Upper Gastrointestinal Endoscopy and Gastrointestinal Biopsy (CPB 0738, reviewed 2025-10-29)

By 2025-10-29: Billing team must review and update internal authorization protocols to enforce Aetna's medical necessity criteria for all EGD and upper GI biopsy claims. Specifically: (1) Configure billing system to require documentation of specific indication from policy (e.g., chronic GERD with Barrett's screening, dyspepsia post-PPI failure, iron deficiency anemia evaluation); (2) Providers must document which policy criterion is being met on all EGD orders; (3) Front desk staff must flag orders that do not clearly match one of the listed indications for provider review before submission; (4) Update prior authorization templates to reference CPB 0738 and require providers to select the specific medical necessity indication; (5) Train coding and authorization staff on surveillance intervals (e.g., Barrett's without dysplasia = every 3 years after 2 negative exams, BE with LGD = 6-month then annual surveillance); (6) Implement documentation requirements for gastric premalignant condition evaluation (visual station mapping, photo documentation, adequate evaluation time); (7) Claims submitted without documented medical necessity meeting these criteria will be denied by Aetna. Process all existing pending EGD authorizations against this policy immediately.