malignant neoplasm of jejunum C17.2 Malignant neoplasm of ileum C17.3 Meckel's diverticulum, malignant C17.8 Malignant neoplasm of overlapping sites of small intestine C17.9 Malignant neoplasm of small intestine, unspecified C18.0 Malignant neoplasm of cecum C18.1 Malignant neoplasm of appendix C18.2 Malignant neoplasm of ascending colon C18.3 Malignant neoplasm of hepatic flexure C18.4 Malignant neoplasm of transverse colon C18.5 Malignant neoplasm of splenic flexure C18.6 Malignant neoplasm of descending colon C18.7 Malignant neoplasm of sigmoid colon

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C18.8 Malignant neoplasm of overlapping sites of colon C18.9 Malignant neoplasm of colon, unspecified C19 Malignant neoplasm of rectosigmoid junction C20 Malignant neoplasm of rectum C21.0 Malignant neoplasm of anus, unspecified C21.1 Malignant neoplasm of anal canal C21.2 Malignant neoplasm of cloacogenic zone C21.8 Malignant neoplasm of overlapping sites of rectum, anus and anal canal C22.1 Intrahepatic carcinoma C24.0 Malignant neoplasm of extrahepatic bile duct C24.1 Malignant neoplasm of ampulla of Vater C24.8 Malignant neoplasm of overlapping sites of biliary tract C24.9 Malignant neoplasm of biliary tract, unspecified C25.0 Malignant neoplasm of head of pancreas C25.1 Malignant neoplasm of body of pancreas C25.2 Malignant neoplasm of tail of pancreas C25.3 Malignant neoplasm of pancreatic duct C25.4 Malignant neoplasm of endocrine pancreas C25.7 Malignant neoplasm of other parts of pancreas C25.8 Malignant neoplasm of overlapping sites of pancreas C25.9 Malignant neoplasm of pancreas, unspecified C26.0 Malignant neoplasm of intestinal tract, part unspecified C26.1 Malignant neoplasm of spleen C26.9 Malignant neoplasm of ill-defined sites within the digestive system C32.0 Malignant neoplasm of glottis C32.1 Malignant neoplasm of supraglottis C32.2 Malignant neoplasm of subglottis C32.3 Malignant neoplasm of laryngeal cartilage

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C32.8 Malignant neoplasm of overlapping sites of larynx C33 Malignant neoplasm of trachea C34.00 Malignant neoplasm of unspecified main bronchus C34.01 Malignant neoplasm of right main bronchus C34.02 Malignant neoplasm of left main bronchus C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung C34.11 Malignant neoplasm of upper lobe, right bronchus or lung C34.12 Malignant neoplasm of upper lobe, left bronchus or lung C34.2 Malignant neoplasm of middle lobe, bronchus or lung C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung C34.31 Malignant neoplasm of lower lobe, right bronchus or lung C34.32 Malignant neoplasm of lower lobe, left bronchus or lung C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung C34.91 Malignant neoplasm of unspecified part of right bronchus or lung C34.92 Malignant neoplasm of unspecified part of left bronchus or lung C38.1 Malignant neoplasm of anterior mediastinum C38.2 Malignant neoplasm of posterior mediastinum C38.3 Malignant neoplasm of mediastinum, part unspecified C38.4 Malignant neoplasm of pleura C38.8 Malignant neoplasm of overlapping sites of heart, mediastinum and pleura C48.0 Malignant neoplasm of retroperitoneum C48.1 Malignant neoplasm of specified parts of peritoneum C48.2 Malignant neoplasm of peritoneum, unspecified C48.8 Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum C7A.010 Malignant carcinoid tumor of the duodenum

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C7A.011 Malignant carcinoid tumor of the jejunum C7A.012 Malignant carcinoid tumor of the ileum C7A.021 Malignant carcinoid tumor of the cecum C7A.022 Malignant carcinoid tumor of the ascending colon C7A.023 Malignant carcinoid tumor of the transverse colon C7A.024 Malignant carcinoid tumor of the descending colon C7A.025 Malignant carcinoid tumor of the sigmoid colon C7A.026 Malignant carcinoid tumor of the rectum C7A.029 Malignant carcinoid tumor of the , unspecified portion C7A.090 Malignant carcinoid tumor of the bronchus and lung C7A.091 Malignant carcinoid tumor of the thymus C7A.092 Malignant carcinoid tumor of the stomach C78.00 Secondary malignant neoplasm of unspecified lung C78.01 Secondary malignant neoplasm of right lung C78.02 Secondary malignant neoplasm of left lung C78.1 Secondary malignant neoplasm of mediastinum C78.2 Secondary malignant neoplasm of pleura C78.30 Secondary malignant neoplasm of unspecified respiratory organ C78.39 Secondary malignant neoplasm of other respiratory organs C78.4 Secondary malignant neoplasm of small intestine C78.5 Secondary malignant neoplasm of large intestine and rectum C78.6 Secondary malignant neoplasm of retroperitoneum and peritoneum C78.7 Secondary malignant neoplasm of liver and intrahepatic bile duct C78.80 Secondary malignant neoplasm of unspecified digestive organ C78.89 Secondary malignant neoplasm of other digestive organs C81.01 Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of head, face, and neck C81.02 Nodular lymphocyte predominant Hodgkin lymphoma, intrathoracic lymph nodes

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C81.03 Nodular lymphocyte predominant Hodgkin lymphoma, intra-abdominal lymph nodes C81.11 Nodular sclerosis Hodgkin lymphoma, lymph nodes of head, face, and neck C81.12 Nodular sclerosis Hodgkin lymphoma, intrathoracic lymph nodes C81.13 Nodular sclerosis Hodgkin lymphoma, intra-abdominal lymph nodes C81.21 Mixed cellularity Hodgkin lymphoma, lymph nodes of head, face, and neck C81.22 Mixed cellularity Hodgkin lymphoma, intrathoracic lymph nodes C81.23 Mixed cellularity Hodgkin lymphoma, intra-abdominal lymph nodes C81.31 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of head, face, and neck C81.32 Lymphocyte depleted Hodgkin lymphoma, intrathoracic lymph nodes C81.33 Lymphocyte depleted Hodgkin lymphoma, intra-abdominal lymph nodes C81.41 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of head, face, and neck C81.42 Lymphocyte-rich Hodgkin lymphoma, intrathoracic lymph nodes C81.43 Lymphocyte-rich Hodgkin lymphoma, intra-abdominal lymph nodes C81.71 Other Hodgkin lymphoma, lymph nodes of head, face, and neck C81.72 Other Hodgkin lymphoma, intrathoracic lymph nodes C81.73 Other Hodgkin lymphoma, intra-abdominal lymph nodes C81.91 Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck C81.92 Hodgkin lymphoma, unspecified, intrathoracic lymph nodes C81.93 Hodgkin lymphoma, unspecified, intra-abdominal lymph nodes C82.51 Diffuse follicle center lymphoma, lymph nodes of head, face, and neck C82.52 Diffuse follicle center lymphoma, intrathoracic lymph nodes C82.53 Diffuse follicle center lymphoma, intra-abdominal lymph nodes C82.61 Cutaneous follicle center lymphoma, lymph nodes of head, face, and neck C82.62 Cutaneous follicle center lymphoma, intrathoracic lymph nodes C82.63 Cutaneous follicle center lymphoma, intra-abdominal lymph nodes C82.81 Other types of follicular lymphoma, lymph nodes of head, face, and neck C82.82 Other types of follicular lymphoma, intrathoracic lymph nodes C82.83 Other types of follicular lymphoma, intra-abdominal lymph nodes

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C83.01 Small cell B-cell lymphoma, lymph nodes of head, face, and neck C83.02 Small cell B-cell lymphoma, intrathoracic lymph nodes C83.03 Small cell B-cell lymphoma, intra-abdominal lymph nodes C83.11 Mantle cell lymphoma, lymph nodes of head, face, and neck C83.12 Mantle cell lymphoma, intrathoracic lymph nodes C83.13 Mantle cell lymphoma, intra-abdominal lymph nodes C83.31 Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck C83.32 Diffuse large B-cell lymphoma, intrathoracic lymph nodes C83.33 Diffuse large B-cell lymphoma, intra-abdominal lymph nodes C83.51 Lymphoblastic (diffuse) lymphoma, lymph nodes of head, face, and neck C83.52 Lymphoblastic (diffuse) lymphoma, intrathoracic lymph nodes C83.53 Lymphoblastic (diffuse) lymphoma, intra-abdominal lymph nodes C83.71 Burkitt lymphoma, lymph nodes of head, face, and neck C83.72 Burkitt lymphoma, intrathoracic lymph nodes C83.73 Burkitt lymphoma, intra-abdominal lymph nodes C83.81 Other non-follicular lymphoma, lymph nodes of head, face, and neck C83.82 Other non-follicular lymphoma, intrathoracic lymph nodes C83.83 Other non-follicular lymphoma, intra-abdominal lymph nodes C83.91 Non-follicular (diffuse) lymphoma, unspecified, lymph nodes of head, face, and neck C83.92 Non-follicular (diffuse) lymphoma, unspecified, intrathoracic lymph nodes C83.93 Non-follicular (diffuse) lymphoma, unspecified, intra-abdominal lymph nodes C84.01 Mycosis fungoides, lymph nodes of head, face, and neck C84.02 Mycosis fungoides, intrathoracic lymph nodes C84.03 Mycosis fungoides, intra-abdominal lymph nodes C84.11 Sezary disease, lymph nodes of head, face, and neck C84.12 Sezary disease, intrathoracic lymph nodes C84.13 Sezary disease, intra-abdominal lymph nodes C84.41 Peripheral T-cell lymphoma, not classified, lymph nodes of head, face, and neck

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C84.42 Peripheral T-cell lymphoma, not classified, intrathoracic lymph nodes C84.43 Peripheral T-cell lymphoma, not classified, intra-abdominal lymph nodes C84.61 Anaplastic large cell lymphoma, ALK-positive, lymph nodes of head, face, and neck C84.62 Anaplastic large cell lymphoma, ALK-positive, intrathoracic lymph nodes C84.63 Anaplastic large cell lymphoma, ALK-positive, intra-abdominal lymph nodes C84.71 Anaplastic large cell lymphoma, ALK-negative, lymph nodes of head, face, and neck C84.72 Anaplastic large cell lymphoma, ALK-negative, intrathoracic lymph nodes C84.73 Anaplastic large cell lymphoma, ALK-negative, intra-abdominal lymph nodes C84.A1 Cutaneous T-cell lymphoma, unspecified lymph nodes of head, face, and neck C84.A2 Cutaneous T-cell lymphoma, unspecified, intrathoracic lymph nodes C84.A3 Cutaneous T-cell lymphoma, unspecified, intra-abdominal lymph nodes C84.Z1 Other mature T/NK-cell lymphomas, lymph nodes of head, face, and neck C84.Z2 Other mature T/NK-cell lymphomas, intrathoracic lymph nodes C84.Z3 Other mature T/NK-cell lymphomas, intra-abdominal lymph nodes C84.91 Mature T/NK-cell lymphomas, unspecified, lymph nodes of head, face, and neck C84.92 Mature T/NK-cell lymphomas, unspecified, intrathoracic lymph nodes C84.93 Mature T/NK-cell lymphomas, unspecified, intra-abdominal lymph nodes C85.11 Unspecified B-cell lymphoma, lymph nodes of head, face, and neck C85.12 Unspecified B-cell lymphoma, intrathoracic lymph nodes C85.13 Unspecified B-cell lymphoma, intra-abdominal lymph nodes C85.21 Mediastinal (thymic) large B-cell lymphoma, lymph nodes of head, face, and neck C85.22 Mediastinal (thymic) large B-cell lymphoma, intrathoracic lymph nodes C85.23 Mediastinal (thymic) large B-cell lymphoma, intra-abdominal lymph nodes C85.81 Other specified types of non-Hodgkin lymphoma, lymph nodes of head, face, and neck C85.82 Other specified types of non-Hodgkin lymphoma, intrathoracic lymph nodes C85.83 Other specified types of non-Hodgkin lymphoma, intra-abdominal lymph nodes C85.91 Non-Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck

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C85.92 Non-Hodgkin lymphoma, unspecified, intrathoracic lymph nodes C85.93 Non-Hodgkin lymphoma, unspecified, intra-abdominal lymph nodes C86.0 Extranodal NK/T-cell lymphoma, nasal type C86.1 Hepatosplenic T-cell lymphoma C86.2 Enteropathy-type (intestinal) T-cell lymphoma C86.3 Subcutaneous panniculitis-like T-cell lymphoma C86.4 Blastic NK-cell lymphoma C88.4 Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma] D00.00 Carcinoma in situ of oral cavity, unspecified site D00.01 Carcinoma in situ of labial mucosa and vermilion border D00.02 Carcinoma in situ of buccal mucosa D00.03 Carcinoma in situ of gingiva and edentulous alveolar ridge D00.04 Carcinoma in situ of soft palate D00.05 Carcinoma in situ of hard palate D00.06 Carcinoma in situ of floor of mouth D00.07 Carcinoma in situ of tongue D00.08 Carcinoma in situ of pharynx D00.1 Carcinoma in situ of esophagus D00.2 Carcinoma in situ of stomach D01.0 Carcinoma in situ of colon D01.1 Carcinoma in situ of rectosigmoid junction D01.2 Carcinoma in situ of rectum D01.3 Carcinoma in situ of anus and anal canal D01.40 Carcinoma in situ of unspecified part of intestine D01.49 Carcinoma in situ of other parts of intestine D01.5 Carcinoma in situ of liver, gallbladder and bile ducts D01.7 Carcinoma in situ of other specified digestive organs

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D01.9 Carcinoma in situ of digestive organ, unspecified D12.0 Benign neoplasm of cecum D12.1 Benign neoplasm of appendix D12.2 Benign neoplasm of ascending colon D12.3 Benign neoplasm of transverse colon D12.4 Benign neoplasm of descending colon D12.5 Benign neoplasm of sigmoid colon D12.6 Benign neoplasm of colon, unspecified D12.7 Benign neoplasm of rectosigmoid junction D12.8 Benign neoplasm of rectum D12.9 Benign neoplasm of anus and anal canal D13.0 Benign neoplasm of esophagus D13.1 Benign neoplasm of stomach D13.2 Benign neoplasm of duodenum D13.30 Benign neoplasm of unspecified part of small intestine D13.39 Benign neoplasm of other parts of small intestine D13.4 Benign neoplasm of liver D13.5 Benign neoplasm of extrahepatic bile ducts D13.6 Benign neoplasm of pancreas D13.7 Benign neoplasm of endocrine pancreas D13.9 Benign neoplasm of ill-defined sites within the digestive system D14.1 Benign neoplasm of larynx D14.2 Benign neoplasm of trachea D14.30 Benign neoplasm of unspecified bronchus and lung D14.31 Benign neoplasm of right bronchus and lung D14.32 Benign neoplasm of left bronchus and lung D15.2 Benign neoplasm of mediastinum D17.5 Benign lipomatous neoplasm of intra-abdominal organs

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D19.0 Benign neoplasm of mesothelial tissue of pleura D3A.010 Benign carcinoid tumor of the duodenum D3A.011 Benign carcinoid tumor of the jejunum D3A.012 Benign carcinoid tumor of the ileum D3A.021 Benign carcinoid tumor of the cecum D3A.022 Benign carcinoid tumor of the ascending colon D3A.023 Benign carcinoid tumor of the transverse colon D3A.024 Benign carcinoid tumor of the descending colon D3A.025 Benign carcinoid tumor of the sigmoid colon D3A.026 Benign carcinoid tumor of the rectum D3A.092 Benign carcinoid tumor of the stomach D3A.8 Other benign neuroendocrine tumors D37.1 Neoplasm of uncertain behavior of stomach D37.2 Neoplasm of uncertain behavior of small intestine D37.3 Neoplasm of uncertain behavior of appendix D37.4 Neoplasm of uncertain behavior of colon D37.5 Neoplasm of uncertain behavior of rectum D37.6 Neoplasm of uncertain behavior of liver, gallbladder and bile ducts D37.8 Neoplasm of uncertain behavior of other specified digestive organs D38.0 Neoplasm of uncertain behavior of larynx D38.1 Neoplasm of uncertain behavior of trachea, bronchus and lung

D38.2 Neoplasm of uncertain behavior of pleura D38.3 Neoplasm of uncertain behavior of mediastinum D38.4 Neoplasm of uncertain behavior of thymus D49.0 Neoplasm of unspecified behavior of digestive system D50.0 Iron deficiency anemia secondary to blood loss (chronic) D50.9 Iron deficiency anemia, unspecified D51.0 Vitamin B12 deficiency anemia due to intrinsic factor deficiency

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D62 Acute posthemorrhagic anemia E41 Nutritional marasmus E43 Unspecified severe protein-calorie malnutrition E44.0 Moderate protein-calorie malnutrition E46 Unspecified protein-calorie malnutrition E64.0 Sequelae of protein-calorie malnutrition I69.091 Dysphagia following nontraumatic subarachnoid hemorrhage I69.191 Dysphagia following nontraumatic intracerebral hemorrhage I69.291 Dysphagia following other nontraumatic intracranial hemorrhage I69.391 Dysphagia following cerebral infarction I69.891 Dysphagia following other cerebrovascular disease I69.991 Dysphagia following unspecified cerebrovascular disease I77.2 Rupture of artery I78.0 Hereditary hemorrhagic telangiectasia I85.00 Esophageal varices without bleeding I85.01 Esophageal varices with bleeding I85.10 Secondary esophageal varices without bleeding I85.11 Secondary esophageal varices with bleeding J86.0 Pyothorax with fistula K20.0 Eosinophilic esophagitis K20.80 Other esophagitis without bleeding K20.81 Other esophagitis with bleeding K20.90 Esophagitis, unspecified without bleeding K20.91 Esophagitis, unspecified with bleeding K21.00 Gastro-esophageal reflux disease with esophagitis, without bleeding K21.01 Gastro-esophageal reflux disease with esophagitis, with bleeding K21.9 Gastro-esophageal reflux disease without esophagitis K22.0 Achalasia of cardia Advertise with Us | License ICD10 Data This document is designated for informational purposes only and is not an authorization, or an explanationCopyright of benefits © | (EOB), ICD10data.com or a contract. 15 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 15 All Rights Reserved®

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K22.10 Ulcer of esophagus without bleeding K22.11 Ulcer of esophagus with bleeding K22.2 Esophageal obstruction K22.3 Perforation of esophagus K22.4 Dyskinesia of esophagus K22.5 Diverticulum of esophagus, acquired K22.6 Gastro-esophageal laceration-hemorrhage syndrome K22.70 Barrett's esophagus without dysplasia K22.710 Barrett's esophagus with low grade dysplasia K22.711 Barrett's esophagus with high grade dysplasia K22.719 Barrett's esophagus with dysplasia, unspecified K22.8 Other specified diseases of esophagus K25.0 Acute gastric ulcer with hemorrhage K25.1 Acute gastric ulcer with perforation K25.2 Acute gastric ulcer with both hemorrhage and perforation K25.3 Acute gastric ulcer without hemorrhage or perforation K25.4 Chronic or unspecified gastric ulcer with hemorrhage K25.7 Chronic gastric ulcer without hemorrhage or perforation K25.9 Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation K26.0 Acute duodenal ulcer with hemorrhage K26.3 Acute duodenal ulcer without hemorrhage or perforation K26.4 Chronic or unspecified duodenal ulcer with hemorrhage K26.7 Chronic duodenal ulcer without hemorrhage or perforation K26.9 Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation K27.0 Acute peptic ulcer, site unspecified, with hemorrhage K27.3 Acute peptic ulcer, site unspecified, without hemorrhage or perforation K27.4 Chronic or unspecified peptic ulcer, site unspecified, with hemorrhage K27.7 Chronic peptic ulcer, site unspecified, without hemorrhage or perforation

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K27.9 Peptic ulcer, site unspecified, unspecified as acute or chronic, without hemorrhage or perforation K28.0 Acute gastrojejunal ulcer with hemorrhage K28.3 Acute gastrojejunal ulcer without hemorrhage or perforation K28.4 Chronic or unspecified gastrojejunal ulcer with hemorrhage K28.7 Chronic gastrojejunal ulcer without hemorrhage or perforation K28.9 Gastrojejunal ulcer, unspecified as acute or chronic, without hemorrhage or perforation K29.00 Acute gastritis without bleeding K29.01 Acute gastritis with bleeding K29.20 Alcoholic gastritis without bleeding K29.21 Alcoholic gastritis with bleeding K29.30 Chronic superficial gastritis without bleeding K29.31 Chronic superficial gastritis with bleeding K29.40 Chronic atrophic gastritis without bleeding K29.41 Chronic atrophic gastritis with bleeding K29.50 Unspecified chronic gastritis without bleeding K29.51 Unspecified chronic gastritis with bleeding K29.60 Other gastritis without bleeding K29.61 Other gastritis with bleeding K29.70 Gastritis, unspecified, without bleeding K29.71 Gastritis, unspecified, with bleeding K29.80 Duodenitis without bleeding K29.81 Duodenitis with bleeding K29.90 Gastroduodenitis, unspecified, without bleeding K29.91 Gastroduodenitis, unspecified, with bleeding K30 Functional dyspepsia K31.0 Acute dilatation of stomach K31.1 Adult hypertrophic pyloric stenosis

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K31.2 Hourglass stricture and stenosis of stomach K31.3 Pylorospasm, not elsewhere classified K31.4 Gastric diverticulum K31.5 Obstruction of duodenum K31.6 Fistula of stomach and duodenum K31.7 Polyp of stomach and duodenum K31.811 Angiodysplasia of stomach and duodenum with bleeding K31.819 Angiodysplasia of stomach and duodenum without bleeding K31.82 Dieulafoy lesion (hemorrhagic) of stomach and duodenum K31.89 Other diseases of stomach and duodenum K44.0 Diaphragmatic hernia with obstruction, without gangrene K50.00 Crohn's disease of small intestine without complications K50.011 Crohn's disease of small intestine with rectal bleeding K50.014 Crohn's disease of small intestine with abscess K50.018 Crohn's disease of small intestine with other complication K50.80 Crohn's disease of both small and large intestine without complications K50.811 Crohn's disease of both small and large intestine with rectal bleeding K50.813 Crohn's disease of both small and large intestine with fistula K50.814 Crohn's disease of both small and large intestine with abscess K50.818 Crohn's disease of both small and large intestine with other complication K52.0 Gastroenteritis and colitis due to radiation K52.1 Toxic gastroenteritis and colitis K52.21 Food protein-induced enterocolitis syndrome K52.22 Food protein-induced enteropathy K52.29 Other allergic and dietetic gastroenteritis and colitis K52.3 Indeterminate colitis K52.81 Eosinophilic gastritis or gastroenteritis K52.831 Collagenous colitis

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K52.832 Lymphocytic colitis K52.838 Other microscopic colitis K52.839 Microscopic colitis, unspecified K52.89 Other specified noninfective gastroenteritis and colitis K52.9 Noninfective gastroenteritis and colitis, unspecified K55.011 Focal (segmental) acute (reversible) ischemia of small intestine K55.012 Diffuse acute (reversible) ischemia of small intestine K55.019 Acute (reversible) ischemia of small intestine, extent unspecified K55.021 Focal (segmental) acute infarction of small intestine K55.022 Diffuse acute infarction of small intestine K55.029 Acute infarction of small intestine, extent unspecified K55.051 Focal (segmental) acute (reversible) ischemia of intestine, part unspecified K55.052 Diffuse acute (reversible) ischemia of intestine, part unspecified K55.059 Acute (reversible) ischemia of intestine, part and extent unspecified K55.061 Focal (segmental) acute infarction of intestine, part unspecified K55.062 Diffuse acute infarction of intestine, part unspecified K55.069 Acute infarction of intestine, part and extent unspecified K55.1 Chronic vascular disorders of intestine K55.20 Angiodysplasia of colon without hemorrhage K55.21 Angiodysplasia of colon with hemorrhage K55.30 Necrotizing enterocolitis, unspecified K55.31 Stage 1 necrotizing enterocolitis K55.32 Stage 2 necrotizing enterocolitis K55.33 Stage 3 necrotizing enterocolitis K55.8 Other vascular disorders of intestine K55.9 Vascular disorder of intestine, unspecified K63.3 Ulcer of intestine K63.5 Polyp of colon

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K70.0 Alcoholic fatty liver K74.60 Unspecified cirrhosis of liver K76.6 Portal hypertension K76.81 Hepatopulmonary syndrome K76.89 Other specified diseases of liver K80.00 Calculus of gallbladder with acute cholecystitis without obstruction K80.01 Calculus of gallbladder with acute cholecystitis with obstruction K80.10 Calculus of gallbladder with chronic cholecystitis without obstruction K80.11 Calculus of gallbladder with chronic cholecystitis with obstruction K80.18 Calculus of gallbladder with other cholecystitis without obstruction K80.19 Calculus of gallbladder with other cholecystitis with obstruction K80.20 Calculus of gallbladder without cholecystitis without obstruction K80.21 Calculus of gallbladder without cholecystitis with obstruction K80.30 Calculus of bile duct with cholangitis, unspecified, without obstruction K80.31 Calculus of bile duct with cholangitis, unspecified, with obstruction K80.40 Calculus of bile duct with cholecystitis, unspecified, without obstruction K80.41 Calculus of bile duct with cholecystitis, unspecified, with obstruction K80.42 Calculus of bile duct with acute cholecystitis without obstruction K80.43 Calculus of bile duct with acute cholecystitis with obstruction K80.44 Calculus of bile duct with chronic cholecystitis without obstruction K80.45 Calculus of bile duct with chronic cholecystitis with obstruction K80.50 Calculus of bile duct without cholangitis or cholecystitis without obstruction K80.51 Calculus of bile duct without cholangitis or cholecystitis with obstruction K80.60 Calculus of gallbladder and bile duct with cholecystitis, unspecified, without obstruction K80.61 Calculus of gallbladder and bile duct with cholecystitis, unspecified, with obstruction K80.62 Calculus of gallbladder and bile duct with acute cholecystitis without obstruction K80.63 Calculus of gallbladder and bile duct with acute cholecystitis with obstruction

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 20 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 20 All Rights Reserved®

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K80.64 Calculus of gallbladder and bile duct with chronic cholecystitis without obstruction K80.65 Calculus of gallbladder and bile duct with chronic cholecystitis with obstruction K80.66 Calculus of gallbladder and bile duct with acute and chronic cholecystitis without obstruction K80.67 Calculus of gallbladder and bile duct with acute and chronic cholecystitis with obstruction K80.70 Calculus of gallbladder and bile duct without cholecystitis without obstruction K80.71 Calculus of gallbladder and bile duct without cholecystitis with obstruction K80.80 Other cholelithiasis without obstruction K80.81 Other cholelithiasis with obstruction K83.01 Primary sclerosing cholangitis K83.09 Other cholangitis K83.1 Obstruction of bile duct K83.2 Perforation of bile duct K83.3 Fistula of bile duct K83.4 Spasm of sphincter of Oddi K83.5 Biliary cyst K83.8 Other specified diseases of biliary tract K83.9 Disease of biliary tract, unspecified K85.00 Idiopathic acute pancreatitis without necrosis or infection K85.01 Idiopathic acute pancreatitis with uninfected necrosis K85.02 Idiopathic acute pancreatitis with infected necrosis K85.10 Biliary acute pancreatitis without necrosis or infection K85.11 Biliary acute pancreatitis with uninfected necrosis K85.12 Biliary acute pancreatitis with infected necrosis K85.20 Alcohol induced acute pancreatitis without necrosis or infection K85.21 Alcohol induced acute pancreatitis with uninfected necrosis K85.22 Alcohol induced acute pancreatitis with infected necrosis K85.30 Drug induced acute pancreatitis without necrosis or infection

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K85.31 Drug induced acute pancreatitis with uninfected necrosis K85.32 Drug induced acute pancreatitis with infected necrosis K85.80 Other acute pancreatitis without necrosis or infection K85.81 Other acute pancreatitis with uninfected necrosis K85.82 Other acute pancreatitis with infected necrosis K85.90 Acute pancreatitis without necrosis or infection, unspecified K85.91 Acute pancreatitis with uninfected necrosis, unspecified K85.92 Acute pancreatitis with infected necrosis, unspecified K86.0 Alcohol-induced chronic pancreatitis K86.1 Other chronic pancreatitis K86.2 Cyst of pancreas K86.3 Pseudocyst of pancreas K86.81 Exocrine pancreatic insufficiency K86.89 Other specified diseases of pancreas K86.9 Disease of pancreas, unspecified K87 Disorders of gallbladder, biliary tract and pancreas in diseases classified elsewhere K90.0 Celiac disease K90.1 Tropical sprue K90.41 Non-celiac gluten sensitivity K90.49 Malabsorption due to intolerance, not elsewhere classified K90.81 Whipple's disease K90.89 Other intestinal malabsorption K90.9 Intestinal malabsorption, unspecified K91.30 Postprocedural intestinal obstruction, unspecified as to partial versus complete K91.31 Postprocedural partial intestinal obstruction K91.32 Postprocedural complete intestinal obstruction K91.5 Postcholecystectomy syndrome K91.81 Other intraoperative complications of digestive system

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K91.82 Postprocedural hepatic failure K91.83 Postprocedural hepatorenal syndrome K91.86 Retained cholelithiasis following cholecystectomy K91.870 Postprocedural hematoma of a digestive system organ or structure following a digestive system procedure K91.871 Postprocedural hematoma of a digestive system organ or structure following other procedure K91.872 Postprocedural seroma of a digestive system organ or structure following a digestive system procedure K91.873 Postprocedural seroma of a digestive system organ or structure following other procedure K91.89 Other postprocedural complications and disorders of digestive system K92.0 Hematemesis K92.1 Melena K92.2 Gastrointestinal hemorrhage, unspecified K92.81 Gastrointestinal mucositis (ulcerative) K94.20 Gastrostomy complication, unspecified K94.23 Gastrostomy malfunction K94.30 Esophagostomy complications, unspecified K94.31 Esophagostomy hemorrhage K94.33 Esophagostomy malfunction K94.39 Other complications of esophagostomy Q26.5 Anomalous portal venous connection Q26.6 Portal vein-hepatic artery fistula Q27.33 Arteriovenous malformation of digestive system vessel Q39.0 Atresia of esophagus without fistula Q39.1 Atresia of esophagus with tracheo-esophageal fistula Q39.2 Congenital tracheo-esophageal fistula without atresia Q39.3 Congenital stenosis and stricture of esophagus Q39.4 Esophageal web

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 23 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 23 All Rights Reserved®

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Q39.5 Congenital dilatation of esophagus Q39.6 Congenital diverticulum of esophagus Q39.8 Other congenital malformations of esophagus Q39.9 Congenital malformation of esophagus, unspecified Q40.1 Congenital hiatus hernia Q40.2 Other specified congenital malformations of stomach Q40.3 Congenital malformation of stomach, unspecified Q44.0 Agenesis, aplasia and hypoplasia of gallbladder Q44.1 Other congenital malformations of gallbladder Q44.4 Choledochal cyst Q85.8 Other phakomatoses, not elsewhere classified R07.9 Chest pain, unspecified R10.11 Right upper quadrant pain R10.12 Left upper quadrant pain R10.13 Epigastric pain R10.33 Periumbilical pain R11.0 Nausea R11.10 Vomiting, unspecified R11.11 Vomiting without nausea R11.12 Projectile vomiting R11.15 Cyclical vomiting syndrome unrelated to migraine R11.2 Nausea with vomiting, unspecified R12 Heartburn R13.0 Aphagia R13.10 Dysphagia, unspecified R13.11 Dysphagia, oral phase R13.12 Dysphagia, oropharyngeal phase R13.13 Dysphagia, pharyngeal phase

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R13.14 Dysphagia, pharyngoesophageal phase R13.19 Other dysphagia R17 Unspecified jaundice R19.00 Intra-abdominal and pelvic swelling, mass and lump, unspecified site R19.01 Right upper quadrant abdominal swelling, mass and lump R19.02 Left upper quadrant abdominal swelling, mass and lump R19.03 Right lower quadrant abdominal swelling, mass and lump R19.04 Left lower quadrant abdominal swelling, mass and lump R19.05 Periumbilic swelling, mass or lump R19.06 Epigastric swelling, mass or lump R19.07 Generalized intra-abdominal and pelvic swelling, mass and lump R19.09 Other intra-abdominal and pelvic swelling, mass and lump R22.2 Localized swelling, mass and lump, trunk R59.0 Localized enlarged lymph nodes R59.1 Generalized enlarged lymph nodes R59.9 Enlarged lymph nodes, unspecified R63.0 Anorexia R63.3 Feeding difficulties R63.4 Abnormal weight loss R93.2* Abnormal findings on diagnostic imaging of liver and biliary tract R93.3 Abnormal findings on diagnostic imaging of other parts of digestive tract R93.5 Abnormal findings on diagnostic imaging of other abdominal regions, including retroperitoneum S11.20XA Unspecified open wound of pharynx and cervical esophagus, initial encounter S11.20XD Unspecified open wound of pharynx and cervical esophagus, subsequent encounter S11.20XS Unspecified open wound of pharynx and cervical esophagus, sequela S11.21XA Laceration without foreign body of pharynx and cervical esophagus, initial encounter S11.21XD Laceration without foreign body of pharynx and cervical esophagus, subsequent encounter

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S11.21XS Laceration without foreign body of pharynx and cervical esophagus, sequela S11.22XA Laceration with foreign body of pharynx and cervical esophagus, initial encounter S11.22XD Laceration with foreign body of pharynx and cervical esophagus, subsequent encounter S11.22XS Laceration with foreign body of pharynx and cervical esophagus, sequela S11.23XA Puncture wound without foreign body of pharynx and cervical esophagus, initial encounter S11.23XD Puncture wound without foreign body of pharynx and cervical esophagus, subsequent encounter S11.23XS Puncture wound without foreign body of pharynx and cervical esophagus, sequela

S11.24XA Puncture wound with foreign body of pharynx and cervical esophagus, initial encounter S11.24XD Puncture wound with foreign body of pharynx and cervical esophagus, subsequent encounter S11.24XS Puncture wound with foreign body of pharynx and cervical esophagus, sequela

S11.25XA Open bite of pharynx and cervical esophagus, initial encounter

S11.25XD Open bite of pharynx and cervical esophagus, subsequent encounter

S11.25XS Open bite of pharynx and cervical esophagus, sequela

S27.812A Contusion of esophagus (thoracic part), initial encounter

S27.812D Contusion of esophagus (thoracic part), subsequent encounter

S27.812S Contusion of esophagus (thoracic part), sequela

S27.813A Laceration of esophagus (thoracic part), initial encounter

S27.813D Laceration of esophagus (thoracic part), subsequent encounter

S27.813S Laceration of esophagus (thoracic part), sequela

S27.818A Other injury of esophagus (thoracic part), initial encounter

S27.818D Other injury of esophagus (thoracic part), subsequent encounter

S27.818S Other injury of esophagus (thoracic part), sequela

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 26 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 26 All Rights Reserved®

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S27.819A Unspecified injury of esophagus (thoracic part), initial encounter

S27.819D Unspecified injury of esophagus (thoracic part), subsequent encounter

S27.819S Unspecified injury of esophagus (thoracic part), sequela

T18.100A Unspecified foreign body in esophagus causing compression of trachea, initial encounter T18.100D Unspecified foreign body in esophagus causing compression of trachea, subsequent encounter T18.100S Unspecified foreign body in esophagus causing compression of trachea, sequela

T18.108A Unspecified foreign body in esophagus causing other injury, initial encounter

T18.108D Unspecified foreign body in esophagus causing other injury, subsequent encounter

T18.108S Unspecified foreign body in esophagus causing other injury, sequela

T18.110A Gastric contents in esophagus causing compression of trachea, initial encounter

T18.110D Gastric contents in esophagus causing compression of trachea, subsequent encounter

T18.110S Gastric contents in esophagus causing compression of trachea, sequela

T18.118A Gastric contents in esophagus causing other injury, initial encounter

T18.118D Gastric contents in esophagus causing other injury, subsequent encounter

T18.118S Gastric contents in esophagus causing other injury, sequela

T18.120A Food in esophagus causing compression of trachea, initial encounter

T18.120D Food in esophagus causing compression of trachea, subsequent encounter

T18.120S Food in esophagus causing compression of trachea, sequela

T18.128A Food in esophagus causing other injury, initial encounter

T18.128D Food in esophagus causing other injury, subsequent encounter

T18.128S Food in esophagus causing other injury, sequela

T18.190A Other foreign object in esophagus causing compression of trachea, initial encounter

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T18.190D Other foreign object in esophagus causing compression of trachea, subsequent encounter T18.190S Other foreign object in esophagus causing compression of trachea, sequela

T18.198A Other foreign object in esophagus causing other injury, initial encounter

T18.198D Other foreign object in esophagus causing other injury, subsequent encounter

T18.198S Other foreign object in esophagus causing other injury, sequela

T18.2XXA Foreign body in stomach, initial encounter

T18.2XXD Foreign body in stomach, subsequent encounter

T18.2XXS Foreign body in stomach, sequela

T18.3XXA Foreign body in small intestine, initial encounter

T18.3XXD Foreign body in small intestine, subsequent encounter

T18.3XXS Foreign body in small intestine, sequela

T18.8XXA Foreign body in other parts of alimentary tract, initial encounter

T18.8XXD Foreign body in other parts of alimentary tract, subsequent encounter

T18.8XXS Foreign body in other parts of alimentary tract, sequela

T28.0XXA Burn of mouth and pharynx, initial encounter

T28.0XXD Burn of mouth and pharynx, subsequent encounter

T28.0XXS Burn of mouth and pharynx, sequela

T28.1XXA Burn of esophagus, initial encounter

T28.1XXD Burn of esophagus, subsequent encounter

T28.1XXS Burn of esophagus, sequela

T28.2XXA Burn of other parts of alimentary tract, initial encounter

T28.2XXD Burn of other parts of alimentary tract, subsequent encounter

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 28 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 28 All Rights Reserved®

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T28.2XXS Burn of other parts of alimentary tract, sequela

T28.5XXA Corrosion of mouth and pharynx, initial encounter

T28.5XXD Corrosion of mouth and pharynx, subsequent encounter

T28.5XXS Corrosion of mouth and pharynx, sequela

T28.6XXA Corrosion of esophagus, initial encounter

T28.6XXD Corrosion of esophagus, subsequent encounter

T28.6XXS Corrosion of esophagus, sequela

T28.7XXA Corrosion of other parts of alimentary tract, initial encounter

T28.7XXD Corrosion of other parts of alimentary tract, subsequent encounter

T28.7XXS Corrosion of other parts of alimentary tract, sequela

T54.1X1A Toxic effect of other corrosive organic compounds, accidental (unintentional), initial encounter T54.1X1D Toxic effect of other corrosive organic compounds, accidental (unintentional), subsequent T54.1X1S Toxicencounter effect of other corrosive organic compounds, accidental (unintentional), sequela

T54.1X2A Toxic effect of other corrosive organic compounds, intentional self-harm, initial encounter T54.1X2D Toxic effect of other corrosive organic compounds, intentional self-harm, subsequent encounter T54.1X2S Toxic effect of other corrosive organic compounds, intentional self-harm, sequela

T54.1X3A Toxic effect of other corrosive organic compounds, assault, initial encounter

T54.1X3D Toxic effect of other corrosive organic compounds, assault, subsequent encounter

T54.1X3S Toxic effect of other corrosive organic compounds, assault, sequela

T54.1X4A Toxic effect of other corrosive organic compounds, undetermined, initial encounter

T54.1X4D Toxic effect of other corrosive organic compounds, undetermined, subsequent encounter T54.1X4S Toxic effect of other corrosive organic compounds, undetermined, sequela

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 29 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 29 All Rights Reserved®

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T54.3X1A Toxic effect of corrosive alkalis and alkali-like substances, accidental (unintentional), initial T54.3X1D Toxicencounter effect of corrosive alkalis and alkali-like substances, accidental (unintentional), subsequent T54.3X1S Toxicencounter effect of corrosive alkalis and alkali-like substances, accidental (unintentional), sequela T54.3X2A Toxic effect of corrosive alkalis and alkali-like substances, intentional self-harm, initial encounter T54.3X2D Toxic effect of corrosive alkalis and alkali-like substances, intentional self-harm, subsequent T54.3X2S Toxicencounter effect of corrosive alkalis and alkali-like substances, intentional self-harm, sequela T54.3X3A Toxic effect of corrosive alkalis and alkali-like substances, assault, initial encounter

T54.3X3D Toxic effect of corrosive alkalis and alkali-like substances, assault, subsequent encounter T54.3X3S Toxic effect of corrosive alkalis and alkali-like substances, assault, sequela

T54.3X4A Toxic effect of corrosive alkalis and alkali-like substances, undetermined, initial encounter T54.3X4D Toxic effect of corrosive alkalis and alkali-like substances, undetermined, subsequent encounter T54.3X4S Toxic effect of corrosive alkalis and alkali-like substances, undetermined, sequela

T54.91XA Toxic effect of unspecified corrosive substance, accidental (unintentional), initial encounter T54.91XD Toxic effect of unspecified corrosive substance, accidental (unintentional), subsequent encounter T54.91XS Toxic effect of unspecified corrosive substance, accidental (unintentional), sequela

T54.92XA Toxic effect of unspecified corrosive substance, intentional self-harm, initial encounter T54.92XD Toxic effect of unspecified corrosive substance, intentional self-harm, subsequent encounter T54.92XS Toxic effect of unspecified corrosive substance, intentional self-harm, sequela

T54.93XA Toxic effect of unspecified corrosive substance, assault, initial encounter

T54.93XD Toxic effect of unspecified corrosive substance, assault, subsequent encounter

T54.93XS Toxic effect of unspecified corrosive substance, assault, sequela

T54.94XA Toxic effect of unspecified corrosive substance, undetermined, initial encounter

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 30 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 30 All Rights Reserved®

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T54.94XD Toxic effect of unspecified corrosive substance, undetermined, subsequent encounter

T54.94XS Toxic effect of unspecified corrosive substance, undetermined, sequela

T57.1X1A Toxic effect of phosphorus and its compounds, accidental (unintentional), initial encounter T57.1X1D Toxic effect of phosphorus and its compounds, accidental (unintentional), subsequent encounter T57.1X1S Toxic effect of phosphorus and its compounds, accidental (unintentional), sequela

T57.1X2A Toxic effect of phosphorus and its compounds, intentional self-harm, initial encounter

T57.1X2D Toxic effect of phosphorus and its compounds, intentional self-harm, subsequent encounter T57.1X2S Toxic effect of phosphorus and its compounds, intentional self-harm, sequela

T57.1X3A Toxic effect of phosphorus and its compounds, assault, initial encounter

T57.1X3D Toxic effect of phosphorus and its compounds, assault, subsequent encounter

T57.1X3S Toxic effect of phosphorus and its compounds, assault, sequela

T57.1X4A Toxic effect of phosphorus and its compounds, undetermined, initial encounter

T57.1X4D Toxic effect of phosphorus and its compounds, undetermined, subsequent encounter

T57.1X4S Toxic effect of phosphorus and its compounds, undetermined, sequela

Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm Z09 Encounter for follow-up examination after completed treatment for conditions other than Z43.1 Encountermalignant neoplasmfor attention to gastrostomy

Z46.59* Encounter for fitting and adjustment of other gastrointestinal appliance and device

Z79.01 Long term (current) use of anticoagulants

Z79.82 Long term (current) use of aspirin

Z79.83 Long term (current) use of bisphosphonates

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 31 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 31 All Rights Reserved®

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Z79.891 Long term (current) use of opiate analgesic

Z79.899 Other long term (current) drug therapy

Z85.01 Personal history of malignant neoplasm of esophagus

Z85.028 Personal history of other malignant neoplasm of stomach

Note1: HCPCS Code J0585 is allowed only when reporting for ICD-10 Diagnosis Code K22.0 on the claim.

REFERENCES

1. Cook Medical. (2021). GI Endoscopy Coding and Reimbursement Guide. Accessed April 23, 2021. Available at URL address: https://www.cookmedical.com/wp- content/uploads/2021/01/RG_ESC_50099_RE_202101.pdf

2. American Gastroenterological Association (AGA) Institute Medical Position Statement on the Management of Gastric Subepithelial Masses (2006). , 130 (7), 2215 - 2216. DOI: http://dx.doi.org/10.1053/j.gastro.2006.04.032. Accessed April 23, 2021. Available at URL address: https://www.gastrojournal.org/article/S0016-5085(06)00844-4/pdf

3. American Society for Gastrointestinal Endoscopy (ASGE) and the American College of Gastroenterology (ACG)/ Wani, S., Wallace, M.B., Cohen, J., Pike, I.M., Adler, D.G., Kochman, M.L., Lieb II, J.G., et al. (2015). Quality Indicators for EUS. Gastrointestinal Endoscopy, 81(1), 67- 80. http://dx.doi.org/10.1016/j.gie.2014.07.054. Accessed April 23, 2021. Available at URL address: https://www.giejournal.org/article/S0016-5107(14)02047-1/pdf

4. American Society for Gastrointestinal Endoscopy (ASGE) (2014, August). Media Backgrounder – Endoscopic Procedures: Endoscopic Ultrasound (EUS). Accessed April 23, 2021. Available at URL address: http://www.asge.org/press/press.aspx?id=548

5. American Society for Gastrointestinal Endoscopy (ASGE) (2020). Patient Information: Understanding EUS (Endoscopic Ultrasonography). Accessed April 23, 2021. Available at URL address: https://www.asge.org/home/for-patients/patient-information/understanding-eus

6. American Society for Gastrointestinal Endoscopy (ASGE) (2013). Adverse events associated with EUS and EUS with FNA. Gastrointestinal Endoscopy, 77(6), 839 - 843. Accessed April 23, 2021. Available at URL address: http://www.giejournal.org/article/S0016-5107(13)00176-4/pdf

7. American Society for Gastrointestinal Endoscopy (ASGE) (2013). Guideline: Modifications in endoscopic practice for the elderly. Gastrointestinal Endoscopy, 78(1), 1 - 7. http://dx.doi.org/10.1016/j.gie.2013.04.161. Accessed April 23, 2021. Available at URL address:

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 32 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 32 All Rights Reserved®

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http://www.asge.org/uploadedFiles/Publications_(public)/Practice_guidelines/Modifications%2 0in%20endoscopic%20practice%20for%20the%20elderly.pdf

8. American Society for Gastrointestinal Endoscopy (ASGE) (2013). The role of endoscopy in the assessment and treatment of . Gastrointestinal Endoscopy, 77 (3), 328 - 344. Accessed April 23, 2021. Available at URL address: http://www.asge.org/uploadedFiles/Publications_(public)/Practice_guidelines/The%20role%20o f%20endoscopy%20in%20the%20assessment%20and%20treatment%20of%20esophageal%20ca ncer.pdf

9. American Society for Gastrointestinal Endoscopy (ASGE) (2013). The role of endoscopy in the evaluation and treatment of patients with biliary neoplasia. Gastrointestinal Endoscopy, 77(2), 167 - 174. Accessed April 23, 2021. Available at URL address: http://www.asge.org/uploadedFiles/Publications_(public)/Practice_guidelines/The%20role%20o f%20endoscopy%20in%20the%20evaluation%20and%20treatment%20of%20patients%20with% 20biliary%20neoplasia.pdf

10. American Society for Gastrointestinal Endoscopy (ASGE) (2012). Appropriate Use of GI Endoscopy. Gastrointestinal Endoscopy, 75(6), 1127 - 1131. DOI: http://dx.doi.org/10.1016/j.gie.2012.01.011. Accessed April 23, 2021. Available at URL address: http://www.giejournal.org/article/S0016-5107(12)00033-8/pdf

11. American Society for Gastrointestinal Endoscopy (ASGE) (2011). Role of the EUS for the evaluation of mediastinal adenopathy. Gastrointestinal Endoscopy, 74(2), 239 - 245. Accessed April 23, 2021. Available at URL address: http://www.giejournal.org/article/S0016- 5107(11)01532-X/pdf

12. American Society for Gastrointestinal Endoscopy (ASGE) (2017). Interventional EUS (with Videos). Gastrointestinal Endoscopy, 85(3), 465-481. Accessed April 26, 2021. Available at URL address: https://asge.org/docs/default- source/education/Technology_Reviews/interventional_eus.pdf?sfvrsn=6

13. American Society for Gastrointestinal Endoscopy (ASGE) (2006). Technology Status Evaluation Report: Endoscopic ultrasound probes. Gastrointestinal Endoscopy, 63(6), 751-754. Accessed April 26, 2021. Available at URL address: https://www.asge.org/docs/default- source/education/Technology_Reviews/doc- 143255d4c8b9407db8444783ed6886a2.pdf?sfvrsn=10

14. American Society for Gastrointestinal Endoscopy (ASGE) (2017). Guidelines for privileging, credentialing, and proctoring to perform GI endoscopy. Dated: February 2017. Gastrointestinal Endoscopy, Volume 85, No. 2. Pages 273–281. DOI: https://doi.org/10.1016/j.gie.2016.10.036. Accessed April 26, 2021. Available at URL address: http://www.giejournal.org/article/S0016- 5107(16)30723-4/fulltext

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 33 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 33 All Rights Reserved®

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15. Boston Scientific. (2021). GI Endoscopy 2021 Procedural Payment Guide. Accessed April 26, 2021. Available at URL Address: https://www.bostonscientific.com/content/dam/bostonscientific/Reimbursement/Gastroentero logy/pdf/GI_Procedural_Reimbursement_Guide.pdf or https://www.bostonscientific.com/content/dam/bostonscientific/Reimbursement/Gastroentero logy/pdf/EUS_Coding_and_Payment_Quick_Reference.pdf

16. Centers for Medicare & Medicaid Services (CMS). Local Coverage Determination (LCD) for Upper Gastrointestinal Endoscopy and Visualization (L34434). Contractor Name: Palmetto GBA. Contract Number: 11401. Contract Type: MAC - Part A. Geographical Jurisdiction: West Virginia. Original Effective Date: For services performed on or after 10/01/2015. Revision Effective Date: For services performed on or after 10/24/2019. Notice Period Start Date: 10/13/2016. Notice Period End Date: 11/27/2016. Accessed April 26, 2021. Available at URL address: https://www.cms.gov/medicare-coverage-database/details/lcd- details.aspx?LCDId=34434&ver=53&SearchType=Advanced&CoverageSelection=Both&NCSelecti on=NCD%7cMCD&PolicyType=Final&s=12%7c19%7c20%7c22%7c23%7c29%7c36%7c38%7c45% 7c47%7c48&KeyWord=capsule+endoscopy&KeyWordLookUp=Doc&KeyWordSearchType=And& kq=true&bc=IAAAACAAgAAA&

17. Centers for Medicare & Medicaid Services (CMS). Local Coverage Article (LCA) Billing and Coding for Upper Gastrointestinal Endoscopy and Visualization (A56389). Contractor Name: Palmetto GBA. Contract Number: 11401. Contract Type: MAC - Part A. Geographical Jurisdiction: West Virginia. Original Effective Date: 03/21/2019. Revision Effective Date: 01/01/2021. Accessed April 26, 2021. Available at URL address: https://www.cms.gov/medicare-coverage- database/details/article- details.aspx?articleId=56389&ver=15&LCDId=34434&SearchType=Advanced&CoverageSelection =Both&NCSelection=NCD%7cMCD&PolicyType=Final&s=12%7c19%7c20%7c22%7c23%7c29%7c 36%7c38%7c45%7c47%7c48&KeyWord=capsule+endoscopy&KeyWordLookUp=Doc&KeyWordS earchType=And&kq=true&bc=IAAAACAAoAAA&

18. Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners. Section 30.1 – Digestive System. Rev. 10639. 03/12/21. Issued: 03/12/21. Accessed April 26, 2021. Available at URL address: https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/clm104c12.pdf

19. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Endoscopy (100.2). Publication Number 100-3. Version Number #1. Effective Date of this Version: This is a longstanding national coverage determination. The effective date of this version has not been posted. Accessed April 26, 2021. Available at URL address: http://www.cms.gov/medicare-coverage-database/details/ncd- details.aspx?NCDId=81&ncdver=1&bc=AgAAQAAAAAAAAA%3d%3d&

20. Faigel, D.O., Pike, I.M., Baron, T.H., Chak, A.; Cohen, J.; Deal, S.E., Hoffman, B. et al. (2006). Quality Indicators for Gastrointestinal Endoscopic Procedures: An Introduction. American

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 34 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 34 All Rights Reserved®

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Journal of Gastroenterology, 101, 866-872. DOI: 10.1111/j.1572-0241.2006.00677.x. Accessed April 26, 2021. Available at URL address: http://s3.gi.org/media/QualityIndicatorsIntro.pdf

21. MedicineNet, Inc. (2021). Endoscopic Ultrasound (EUS). Accessed April 26, 2021. Available at URL address: http://www.medicinenet.com/endoscopic_ultrasound/article.htm

22. UpToDate®, Inc. / Fasanella, K.E. & Sanders, M.K. (2021). Therapeutic endoscopic ultrasound. Literature review current through April 2021. This topic last updated: October 30, 2020. Accessed April 26, 2021. Available at URL address: http://www.uptodate.com/contents/therapeutic-endoscopic-ultrasound

23. UpToDate®, Inc. / LeBlanc, J.K. (2021). Endoscopic ultrasound-guided sampling of the mediastinum: Technique, indications, contraindications, and complications. Literature review current through: April 2021. This topic last updated: October 13, 2020. Accessed April 26, 2021. Available at URL address: http://www.uptodate.com/contents/endoscopic-ultrasound-guided- fine-needle-aspiration-in-the-mediastinum#H4

24. UpToDate®, Inc. / Levy, M.J. & Wiersema, M.J. (2021). Endoscopic ultrasound-guided celiac plexus and ganglia interventions. Literature review current through April 2021. This topic last updated: February 25, 2021. Accessed April 26, 2021. Available at URL address: http://www.uptodate.com/contents/endoscopic-ultrasound-guided-celiac-plexus-and-ganglia- interventions

25. UpToDate®, Inc. / Thomas, K.W. & Gould, M.K. (2021). Procedures for tissue biopsy in patients with suspected non-small cell lung cancer. Literature review current through April 2021. This topic last updated: November 20, 2020. Accessed April 26, 2021. Available at URL address: http://www.uptodate.com/contents/procedures-for-tissue-biopsy-in-patients-with-suspected- non-small-cell-lung-cancer?source=see_link&anchor=H58288371%20-%20H58288371

26. WebMD LLC. / Medscape / Yamao, K. et al. 2009. Interventional Endoscopic Ultrasonography. Journal of Gastroenterology and Hepatology 24(4), 509 - 519. Accessed April 26, 2021. Available at URL address: http://www.medscape.com/viewarticle/707615_3

POLICY HISTORY DATE ACTION COMMENT June 12, 2008 Origination of Policy August 11, 2009 Yearly Revision August 24, 2010 Yearly Revision August 23, 2011 Yearly Revision References updated. July 13, 2012 Yearly Revision References updated. December 10, 2012 Revised Policy was reviewed and approved by the Medical Card System (MCS) Medical Advisory Committee (MAC) on December 10, 2012. February 20, 2013 Revised Coding information Revised: Added ICD-9 Codes 789.30 - 789.39. September 20, 2013 Revised References updated. Added new references, numbers 3-17, 21-24, 29, 30,

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 35 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 35 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division

& 33.

To the Descriptions Section Added: EUS provides more detailed pictures of the digestive tract anatomy. It can be used to evaluate an abnormality below the surface of the inner lining (mucosa) such as a growth that was detected at a prior endoscopy or by X-ray. EUS, because of its ability to examine the wall layers of the GI tract, provides a detailed picture of the growth, which can help the doctor determine its nature and decide on the best treatment (ASGE, 2010). EUS can also be used to diagnose diseases of the pancreas, bile duct, and gallbladder when other tests are inconclusive, and EUS can be used to determine the stage of cancers. More importantly, EUS provides a minimally invasive method for acquiring tissue samples from gastrointestinal tumors and lymph nodes that may not be easily accessible by other methods (i.e. radiographic or surgical guidance). Fine Needle Aspiration (FNA) can be performed by passing a biopsy needle down the channel of the endoscope and across the intestinal wall under ultrasound guidance to obtain tissue for the diagnosis and staging of cancer. More recently, EUS has emerged as a therapeutic tool for treating both solid and cystic tumors of the pancreas, alleviating intractable abdominal pain secondary to advanced pancreatic cancer, and obtaining access to the bile ducts and pancreatic duct in cases of failed Endoscopic Retrograde Cholangiopancreatography (ERCP) (ASGE, 2010). EUS technology and related interventions have evolved dramatically over the past 2 decades. More recently, interventional EUS has become more central to the field of minimally invasive endosurgery. The combination of modern, large channel echoendoscopes with high-quality imaging transducers and dedicated accessories has been critical for the development of transluminal procedures. Further progress in device technology and well-designed clinical studies are needed to clarify the role of interventional EUS in clinical practice (ASGE, 2010).

To the Indications Section:

 To Indication #1 added: including lung cancer.  To Indication #3 added: cysts.  Added new indications: # 8-15.  Added new Experimental, Investigational or Unproven indications Section: 1. EUS guided pancreaticobiliary technique to access biliary and pancreatic ducts via EUS guided needle puncture through the gastric or duodenal wall (ASGE, 2013). 2. EUS-guided drainage procedures (i.e. Pelvic abscesses, proximal pelvic collections, multiloculated collections, and stent clogging) (ASGE, 2010). 3. Interventional biliary access procedures including EUS guided transpapillary rendezvous, choledochoduodenostomy, and hepaticogastrostomy techniques (ASGE, 2010). 4. EUS-guided oncologic interventions (i.e. cancer cytoreductive therapies including EUS-guided fine needle injection of chemotherapeutics, and brachytherapy) (ASGE, 2010). 5. EUS-guided pancreatic cyst ablation (ASGE, 2010). 6. EUS-guided vascular interventions (i.e. access intra- abdominal vascular structures for both diagnostic and therapeutic applications for GI bleeding) (ASGE, 2010). 7. EUS- guided endosurgical interventions (i.e. EUS-guided luminal anastomoses, antireflux therapy, and lymphadenectomy; also, Tissue-anchoring and apposition systems in performing transluminal EUS-guided NOTES (Natural Orifice Transluminal Endoscopic Surgery) interventions) (ASGE, 2010).

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 36 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 36 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division

To the Contraindications/ Limitations Section:

 Eliminated the Contraindication: High grade esophageal structure.  Added new Contraindications: #6-9.

To the Coding Information:

 Added new CPT® Codes: 64530 & 64680.  Added: Note1: Do not report CPT® Code 76975 in conjunction with the following CPT® Codes: 43231, 43232, 43237, 43238, 43242, 43259, 45341, 45342, or 76942 (AMA CPT® Manual, 2013).  Added new ICD-9 Codes: 171.4. 171.8, 171.9, 200.03-209.79, 228.04, 239.0 – 751.7 & 793.11 – V55.1.  Added: When using endoscopic ultrasound (CPT® code 76975) to guide celiac plexus block/neurolysis, ICD-9-CM diagnosis codes 789.00 through 789.09, 789.51 and 789.59 through 789.9 may be covered. To this Section added ICD-9 Codes: 789.00 – 789.9.

February 21,2014 Revised To the Coding section: A new ICD-10 Codes (Preview Draft) section was added to the policy. October 29, 2014 Revised References updated. Added new references, numbers 1, 16, 22, 33, 37-40, & 42. Deleted: CMS Retired LCD L26404. Contractor Name: National Government Services. Jurisdiction: Illinois. Retirement Date: 7/31/14. Also deleted: MedicineNet, Inc. (2013). Endoscopic Ultrasound (EUS): When is EUS useful? Available at URL address: http://www.medicinenet.com/endoscopic_ultrasound/page2.htm. Also deleted: National Guideline Clearinghouse (NGC) (2008). Quality indicators for endoscopic ultrasonography, withdrawn from: http://www.guideline.gov/. Also deleted, 3NHIC, Corp. – A CMS Contractor (2009). Local Coverage Determination (LCD) for Esophagogastroduodenoscopy (EGD) (L26394). Contractor Name: National Government Services, Inc. Contractor Number: 00180. Geographical Jurisdiction: Massachusetts & Maine. Original Determination Effective Date: For services performed on or after 04/01/2008. Revision Effective Date: For services performed on or after 12/01/2008.

To the Description Section:  Deleted: EUS provides more detailed pictures of the digestive tract anatomy. It can be used to evaluate an abnormality below the surface of the inner lining (mucosa) such as a growth that was detected at a prior endoscopy or by X-ray. EUS, because of its ability to examine the wall layers of the GI tract, provides a detailed picture of the growth, which can help the doctor determine its nature and decide on the best treatment (ASGE, 2010).  Deleted: EUS can also be used to diagnose diseases of the pancreas, bile duct, and gallbladder when other tests are inconclusive, and EUS can be used to determine the stage of cancers. More importantly, EUS provides a minimally invasive method for acquiring tissue samples from gastrointestinal tumors and lymph nodes that may not be easily accessible by other methods (i.e. radiographic or surgical guidance). Fine Needle Aspiration (FNA) can be performed by passing a biopsy needle down the channel of the endoscope and across the intestinal wall under ultrasound guidance to obtain tissue for the diagnosis and staging of cancer. More recently, EUS has

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 37 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 37 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division

emerged as a therapeutic tool for treating both solid and cystic tumors of the pancreas, alleviating intractable abdominal pain secondary to advanced pancreatic cancer, and obtaining access to the bile ducts and pancreatic duct in cases of failed Endoscopic Retrograde Cholangiopancreatography (ERCP) (ASGE, 2010).  Deleted: EUS technology and related interventions have evolved dramatically over the past 2 decades. More recently, interventional EUS has become more central to the field of minimally invasive endosurgery. The combination of modern, large channel echoendoscopes with high-quality imaging transducers and dedicated accessories has been critical for the development of transluminal procedures. Further progress in device technology and well-designed clinical studies are needed to clarify the role of interventional EUS in clinical practice (ASGE, 2010).  Added: Endoscopic Ultrasound (EUS) was developed as a diagnostic modality but rapidly gained a role for a variety of therapeutic applications. EUS has been used increasingly for drainage of pancreatic pseudocysts, treatment of cystic lesions of the pancreas, EUS-guided cholangiopancreatography, localized therapy for pancreatic tumors, and treatment of subepithelial lesions and gastric varices (UpToDate®, 2014).

To the Indications Section:  Revised and modified wording of #2 as to read as: Evaluation and tissue sampling of abnormalities of the Gastrointestinal (GI) tract wall or adjacent structures.  Added to #6 the phrase: or in the inferior mediastinum.  Revised and modified wording of #7 as to read as: Staging of patients with non-small cell lung cancer (NSCLC), with Endoscopic Ultrasonography-Fine Needle Aspiration (EUS-FNA).  Revised and confirmed validity of #8 – #15.

To the Experimental, Investigational and/or Unproven Coverage:  Deleted entire section: 1. EUS guided pancreaticobiliary technique to access biliary and pancreatic ducts via EUS guided needle puncture through the gastric or duodenal wall (ASGE, 2013). 2. EUS-guided drainage procedures (i.e. Pelvic abscesses, proximal pelvic collections, multiloculated collections, and stent clogging) (ASGE, 2010). 3. Interventional biliary access procedures including EUS guided transpapillary rendezvous, choledochoduodenostomy, and hepaticogastrostomy techniques (ASGE, 2010). 4. EUS-guided oncologic interventions (i.e. cancer cytoreductive therapies including EUS-guided fineneedle injection of chemotherapeutics, and brachytherapy) (ASGE, 2010). 5. EUS-guided pancreatic cyst ablation (ASGE, 2010). 6. EUS-guided vascular interventions (i.e. access intra- abdominal vascular structures for both diagnostic and therapeutic applications for GI bleeding) (ASGE, 2010). 7. EUS-guided endosurgical interventions (i.e. EUS-guided luminal anastomoses, antireflux therapy, and lymphadenectomy; also, Tissue-anchoring and apposition systems in performing transluminal EUS-guided NOTES (Natural Orifice Transluminal Endoscopic Surgery) interventions) (ASGE, 2010).

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 38 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 38 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division

To the Contraindications/Limitations Section:  Deleted: Known or suspected perforated viscus.  Deleted: Acute diverticulitis.  Deleted: Fulminant Colitis.  Added: Contraindications to EUS-FNA include situations in which the FNA result would not affect management, inability to clearly visualize a lesion, a tumor mass or vessel interposed in the path between the needle and target, bleeding diathesis, and risk of tumor seeding.

To the Coding Information:  Updated Codes’ Descriptions.  Added new CPT® Code: 43253.  Deleted: CPT® Codes: 64530 & 64680.  Moved previous Note 1, to CPT® Codes table (i.e., Do not report CPT® Code 76975 in conjunction with the following CPT® Codes: 43231, 43232, 43237, 43238, 43242, 43259, 45341, 45342, or 76942 [AMA CPT® Manual, 2014]).  Added new ICD-9-CM Codes: 156.0, 209.02, 209.03, 209.17, 209.43, 209.50, 209.52, 209.53, 209.54, 209.55, 209.56, & 209.57.  Deleted ICD9-CM Code: V55.1.  Modified ICD-9 CM® Diagnosis Codes when using EUS to guide celiac plexus block/neurolysis Section Heading from CPT® code 76975 to new CPT® Code 43253, as is established in AMA’s 2014 CPT® Manual. February 6, 2015 Revised References updated.

To the Indications Section:  Revised and modified opening coverage statement to read as it follows: Medical Card System, Inc. (MCS) considers the use of Endoscopic Ultrasonography (EUS) medically reasonable necessary, for Both the Commercial & Classicare (Advantage) Lines of Business (LOB), for Any of the following indications.

To the Coding Information:  Added to Title: Coding Information for Both the Commercial & Classicare (Advantage) LOB.  Added the following ICD-10 Codes: C7A.011, C7A.012, C7A.029, C7A.021, C7A.022, C7A.023, C7A.024, C7A.025, C7A.026, C7A.00, C7A.090, C7A.091, C7A.092, C7A.094, C7A.095, C7A.096, C7A.098, C7A.029, C7A.1, C7A.8, C4A.8, C4A.9, D3A.019, D3A.010, D3A.011, D3A.012, D3A.029, D3A.021, D3A.022, D3A.023, D3A.024, D3A.025, D3A.026, D3A.092, D3A.094, D3A.095, D3A.098, C7B.1, and C7B.09. November 23, 2015 Revised To the coding section:  Eliminate ICD-9 codes since they are no longer valid for diagnosis classification.  Add new section of ICD-10 codes which are the valid diagnosis classification since October 1, 2015. November 1, 2016 Revised References updated. Deleted #1, 3, 16 & 18. Added #3.

To the Indications Section:  Rephrased opening sentence to read: Medical Card System, Inc. (MCS) considers the use of Endoscopic Ultrasonography (EUS) medically necessary and reasonable, for Both the Commercial and Classicare (Advantage) Lines of Business (LOB), for Any of the following indications:  Added to #5: of the gastrointestinal tract.  Added #6: Staging tumors shown to be metastatic only when the results are the basis for therapeutic decision.

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 39 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 39 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division

To the Coding Section:  Added new ICD-10 code R22.2

April 17, 2018 Revised To the Contraindications Section:  New Information was added to the statement of the Contraindication #1: “To be performed at elderly patients with”.

 New Contraindication #8 was added to the Policy: “When a perforated viscus is known or suspected”.

To the Coding Section:  To the CPTs Code Section: The following CPTs Codes were added to the Policy: 43240, 43247, 43252 and 44407.

 To the ICD-10 Code Section: The following ICD-10 Codes were added to the Policy: B37.81, C12, C13.0, C13.1, C13.2, C13.8, C13.9, C32.0, C32.1, C32.2, C32.3, C32.8, C7A.010, D00.00, D00.01, D00.02, D00.03, D00.04, D00.05, D00.06, D00.07, D00.08, D49.0, I85.00, I85.01, I85.10, I85.11, K20.0, K20.8, K20.9, K21.0, K21.9, K22.0, K22.10, K22.11, K22.2, K22.3, K22.4, K22.5, K22.6, K22.70, K22.710, K22.711, K22.719, K22.8, K25.0, K25.1, K25.2, K25.3, K25.4, K25.7, K25.9, K26.0, K26.3, K26.4, K26.7, K26.9, K27.0, K27.3, K27.4, K27.7, K27.9, K28.0, K28.3, K28.4, K28.7, K28.9, K29.00, K29.01, K29.20, K29.21, K29.30, K29.31, K29.40, K29.41, K29.50, K29.51, K29.60, K29.61, K29.70, K29.71, K29.80, K29.81, K29.90, K29.91, K30, K31.0, K31.1, K31.2, K31.3, K31.4, K31.5, K31.6, K31.811, K31.819, K31.82, K31.89, K44.0, K50.00, K50.011, K50.014, K50.018, K50.80, K50.811, K50.813, K50.814, K50.818, K52.0, K52.1, K52.81, K52.89, K52.9, K63.3, K91.30, K91.31, K91.32, K92.2, K92.81, K94.20, K94.23, K94.30, K94.31, K94.33, K94.39, Q39.0, Q39.1, Q39.2, Q39.3, Q39.4, Q39.5, Q39.6, Q39.8, Q39.9, Q40.1, Q40.2, S11.20XA, S11.20XD, S11.20XS, S11.21XA, S11.21XD, S11.21XS, S11.22XA, S11.22XD, S11.22XS, S11.23XA, S11.23XD, S11.23XS, S11.24XA, S11.24XD, S11.24XS, S11.25XA, S11.25XD, S11.25XS, S27.812A, S27.812D, S27.812S, S27.813A, S27.813D, S27.813S, S27.818A, S27.818D, S27.818S, S27.819A, S27.819D, S27.819S, T18.100A, T18.100D, T18.100S, T18.108A, T18.108D, T18.108S, T18.110A, T18.110D, T18.110S, T18.118A, T18.118D, T18.118S, T18.120A, T18.120D, T18.120S, T18.128A, T18.128D, T18.128S, T18.190A, T18.190D, T18.190S, T18.198A, T18.198D, T18.198S, T18.2XXA, T18.2XXD, T18.2XXS, T18.3XXA, T18.3XXD, T18.3XXS, T18.8XXA, T18.8XXD, T18.8XXS, T28.0XXA, T28.0XXD, T28.0XXS, T28.1XXA, T28.1XXD, T28.1XXS, T28.2XXD, T28.2XXS, T28.5XXA, T28.5XXD, T28.5XXS, T28.6XXA, T28.6XXD, T28.6XXS, T28.7XXA, T28.7XXD, T28.7XXS, T54.1X1A, T54.1X1D, T54.1X1S, T54.1X2A, T54.1X2D, T54.1X2S, T54.1X3A, T54.1X3D, T54.1X3S, T54.1X4A, T54.1X4D, T54.1X4S, T54.3X1A, T54.3X1D, T54.3X1S, T54.3X2A, T54.3X2D, T54.3X2S, T54.3X3A, T54.3X3D, T54.3X3S, T54.3X4A, T54.3X4D, T54.3X4S, T54.91XA, T54.91XD, T54.91XS, T54.92XA, T54.92XD, T54.92XS, T54.93XA, T54.93XD, T54.93XS, T54.94XA, T54.94XD, T54.94XS, T57.1X1A, T57.1X1D, T57.1X1S, T57.1X2A, T57.1X2D, T57.1X2S, T57.1X3A, T57.1X3D, T57.1X3S, T57.1X4A, T57.1X4D, T57.1X4S, Z08, Z09, Z79.01, Z79.82, Z79.83, Z79.891, Z79.899, Z85.01 and Z85.028.

The following ICD-10 Codes were deleted from this Policy: C26.0, C26.1, C26.9, C38.8, C45.1, C47.4, C49.4, C4A.8, C4A.9, C7A.094, C7A.095, C7A.096, C7A.098, C7A.1, C7A.8, C7B.09,

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 40 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 40 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division

C7B.1, C7B.8, D17.5, D17.71, D19.1, D20.0, D20.1, D21.4, D37.9, D3A.019, D3A.029, D3A.094, D3A.095, D3A.098, D48.1, D48.2, D48.3 and D48.4.

To the References Section: The following References were added to the Policy: #19.

The following References were deleted from this Policy: #16, 23 and 30. June 18, 2019 Revised To the Coding Section:

To the CPT Codes Section:  The following CPT Codes where added to the Policy: 43237 and 44406.

 To the ICD-10 Codes Section: The following ICD-10 Codes were added to this Policy: C26.0, C32.9, C38.4, C38.8, C81.01, C81.02, C81.03, C81.11, C81.12, C81.13, C81.21, C81.22, C81.23, C81.31, C81.32, C81.33, C81.41, C81.42, C81.43, C81.71, C81.72, C81.73, C81.91, C81.92, C81.93, C82.51, C82.52, C82.53, C82.61, C82.62, C82.63, C82.81, C82.82, C82.83, C83.01, C83.02, C83.03, C83.11, C83.12, C83.13, C83.31, C83.32, C83.33, C83.51, C83.52, C83.53, C83.71, C83.72, C83.73, C83.81, C83.82, C83.83, C83.91, C83.92, C83.93, C84.01, C84.02, C84.03, C84.11, C84.12, C84.13, C84.41, C84.42, C84.43, C84.61, C84.62, C84.63, C84.71, C84.72, C84.73, C84.A1, C84.A2, C84.A3, C84.Z1, C84.Z2, C84.Z3, C84.91, C84.92, C84.93, C85.11, C85.12, C85.13, C85.21, C85.22, C85.23, C85.81, C85.82, C85.83, C85.91, C85.92, C85.93, C86.0, C86.1, C86.2, C86.3, C86.4, C88.4, D17.5, D3A.8, D50.0, D50.9, D51.0, D62, E41, E43, E44.0, E46, E64.0, I69.091, I69.191, I69.291, I69.391, I69.891, I69.991, I77.2, I78.0, J86.0, K52.21, K52.22, K52.29, K52.3, K52.831, K52.832, K52.838, K52.839, K55.011, K55.012, K55.019, K55.021, K55.022, K55.029, K55.051, K55.052, K55.059, K55.061, K55.062, K55.069, K55.1, K55.20, K55.21, K55.30, K55.31, K55.32, K55.33, K55.8, K55.9, K70.0, K74.60, K76.6, K76.81, K76.89, K80.00, K80.01, K80.10, K80.11, K80.18, K80.19, K80.20, K80.21, K80.30, K80.31, K80.40, K80.41, K80.42, K80.43, K80.44, K80.45, K80.50, K80.51, K80.60, K80.61, K80.62, K80.63, K80.64, K80.65, K80.66, K80.67, K80.70, K80.71, K80.80, K80.81, K83.01, K83.09, K83.1, K83.2, K83.3, K83.4, K83.5, K83.8, K83.9, K85.00, K85.01, K85.02, K85.10, K85.11, K85.12, K85.20, K85.21, K85.22, K85.30, K85.31, K85.32, K85.80, K85.81, K85.82, K85.90, K85.91, K85.92, K86.0, K86.1, K86.2, K86.3, K86.81, K86.89, K86.9, K87, K90.0, K90.1, K90.41, K90.49, K90.81, K90.89, K90.9, K91.5, K91.81, K91.82, K91.83, K91.86, K91.870, K91.871, K91.872, K91.873, K91.89, K92.0, K92.1, Q26.5, Q26.6, Q27.33, Q40.3, Q44.0, Q44.1, Q44.4, Q85.8, R07.9, R10.11, R10.12, R10.13, R10.33, R11.0, R11.10, R11.11, R11.12, R11.2, R12, R13.0, R13.10, R13.11, R13.12, R13.13, R13.14, R13.19, R17, R63.0, R63.3, R63.4, R93.2, R93.3, R93.5, T28.2XXA, Z43.1, and Z46.59.

To the References Section:  The following References were added to the Policy: #14 and 21.

 The following References were deleted from this Policy: #13, 17, 23, 25, 27, 28, 30, 31, 32, 33, and 38. May 04, 2020 Revised To the Description Section:  Phrase “which is Inserted” was added to the First Paragraph.  Word “Pseudocysts” was adapted to “Fluid Collections” in the Second Paragraph.

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 41 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 41 All Rights Reserved®

Clinical Medical Policy Department Clinical Affairs Division

To the Indications Section: Duplicate information with Indications #7 and 8 was deleted from Indication #1: “And mediastinum, including lung cancer”.

To the Coding Information Section:  To the ICD-10 Codes Section: The following ICD-10 Code was added to the Policy: R11.15.

The following ICD-10 Code was deleted from this Policy: C32.9.

To the References Section:  The following Reference was added to the Policy: #19. May 3, 2021. Revised To the Coding information Section:  To the ICD-10 Section: The following ICD-10 Codes were added to the Policy: C26.1, C26.9, K20.80, K20.81, K20.90, K20.91, K21.00, and K21.01.

 The following ICD-10 Codes were deleted from this Policy: K20.8, K20.9, and K21.0.

New Note #1 was added to the Policy according to the Information contained in the Local Coverage Article: Billing and Coding: Upper Gastrointestinal Endoscopy and Visualization (A56389).

 To the References Section: The following References were deleted from this Policy: #13, and 16.

This document is for informational purposes only. It is not an authorization, certification, explanation of benefits, or contract. Receipt of benefits is subject to satisfaction of all terms and conditions of coverage. Eligibility and benefit coverage are determined in accordance with the terms of the member’s plan in effect as of the date services are rendered. Medical Card System, Inc., (MCS) medical policies are developed with the assistance of medical professionals and are based upon a review of published and unpublished information including, but not limited to, current medical literature, guidelines published by public health and health research agencies, and community medical practices in the treatment and diagnosis of disease. Because medical practice, information, and technology are constantly changing, Medical Card System, Inc., (MCS) reserves the right to review and update its medical policies at its discretion. Medical Card System, Inc., (MCS) medical policies are intended to serve as a resource to the plan. They are not intended to limit the plan’s ability to interpret plan language as deemed appropriate. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment they choose to provide.

This document is designated for informational purposes only and is not an authorization, or an explanation of benefits (EOB), or a contract. 42 Medical technology is constantly changing and we reserve the right to review and update our policies periodically. Medical Card System, Inc. 42 All Rights Reserved®