Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A57753 (Billing and Coding: Wireless Capsule Endoscopy) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A57753: Billing and Coding: Wireless Capsule Endoscopy (Billing and Coding, effective 2022-01-01)
- Covered ICD-10-CM codes
- 54
- 3 groups
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 2
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| A18.32 | — |
| A18.39 | — |
| A18.83 | — |
| C17.0 | — |
| C17.1 | — |
| C17.2 | — |
| C17.3 | — |
| C17.8 | — |
| C17.9 | — |
| C49.A3 | — |
| C49.A4 | — |
| C78.4 | — |
| D01.40 | — |
| D01.49 | — |
| D13.2 | — |
| D13.30 | — |
| D13.39 | — |
| D37.2 | — |
| D50.0 | — |
| D50.9 | — |
| E16.4 | — |
| I77.6 | — |
| I85.10 | — |
| I85.11 | — |
Procedure codes: 91110, 91111.
Coverage indications, limitations and medical necessity
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
History/Background and/or General Information
This LCD pertains to Wireless Capsule Endoscopy (WCE) diagnostic modality in the gastrointestinal tract.
Covered Indications
• WCE is indicated for the diagnosis of occult gastrointestinal bleeding (i.e., likely involving the small intestine), the site of which has not previously been identified by any of the following: upper gastrointestinal endoscopy, colonoscopy, push enteroscopy, nuclear imaging or radiological procedures.
• WCE is limited to those patients who have undergone upper GI endoscopy and colonoscopy and these tests have failed to reveal a source of bleeding. Medicare would not expect to see a WCE provided if upper and lower endoscopy has not previously been performed. Documentation in the medical record must indicate that the beneficiary has suspected GI blood loss with or without anemia. Appropriate differential diagnoses for the evaluation of such bleeding include:
• Angiodysplasia
• Neoplasm
• Iron deficiency anemia, which is unexplained after upper and lower endoscopy
• Zollinger-Ellison syndrome
• Tuberculosis
• Vasculitis
• Radiation enteritis
• Meckels diverticulum
• Jejunal diverticula
• Chronic mesenteric ischemia
• Other indications include the management of celiac disease (e.g., surveillance for small-intestinal cancer) and of Crohn’s disease (that is, either Crohn’s disease is suspected, but not diagnosed, or colonic involvement of Crohn’s disease is known, but it is necessary to determine whether there is also involvement of the small bowel). In addition, WCE is indicated where an indeterminate type of colitis exists, but where a more specific diagnosis is being sought via small bowel evaluation.
• Esophageal capsule endoscopy may be used in the evaluation of esophageal varices in patients with portal hypertension, as an alternative to upper GI endoscopy.
Limitations
In addition to any specific indications noted above, WCE is limited as follows:
• Erosive esophagitis and Barrett’s esophagus may be viable clinical indications in the future, but further peer-reviewed literature is being sought before this additional coverage might become available.
• This test is not reimbursable for colorectal cancer screening.
• The test is payable only for services using FDA-approved devices.
• This test is not reimbursable for the confirmation of lesions or pathology normally within the reach of upper or lower endoscopes (lesions proximal to the ligament of Treitz or distal to the ileum).
• This test is only covered when performed by physicians trained in endoscopy or for independent diagnostic testing facilities, which are under the general supervision of a physician trained in endoscopy procedures.
• Contraindications include: pregnancy, cardiac pacemaker and other implanted electro-medical devices, swallowing disorders, known or suspected GI obstruction, strictures or fistulas based on the clinical picture or preprocedure testing.
• Medicare would not expect to see a second capsule administered per episode of illness unless it was to guarantee an adequate examination (e.g., the initial capsule does not penetrate the pylorus). Please note that any other procedure codes that are used to ensure proper passage of the capsule must be reasonable and necessary and documented appropriately.
• Medicare expects repeat wireless capsule endoscopic studies for any patient to be for medically reasonable and necessary clinical circumstances consistent with accepted standards of medical practice and that the medical records demonstrate such.
Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD.
Summary of evidence (opening)
N/A
the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2015-10-01
- Current revision effective
- 2019-11-21
- Last reviewed by the contractor
- 2018-10-10
- MCD version
- 30
- Derived from
- L34342
The contractor lists one National Coverage Determination as related: NCD 100.2 Endoscopy. Where an NCD speaks, it controls; the LCD can only address what the NCD leaves open.
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Novitas Solutions, Inc. hub lists every other active policy from the same contractor.
The same policy title at other contractors
Contractors often adopt each other's policies and then revise them separately, so the criteria and the diagnosis lists drift apart. The topic comparison lines up every version.
Frequently asked questions
What does LCD L35089 cover?
This LCD pertains to Wireless Capsule Endoscopy (WCE) diagnostic modality in the gastrointestinal tract. The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L35089 apply to?
Novitas Solutions, Inc. applies it to Medicare claims in AR, CO, DC, DE, LA, MD, MS, NJ, NM, OK, PA, TX. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L35089?
The companion billing and coding article A57753 lists 54 ICD-10-CM codes in 3 groups that support medical necessity; the first 24 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L35089?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.