Medicare AdvantageCoverageMedium impact
Diagnostic and Therapeutic Esophagogastroduodenoscopy or Esophagoscopy - Medicare Advantage (Revised)
Humana·AR, CO, LA, MS, NM, OK, TX, DE, MD, NJ, PA, AL, GA, TN, NC, SC, VA, WV, FL · Gastroenterology, General Surgery·Medicare Advantage
Effective date
Mar 2, 2026
We identified it
Jun 24, 2026
Summary
Humana Medicare Advantage has updated their policy for diagnostic and therapeutic esophagogastroduodenoscopy (EGD) and esophagoscopy procedures, establishing coverage criteria based on CMS Local Coverage Determinations. The policy covers standard EGD procedures, endoscopic ultrasound, and optical endomicroscopy when medically necessary according to specific LCD criteria.
Action Required
Before March 2, 2026: Billing team must ensure EGD and esophagoscopy procedures (CPT codes 43191, 43200, 43202, 43235, 43237, 43238, 43239, 43242, 43252, 43253, 43259) meet medical necessity criteria outlined in applicable CMS Local Coverage Determinations. Update billing system to reference LCD criteria for coverage verification. Train providers on documentation requirements to support medical necessity for these procedures.