Mountain State Medical Policy Bulletin
Section: Diagnostic Medical
Number: M-35
Topic: Electrogastrogram (EGG)
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 06/2005

General Policy Guidelines

Indications and Limitations of Coverage

An electrogastrogram (EGG) is considered experimental/investigational. Therefore, it is not covered. A participating, preferred, or network provider can bill the member for the denied service. Based on scientific evidence, EGG does not impact or improve health outcomes.

Description

An electrogastrogram (EGG) (91132, 91133) is a cutaneous recording of the gastric electrical signals that travel through the muscles of the stomach and control the muscles' contraction. Several electrodes are taped onto the abdomen over the stomach in the same manner as electrodes on the chest for an electrocardiogram. The electrodes sense the electrical signals coming from the stomach's muscles, and the signals are recorded for analysis. Generally, recordings are made both fasting and after a meal, with the patient lying quietly. The study typically takes two to three hours. Electrogastrogram recordings provide a non-invasive measurement of gastric myoelectrical activity ranging from normal 3 cycles per minute (cpm) to gastric dysrhythmias (i.e., bradygastria {less than 2 cycles/minute}, tachygastria {greater than 4 cycles/minute}, and mixed dysrhythmias). Many factors such as fasting or postprandial status, contents of meals, physical and psychological stresses can effect the recordings of gastric myoelectrical activity. Methods for performing and analyzing an EGG may vary among different gastrointestinal motility centers.


NOTE:
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.

Procedure Codes

9113291133    

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Under the Federal Employees 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. An electrogastrogram is considered an eligible service when determined medically necessary based on the patient’s condition.

Also refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

PRN References

10/2000, Electrogastrogram

References

Gastric Myoelectrical Activity and Gastric Emptying in Patients with Functional Dyspepsia, The American Journal of Gastroenterology, Volume 94, No. 9, 9/1999

Measurement of Gastrointestinal Motility in the GI Laboratory, Gastroenterology, Volume 115, No. 3, 9/1998

The Diagnosis and Work-up of the Patient with Gastroparesis, Journal of Clinical Gastroenterology, Volume 30, No. 2, 3/2000

Artifact Reduction in Electrogastrogram based on Empirical Mode Decomposition Method, Medical & Biological Engineering & Computing, Volume 38, No. 1, 1/2000

American Gastroenterological Association Practice Guidelines (Published in Gastroenterology), Gastroenterology, Volume 120, No. 1, 1/2001

American Gastroenterological Association Medical Position Statement: Nausea and Vomiting, Gastroenterology, Volume 120, No. 1, 1/2001

Motility Disorders - Diagnosis and Treatment for the Pediatric Patient, Pediatric Clinics of North America, Volume 49, No. 1, 2/2002

Electrogastrography: A Document Prepared by the Gastric Section of the American Motility Society Clinical GI Motility Testing Task Force, Volume 15, No. 2, 04/2003

National Blue Cross Blue Shield Association Medical Policy 2.01.34, Cutaneous Electrogastrography (EGG), 01/2004

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Glossary




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.