Radiofrequency ablation may be considered medically necessary for the treatment of Barrett esophagus with high-grade dysplasia (see Policy Guidelines section).
Radiofrequency ablation may be considered medically necessary for the treatment of Barrett esophagus with low-grade dysplasia, when the initial diagnosis of low-grade dysplasia is confirmed by 2 pathologists. (see Policy Guidelines section).
Radiofrequency ablation is considered investigational for the treatment of Barrett esophagus when the above criteria are not met, including but not limited to Barrett esophagus in the absence of dysplasia.
Cryoablation is considered investigational for the treatment of Barrett esophagus, with or without dysplasia.
