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Medical Policy Revision: Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus and Colon

Effective August 1, 2017, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for wireless capsule endoscopy.

Our revised medical policy, Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus and Colon, identifies when CT-based perfusion imaging is considered medically necessary and when it would be considered investigational.

We encourage you to review this policy in our Medical Policy Manual.


Based on the guidelines of our revised medical policy, Wireless Capsule Endoscopy as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus and Colon:

  • Claims for services provided on and after August 1, 2017 to patients enrolled in all Horizon BCBSNJ plans that include CPT® code 91110 may pend, based on the submitted diagnosis code(s), while information required to determine medical appropriateness is requested and reviewed.
  • CPT code 91111 submitted on claims for services provided on and after August 1, 2017 will be denied as an investigational and non-covered service regardless of the submitted diagnosis code(s).

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after August 1, 2017.

CPT® is a registered mark of the American Medical Association.

Published on: April 27, 2017, 13:55 p.m. ET
Last updated on: April 27, 2017, 14:04 p.m. ET