MedicaidCoverageMedium impact
New York State Medicaid Updated Coverage Criteria for Wireless Capsule Endoscopy
NY Medicaid·NY · Gastroenterology·Medical Policy
We identified it
May 10, 2026
Summary
New York State Medicaid updated coverage criteria for wireless capsule endoscopy, specifying it's only covered when conventional endoscopy can't identify pathology or is contraindicated. The policy excludes colon cancer screening and requires FDA-cleared devices used by trained gastroenterologists with specific documentation requirements.
Action Required
Immediately: Billing teams must verify wireless capsule endoscopy claims meet new coverage criteria before submission. Only bill CPT 91110 and 91111 when conventional endoscopy is unable to identify pathology or contraindicated, performed by trained gastroenterologists using FDA-cleared devices. Do not bill for colon cancer screening. Ensure providers document medical necessity and retain records for 6 years as claims are subject to audit.