Clinical UM Guideline
|Subject:||Esophageal pH Monitoring|
|Guideline #:||CG-MED-02||Current Effective Date:||01/13/2015|
|Status:||Reviewed||Last Review Date:||11/13/2014|
This document addresses the use of standard catheter-based 24 hour and wireless–based 48 hour esophageal pH monitoring for all indications.
Esophageal pH monitoring is considered medically necessary for the following adults, children or adolescents who are able to report their symptoms in the following clinical situations:
Esophageal pH monitoring is considered medically necessary in infants or children who are unable to report or describe symptoms of reflux with:
Not Medically Necessary:
Esophageal pH monitoring is considered not medically necessary for any one of the following:
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|91034||Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode(s) placement, recording, analysis and interpretation|
|91035||Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode placement, recording, analysis and interpretation|
|91038||Esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation; prolonged (greater than 1 hour, up to 24 hours)|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
Gastroesophageal reflux disease (GERD) is a disease where the lower esophageal sphincter that separates the esophagus from the stomach becomes weakened and allows acidic stomach contents to flow backwards into the esophagus. GERD is associated with heartburn, 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 is typically treated initially with an empiric trial of PPI. Individuals who do not respond to PPI therapy or present with more complex symptoms are often referred to endoscopy with pH monitoring for further evaluation. The pH monitoring provides quantitative data on both esophageal acid exposure and on the temporal correlation between individual symptoms and reflux events.
Conventional catheter-based pH monitoring involves the placement of a catheter with a pH electrode attached to its tip within the esophagus at 5 cm above the upper margin of the lower esophageal sphincter (LES). The electrode is attached to an electronic data recorder 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. Subjective symptoms are also manually reported in a patient log; these symptoms can then be temporally related to acid reflux events.
Non catheter-based (i.e. wireless) devices have become available. One such device is the Bravo™ capsule, which is attached to the esophageal wall during an endoscopy procedure. The Bravo capsule contains a sensor that transmits pH data via radio waves to a small data collection device worn on the belt. The Bravo capsule is naturally dislodged from the esophagus in a short period of time. The sensor is then passed through the digestive tract.
Endoscopy: An examination of the interior of a canal or hollow viscus by means of a special instrument, such as an endoscope.
Esophageal pH monitoring: A medical test that measures the acidity in the esophagus.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Websites for Additional Information|
Bravo pH Monitoring System
Esophageal pH Monitoring
Gastroesophageal Reflux Disease,
pH Monitoring, Esophageal
The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.
|Reviewed||11/13/2014||Medical Policy & Technology Assessment Committee (MPTAC) review. Updated review date, References and History sections.|
|Revised||11/14/2013||MPTAC review. In the not medically necessary criteria, added language to indicate esophageal pH monitoring is not medically necessary to establish a diagnosis of GERD in individuals with Barrett's esophagus. Updated review date, References and History sections.|
|Reviewed||11/08/2012||MPTAC review. Updated review date, References and History sections.|
|Reviewed||11/17/2011||MPTAC review. Updated review date, Coding, References and History sections.|
|Reviewed||11/18/2010||MPTAC review. Updated review date, References and History sections.|
|Reviewed||11/19/2009||MPTAC review. Typographical error corrected in third bullet of the medical necessity criteria. No change to the intent of the document. Updated review date, Description, References and History sections. Removed Place of Service/Duration section.|
|Reviewed||11/20/2008||MPTAC review. Updated review date, references and history sections.|
|Revised||11/29/2007||MPTAC review. As a result of MED.00045 (Wireless Esohageal pH Monitoring) being archived, CG-MED-02 revised to address both catheter-based and wireless esophageal pH monitoring. Updated review date, Discussion/General Information, Coding, References and History sections. Title changed to "Esophageal pH Monitoring" in order to address both wireless and catheter-based esophageal pH monitoring.|
|10/01/2007||Updated coding section with 10/01/2007 ICD-9 changes.|
|05/17/2007||MPTAC review. No change to guideline position statement. Updated Coding section; removed CPT 91033 deleted 12/31/2004.|
|Reviewed||06/08/2006||MPTAC review. No change to position statement. Added reference to MED.00045 Wireless Esophageal pH Monitoring. Updated Reference and Coding sections.|
|11/17/2005||Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).|
|Revised||07/14/2005||MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.|
|Pre-Merger Organizations||Last Review Date||Document Number||Title|
|Anthem, Inc.||No document|
|WellPoint Health Networks, Inc.||09/23/2004||2.06.01||Esophageal pH Monitoring|