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| Section: | Diagnostic Medical |
| Number: | M-23 |
| Topic: | Esophageal Studies |
| Effective Date: | March 13, 2006 |
| Issued Date: | January 26, 2009 |
| Date Last Reviewed: | 10/2006 |
Indications and Limitations of Coverage
Gastric Motility Studies and Manometry A comprehensive manometric examination of esophageal motility includes evaluation of the lower esophageal sphincter (LES), the esophageal body, the upper esophageal sphincter (UES), and in some instances the pharynx. If esophageal manometry (91010 or 91011) and acid perfusion studies (91030) are reported as separate procedures, they should be combined under code 91012. When any combination of the above procedures are performed in conjunction with gastric motility (manometric) studies (91020), they should be combined as 91020. Esophageal pH Monitoring Catheter-based esophageal pH monitoring (91034) and wireless catheter-free esophageal pH monitoring (e.g., Bravo pH monitoring - 91035) are eligible for the following indications:
Esophageal pH monitoring performed for indications other than those listed above will be denied as not medically necessary. Effective January 26, 2009, a participating, preferred or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records. Bilitec 2000 The Bilitec 2000 is considered experimental/investigational. There is a lack of published peer-reviewed literature assessing the clinical utility of Bilitec 2000. Additional studies are needed to determine the role of this procedure in evaluating patients with duodenogastroesophageal reflux. A participating, preferred, or network provider can bill the member for the denied service. Description Gastroesophageal reflux disease (GERD) is associated with heartburn, acid regurgitation, peptic esophagitis, Barrett’s esophagus, esophageal stricture, some cases of asthma, posterior laryngitis, chronic cough, dental erosions, chronic hoarseness, pharyngitis, subglottic stenosis or stricture, nocturnal choking, and recurrent pneumonia. GERD is usually diagnosed by clinical history and endoscopy, and is treated empirically with a trial of medical management. Conventional catheter-based pH monitoring involves the placement of a catheter with a pH electrode attached to its tip at 5 cm above the upper margin of the lower esophageal sphincter (LES) using manometric location. The electrode is attached to a data logger worn on a waist belt or shoulder strap. Every instance of acid reflux as well as its duration and pH is recorded, indicating gastric acid reflux over a 24-hour period. Patient recorded symptoms can then be temporally related to acid reflux events. More recently, a catheter free, temporarily implanted device (i.e., Bravo pH Monitoring System) has received FDA approval for the purposes of esophageal monitoring. Using endoscopic guidance, the capsule is temporarily implanted in the esophageal mucosa using a pin. The capsule records pH levels for up to 48 hours and transmits them via radio frequency telemetry to a receiver worn in the patient’s belt. Data from the recorder is uploaded to a computer for analysis. Bilitec 2000 is a fiberoptic spectrophotometer developed for use in evaluating reflux disorders in the gastrointestinal tract. This test measures bile, using sensors in the patient, and records the frequency and duration of bile exposure in either the stomach or the esophagus over a 24-hour period. It is typically, performed in an ambulatory setting independent of esophageal pH. A special diet is required to avoid interference and false readings. A trained technician and/or physician are the main users of the system. This system is similar to those used for ambulatory esophageal pH monitoring. |
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| 91010 | 91011 | 91012 | 91020 | 91030 | 91034 |
| 91035 |
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Under the Federal Employee Program, all services that utilize FDA approved drugs, devices, or biological products are eligible when intended for the treatment of a serious or life-threatening condition and when medically necessary and appropriate for the patient's condition. |
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Ambulatory Esophageal pH Monitoring Using a Wireless System, American Journal Gastroenterology, Volume 98, No. 4, 04/2003 National Blue Cross Blue Shield Association Medical Policy 2.01.20, Esophageal pH Monitoring, 02/2003 New Techinques in Measuring Nonacidic Esophageal Reflux, Seminars in Thoracic Cardiovascular Surgery, Volume 13, No. 3, 07/2001 Duodenogastroesophageal Reflux and Methods to Monitor Nonacidic Reflux, American Journal of Medicine, Volume III, 12/2001 Successful Oesophageal pH Monitoring With a Catheter-Free System, Alimentary Pharmacology and Therapeutics, Volume 19, No. 4, 03/2004 Value of Extended Recording Time with Wireless pH Monitoring in Evaluating Gastroesophageal Reflux Disease, Clinical Gastroenterology and Hepatology, Volume 3, No. 4, 04/2005 Feasibility and Tolerability of Transnasal/Per-Oral Placement of the Wireless pH Capsule vs. Traditional 24-Hour pH Monitoring - a Randomized Trial, Alimentary Pharmacology and Therapeutics, Volume 21, No. 2, 01/2005 Wireless pH Testing as an Adjunct to Unsedated Transnasal Esophagoscopy; the Safety and Efficacy of Transnasal Telemetry Capsule Placement, Otolaryngology-Head and Neck Surgery, Volume 131, No. 1, 07/2004 |
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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.
Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.
Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
