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MP 7.01.42 Endoscopic Laser for Gastrointestinal Bleeding

Medical Policy
Original Policy Date
Last Review Status/Date
Reviewed by consensus/4:2002
Return to Medical Policy Index


Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.


In this procedure, the laser beam is directed to the specific site of gastrointestinal bleeding via a fiberglass fiber inserted through a flexible endoscope. The laser then converts light to heat energy to coagulate bleeding sites within the gastrointestinal tract.


The use of an endoscopic laser is considered medically necessary for control of persistent and severe bleeding gastrointestinal lesions, including angiodysplasia.

Policy Guidelines

No applicable information

Benefit Application

No applicable information


A search of the literature was completed through the MEDLINE database for the period of January 1992 through February 1995. The search strategy focused on references containing the following Medical Subject Headings:

– Gastrointestinal Hemorrhage
– Laser Coagulation or
– Laser Surgery

See also:

Technology Evaluation and Coverage 1986: p. 167





CPT  43255  Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with control of bleeding, any method 
  45382  Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding, any method 
ICD-9 Procedure  44.43  Endoscopic control of gastric or duodenal bleeding 
  45.43  Endoscopic destruction of other lesion of tissue of large intestine 
ICD-9 Diagnosis  531.00–531.01  Acute gastric ulcer with hemorrhage 
  532.00–532.01  Acute duodenal ulcer with hemorrhage 
  532.40–532.41  Chronic gastric ulcer with hemorrhage 
  533.00–533.01  Acute peptic ulcer with hemorrhage 
  533.40–533.41  Chronic peptic ulcer with hemorrhage 
  534.00–534.01  Acute gastrojejunal ulcer with hemorrhage 
  534.40–534.41  Chronic gastrojejunal ulcer with hemorrhage 
  535.0–535.5  Types of gastritis code range. This code range requires the 5th digit of (1) to identify “with hemorrhage” 
  535.61  Duodenitis with hemorrhage 
  537.83  Angiodysplasia of stomach and duodenum with hemorrhage 
  569.82  Ulceration of intestine 
  569.85  Angiodysplasia of intestine with hemorrhage 
  578.9  Hemorrhage of gastrointestinal tract, unspecified 
    Note: Codes 569.82 & 578.9 should always be used together to identify bleeding intestinal ulcer (578.9 would not be used alone because it is unspecified, and there is no intestinal ulcer code that specifies with hemorrhage) 
HCPCS  No code 
Type of Service  Surgery 
Place of Service  Inpatient 


Bleeding, Gastrointestinal, Laser
Endoscopic Laser for Gastrointestinal Bleeding
Laser for Gastrointestinal Bleeding

Policy History

Date Action Reason
03/31/96 Add to Surgery Section New Policy
08/18/00 Replace Policy Archived Policy
12/18/02 Replace Policy Policy retired

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