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Esophageal pH monitoring, using wired or wireless devices, can record acid pH of the lower esophagus for a period of several days. Impedance pH monitoring, also known as multichannel intraluminal impedance (MII), measures changes in electrical resistance to the flow of an electrical current between 2 electrodes when a liquid, semisolid, or gas bolus moves between them. This method measures reflux of liquid or gas across the pH spectrum from acid to alkaline. Esophageal pH and impedance monitoring tests are used in the evaluation of gastroesophageal reflux disease (GERD).
Gastroesophageal reflux disease is most commonly diagnosed by clinical evaluation and treated with a trial of medical management. For some patients who do not respond appropriately to medications, endoscopy is indicated to confirm the diagnosis and assess the severity of reflux esophagitis. However, in some patients, endoscopy is nondiagnostic, or results are inconsistent with the clinical evaluation. In these cases, further diagnostic testing such as esophageal pH monitoring, may be of benefit.
Several pH monitoring systems have been cleared by the U. S. Food and Drug Administration (FDA) through the 510(k) process. A catheter-free, wireless, temporarily implanted device (Bravo™ pH Monitoring System, Medtronic) was cleared for marketing by FDA through the 510(k) process for the purpose of “gastroesophageal pH measurement and monitoring of gastric reflux in adults and children from 4 years of age.” Other cleared, wireless and catheter-based (wired) esophageal pH monitoring devices include the Sandhill Scientific PediaTec™ pH Probe, and the ORION II Ambulatory pH Recorder, and the TRIP CIC Catheter.
Esophageal pH Monitoring
I. Esophageal pH monitoring using a wireless or catheter-based system may be considered MEDICALLY NECESSARY AND APPROPRIATE for ANY the following indications in adults and children or adolescents able to report symptoms:
II. Twenty-four-hour catheter-based esophageal pH monitoring may be considered MEDICALLY NECESSARY AND APPROPRIATE in infants or children who are unable to report or describe symptoms of reflux with ANY of the following indications:
III. Esophageal pH monitoring is considered NOT MEDICALLY NECESSARY for ANY one of the following:
Impedance pH Monitoring (Multichannel Intraluminal Impedance)
I. Catheter-based impedance pH monitoring may be considered MEDICALLY NECESSARY AND APPROPRIATE for evaluation of gastrointestinal reflux disease (GERD) in children and adolescents < 18 years of age.
II. Catheter-based impedance pH monitoring is considered EXPERIMENTAL AND INVESTIGATIVE in adults ≥18 years of age for all indications due to lack of clinical evidence demonstrating an effect on improved health outcomes.
No additional statements.
Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.
Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.
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Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.
Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement.
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Acknowledgements:
CPT® codes copyright American Medical Association® 2022. All rights reserved.
CDT codes copyright American Dental Association® 2022. All rights reserved.
