CAM 70146

Endoscopic Injection Sclerotherapy for Esophageal Varices

Category:Surgery   Last Reviewed:March 2020
Department(s):Medical Affairs   Next Review:March 2999
Original Date:March 1996    

Description:
Endoscopic injection sclerotherapy is a therapeutic procedure used to treat bleeding esophageal varices and prevent future variceal bleeding. An endoscope is passed into the esophagus, and sclerosing agents (sodium morrhuate, sodium tetradecyl sulfate and hypertonic saline or glucose) are injected into or around the varices.

Policy:
Esophageal injection sclerotherapy is considered MEDICALLY NECESSARY in the treatment of esophageal varices and in the prevention of future variceal bleeding once bleeding has occurred.

Prophylactic sclerotherapy to prevent hemorrhage that has not yet occurred is INVESTIGATIONAL.

Policy Guidelines:
Endoscopic injection sclerotherapy generally involves a number of treatment sessions with appropriate injection(s) once an acute hemorrhage has been controlled.

Follow-up sessions to inject remaining varices may be appropriate. However, diagnostic or follow-up endoscopy should be limited to one at inception and one on conclusion of treatment.

Coding Section

Codes Number Description
CPT 43204 Esophagoscopy, rigid or flexible, with injection sclerosis of esophageal varices
ICD-9 Procedure 42.33 Endoscopic excision or destruction of lesion or tissue of esophagus
ICD-9 Diagnosis 456.0 Esophageal varices with bleeding
  456.20 Esophageal varices in diseases classified elsewhere, with bleeding
HCPCS J7130 Hypertronic saline solution 50 or 100 meg, 20 cc vial
ICD-10-CM (effective 10/01/15)  I8501  Esophageal varices with bleeding
  I8511  Secondary esophageal varices with bleeding
ICD-10-PCS (effective 10/01/15)  0D554ZZ  Destruction of Esophagus, Percutaneous Endoscopic Approach
  0D558ZZ  Destruction of Esophagus, Via Natural or Artificial Opening Endoscopic
  0DB54ZZ  Excision of Esophagus, Percutaneous Endoscopic Approach
  DB58ZZ  Excision of Esophagus, Via Natural or Artificial Opening Endoscopic
  0W3P8ZZ  Control Bleeding in Gastrointestinal Tract, Via Natural or Artificial Opening Endoscopic
  3E0G8TZ  Introduction of Destructive Agent into Upper GI, Via Natural or Artificial Opening Endoscopic
Type of Service Surgery  
Place of Service Inpatient/Outpatient  

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

03/02/2020 

Annual review. No change to policy intent. 

03/04/2019 

Annual Review. No change to policy intent. 

03/19/2018 

Annual Review. No change to policy intent. 

03/01/2017 

Annual review.  No change to policy intent 

03/10/2016 

Annual review.  No change to policy intent 

09/21/2015 

Added ICD-10 codes. 

03/05/2015 

Annual review, policy to remain active. No change to policy intent. Added coding. 

03/3/2014

Annual review.  No changes made

 


Go Back