DESCRIPTION
Endoscopic injection sclerotherapy involves an endoscopically guided injection of a chemical agent, or sclerosant, directly into the varices or the esophageal wall. The sclerosant causes clotting, swelling, and/or inflammation that ultimately result in a thickening or scarring of the vein, which reduce the vein's diameter and suppresses the blood flow. The vein may even close entirely and force blood to find collateral routes. Sclerosing treatments are repeated weekly until varices are eradicated. Follow-up endoscopy is required every six to twelve months for the rest of the individual's life. Endoscopic sclerotherapy could be performed in individuals with portal hypertension, caused by cirrhosis of the liver, portal vein obstruction, or congenital disorders, who are experiencing upper gastrointestinal hemorrhage.
POLICY
Endoscopic injection sclerotherapy in the treatment of esophageal varices and in the prevention of future variceal bleeding once bleeding has occurred is considered medically necessary.
Prophylactic sclerotherapy to prevent hemorrhage that has not yet occurred, is considered investigational.
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
Published literature shows that the role of prophylactic sclerotherapy to prevent hemorrhage of esophageal varices remains questionable.
SOURCES
American Society for Gastrointestinal Endoscopy. (2005). ASGE guideline: The role of endoscopic therapy in the management of variceal hemorrhage, updated July 2005. Retrieved September 9, 2009 from http://www.asge.org/WorkArea/showcontent.aspx?id=3308.
American Society for Gastrointestinal Endoscopy. (2004). ASGE guideline: The role of endoscopy in acute non-variceal upper-GI hemorrhage. Retrieved September 9, 2009 from http://www.asge.org/WorkArea/showcontent.aspx?id=3310.
BlueCross BlueShield Association. Medical Policy Reference Manual. (4:2002). Endoscopic injection sclerotherapy for esophageal varices. (7.01.46). Retrieved September 9, 2009 from BlueWeb. (0 articles and/or guidelines reviewed)
Cappell, M. S., & Friedel, D. (2008). Acute nonvariceal upper gastrointestinal bleeding: Endoscopic diagnosis and therapy. The Medical Clinics of North America, 92 (3), 511-550.
Complete Guide to Medicare Coverage Issues [Computer software]. (2009, July). Injection sclerotherapy for esophageal variceal bleeding (NCD. 100.10, p. 2-50). The Ingenix Complete Guide to Medicare Coverage Issues.
Hayes. Medical Technology Directory. (2005, November). Sclerotherapy for esophageal varies. Retrieved September 9, 2009 from www.Hayesinc.com/subscribers. (87 articles and/or guidelines)
Kwak, H. S., & Han, Y. M. (2008). Percutaneous transportal sclerotherapy with N-butyl-2-cyanoacrylate for gastric varices: Technique and clinical efficacy. Korean Journal of Radiology, 9 (6), 526-533.
National Institute for Health and Clinical Excellence (NICE). (2004, April). Endoscopic injection of bulking agents for gastro-oesophageal reflux disease. Retrieved June 26, 2009 from http://www.nice.org.uk/nicemedia/pdf/IPG055guidance.pdf.
Sass, D. A., & Chopra, K. B. (2009). Portal hypertension and variceal hemorrhage. The Medical Clinics of North America, 93 (4), 837-853.
Society of American Gastrointestinal and Endoscopic Surgeons. (2006). The role of endoscopic sclerotherapy: A SAGES co-endorsed ASGE guideline for clinical application. Retrieved October 11, 2006 from http://www.sages.org/sg_asgepub1019.html.
Yu, C. F., Lin, L. W., Hung, S. W., & Yeh, C. T. (2007). Diaphragmatic embolism after endoscopic injection sclerotherapy for gastric variceal bleeding. The American Journal of Emergency Medicine, 25 (7), 860.e5-860.e6.
ORIGINAL EFFECTIVE DATE: 1/1985
MOST RECENT REVIEW DATE: 10/8/2009
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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