Initial Gastroscopy

Laya healthcare will provide benefit for an initial upper Gastroscopy,
procedure procedure code 194 for:

(0001) Suspected treatment failure in patients who remain symptomatic and are
serologically positive for Helicobacter pylori infection, have received
treatment with PPIs and where 4 weeks have lapsed following completion of
treatment

(0002) Presentation with signs or symptoms suggesting serious organic disease
(e.g. anorexia, weight loss) or in patients with upper abdominal symptoms > 45
years old

(0003) Dysphagia or odynophagia

(0004) Oesophageal reflux symptoms that are persistent or recurrent despite
treatment

(0005) Persistent vomiting, unknown aetiology

(0006) Biopsy for suspected coeliac disease after positive tTGA and EMA
serology testing

(0007) Other diseases in which the presence of upper GI pathology might modify
treatment options in:

a) those scheduled for organ transplantation who have a history of upper GI
bleeding, 

b) those on long term anti-coagulation, 

c) those on long-term non-steroidal anti-inflammatory drug therapy for
arthritis, and 

d) those with cancer of the head and neck

(0008) To confirm and secure histological diagnosis of radiological findings of
suspected upper gastro-intestinal tract lesions

(0009) GI haemorrhage in patients with active or recent blood loss

(0010) Presumed chronic blood loss: when the clinical situation suggests an
upper GI bleeding source or when colonoscopy results are negative

(0011) Iron deficiency anaemia

(0012) Pernicious anaemia (further planned endoscopy is on an individual basis
on the submission of a medical report)

(0013) To assess acute injury after ingestion of a corrosive substance

(0014) Therapeutic management of bleeding lesions such as ulcers, tumours,
vascular abnormalities (e.g. electro-coagulation, heater probe, laser
photocoagulation, or injection therapy)

(0015) Diagnosis and further investigation of achalasia

(0016) In exceptional instances where the clinical need is detailed in a
medical report that accompanies the claim form on submission


Repeat Upper GI Endoscopy

Benefit is available for a repeat upper GI endoscopy, procedure code 194, as
per the following clinical indications:

(0017) Previously confirmed diagnosis of gastric ulcer to check for healing and
or re-biopsy

(0018) In Helicobacter pylori infection after a first or second treatment
failure to carry out further susceptibility testing of antimicrobial agents

(0019) Coeliac Disease - in suspected refractory disease, once only. If further
required, include detail on a medical report accompanying the claim

(0020) Monitoring of oesophageal varices

(0021) Stent blockage

(0022) Gastric polyp, other than those associated with a polyposis syndrome

(0023) Follow-up investigation of those with gastric or oesophageal cancer as
clinically indicated

(0024) Following a major bleed where the initial gastroscopy failed to identify
the source of bleeding

(0025) Post treatment of bleeding ulcer or Mallory Weiss tear

Note: New clinical presentation will not be excluded by a prior endoscopy,
please refer to initial endoscopy clinical indicators and/or submit a detailed
medical report with the claim.

Surveillance Upper Gastrointestinal Gastroscopy 

No Consultant or hospital benefits are payable for a surveillance upper GI
endoscopy except for the following clinical indications: 

(0026) Barrett's mucosa shorter than 3cm, without dysplasia on a previous
endoscopy: benefit is for a surveillance endoscopy every 3 years

(0027) Barrett's mucosa, greater than 3cm, without dysplasia on a previous
endoscopy: benefit is for a surveillance endoscopy every 2 years

(0028) Barrett's mucosa, with low-grade dysplasia on a previous endoscopy:
benefit is for a surveillance endoscopy every 6 months until 2 consecutive
endoscopies have no metaplasia

(0029) Barrett's mucosa, with high-grade dysplasia on a previous endoscopy:
benefit is for a surveillance endoscopyevery 3 months

(0030) Gastric intestinal metaplasia/gastric epithelial dysplasia/atrophic
gastritis with low-grade dysplasia: benefit is for a surveillance endoscopy
every 3 years

(0031) Gastric intestinal metaplasia/gastric epithelial dysplasia/atrophic
gastritis with high-grade dysplasia: benefit is for a surveillance endoscopy at
6 months

(0032) Upper GI surveillance for members with Peutz-Jeghers syndrome: benefit
is for a surveillance endoscopy every 2 years from age 18 years

(0033) Upper GI surveillance for members with Juvenile polyposis: benefit is
for a surveillance endoscopy every 3 years from age 18 years

(0034) Upper GI surveillance for members with Lynch Syndrome: benefit is for
surveillance endoscopy every 2 years from age 50 years

(0035) Upper GI surveillance for members with MUTYH bi-allelic carriers:
benefit will be provided for a 3 yearly gastrointestinal endoscopy from age 30
years