REVIEW REQUEST FOR
Wireless Capsule Endoscopy for Gastrointestinal
Imaging & the Patency Capsule
Provider Data Collection Tool Based on Medical Policy RAD.000030
Policy Last Review Date: 05/07/2015
Policy Effective Date: 07/07/2015
Provider Tool Effective Date: 12/12/2015
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Rendering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Facility Name:
Facility ID Number:
Facility Address:
Date/Date Range of Service:
Place of Service:
Service Requested (CPT if known):
Outpatient
Home
Inpatient
Other:
Diagnosis Code(s) ( if known):
This medical policy based data collection tool is for medical necessity review request for the use of
wireless capsule endoscopy (WCE) devices and the patency capsule.
Please check all that apply to the individual:
Request is for wireless capsule endoscopy (WCE) of the small bowel
(If checked, please mark all of the following that apply to the individual)
Individual is two years of age or older
WCE to investigate obscure gastrointestinal bleeding, suspected to be of small bowel origin
(If checked, please mark all of the following that apply to the individual)
Upper endoscopy has excluded a source of bleeding in the upper gastrointestinal tract
Lower endoscopy has excluded a source of bleeding in the colon
WCE is for the initial evaluation of individual with suspected Crohn’s disease
(If checked, please mark all of the following that apply to the individual)
Small bowel follow-through (SBFT) is non-diagnostic
Enteroclysis, including CT enteroclysis is non-diagnostic
Upper endoscopy is non-diagnostic
Lower endoscopy is non-diagnostic
There is no suspected or confirmed gastrointestinal obstruction, stricture, or fistulae
WCE is for an individual with suspected small intestinal tumors
WCE is for an individual age 35 or greater with Lynch syndrome
WCE is for an individual age 35 or greater with polyposis syndrome
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REVIEW REQUEST FOR
Wireless Capsule Endoscopy for Gastrointestinal
Imaging & the Patency Capsule
Provider Data Collection Tool Based on Medical Policy RAD.000030
Policy Last Review Date: 05/07/2015
Policy Effective Date: 07/07/2015
Provider Tool Effective Date: 12/12/2015
WCE is for diagnostic re-evaluation of individual with known Crohn’s disease
(If checked, please mark all of the following that apply to the individual)
Individual remains symptomatic after completion of appropriate treatment
There is no suspected or confirmed gastrointestinal obstruction, stricture, or fistulae
WCE is for an individual with refractory undiagnosed malabsorptive syndromes
Individual has a prior history of negative small bowel biopsy (for example, suspected celiac disease with prior
negative biopsy)
WCE is to investigate anemia with concomitant iron deficiency
(If checked, please mark all of the following that apply to the individual)
The anemia is suspected to be of small bowel origin
Upper endoscopy has excluded a source of anemia from the upper GI tract
Lower endoscopy has excluded a source of anemia from the colon
Request for WCE to investigate small bowel disease for abdominal pain in the absence of gastrointestinal bleeding
Request for WCE for individual with known or suspected gastrointestinal obstruction, stricture or fistulae
Request for WCE for esophageal disease
Request for WCE to perform colorectal cancer screening or identify colon disease
Request is for the use of a patency capsule
Other indication not specified above. (Please list):
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan or its
designees may perform a routine audit and request the medical documentation to verify the accuracy of the information
reported on this form.
_____________________________________________________________
Name and Title of Provider or Provider Representative Completing Form and Attestation (Please Print)*
Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization
management services on behalf of your health benefit plan or the administrator of your health benefit plan.
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