Blue Cross of Idaho Logo

Express Sign-on

Thank you for registering with Blue Cross of Idaho

If you are an Individual or Family Member under age 65, please register here.

If you are an Medicare or Medicare Supplement member, please register here.

New Options for Affordable Health Insurance

MP 7.01.46 Endoscopic Injection Sclerotherapy for Esophageal Varices

Medical Policy
Section
Surgery
Original Policy Date
3/31/96
Last Review Status/Date
Reviewed by consensus/4:2002
Issue
4:2002
Return to Medical Policy Index

Disclaimer

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.


Description

Endoscopic injection sclerotherapy is a therapeutic procedure used to treat bleeding esophageal varices and prevent future variceal bleeding. An endoscope is passed into the esophagus, and sclerosing agents (sodium morrhuate, sodium tetradecyl sulfate, and hypertonic saline or glucose) are injected into or around the varices.


Policy

Esophageal injection sclerotherapy is considered medically necessary in the treatment of esophageal varices and in the prevention of future variceal bleeding once bleeding has occurred. Prophylactic sclerotherapy to prevent hemorrhage that has not yet occurred is investigational.


Policy Guidelines

Endoscopic injection sclerotherapy generally involves a number of treatment sessions with appropriate injection(s) once an acute hemorrhage has been controlled.

Follow-up sessions to inject remaining varices may be appropriate. However, diagnostic or follow-up endoscopy should be limited to one at inception and one on conclusion of treatment.


Benefit Application

No applicable information


Rationale

A search of the literature was completed through the MEDLINE database for the period of January 1992 through April 13, 1995. The search strategy focused on references containing the following Medical Subject Heading:

– Sclerotherapy

Research was limited to English-language journals on humans.

See also:

TEC Assessment 1986: p. 167

 

Codes

Number

Description

CPT 

43204 

Esophagoscopy, rigid or flexible, with injection sclerosis of esophageal varices 

ICD-9 Procedure 

42.33 

Endoscopic excision or destruction of lesion or tissue of esophagus 

ICD-9 Diagnosis 

456.0 

Esophageal varices with bleeding 

 

456.20 

Esophageal varices in diseases classified elsewhere, with bleeding 

HCPCS 

J7130 

Hypertronic saline solution 50 or 100 meg, 20cc vial 

Type of Service 

Surgery 

Place of Service 

Inpatient
 
Outpatient
 


Index

Endoscopic Injection Sclerotherapy for Esophageal Varices
Sclerotherapy for Esophageal Varices, Endoscopic Injection
Varices, Esophageal


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


Search for Policies

Policy Feedback