Blue Cross Blue Shield of Minnesota Medical Policy


Medical Policy:
Esophageal pH Monitoring
Ancillary Services
Effective Date:
August 3, 2020
Issued Date:
June 28, 2021
Last Revision Date:
May 2020
Annual Review:
June 2021

This policy version was replaced June 27, 2022. To find the newest version, go to, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).

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.

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.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

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:

  • Documentation of abnormal acid exposure in endoscopy-negative patients being considered for surgical antireflux repair; OR
  • Evaluation of patients after antireflux surgery who are suspected of having ongoing abnormal reflux; OR
  • Evaluation of patients with either normal or equivocal endoscopic findings and reflux symptoms that are refractory to proton pump inhibitor therapy; OR
  • Evaluation of refractory reflux in patients with chest pain after cardiac evaluation and after a 1-month trial of proton pump inhibitor therapy; OR
  • Evaluation of suspected otolaryngologic manifestations of gastroesophageal reflux disease (ie, laryngitis, pharyngitis, chronic cough) in patient who have failed to respond to at least 4 weeks of proton pump inhibitor therapy; OR
  • Evaluation of concomitant gastroesophageal reflux disease in patients with adult-onset, nonallergic asthma suspected of having reflux-induced asthma.

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:

  • Unexplained apnea; OR
  • Bradycardia; OR
  • Refractory coughing or wheezing, stridor, or recurrent choking (aspiration); OR
  • Persistent or recurrent laryngitis; OR
  • recurrent pneumonia.

III. Esophageal pH monitoring is considered NOT MEDICALLY NECESSARY for ANY one of the following:

  • The routine work up of an individual with symptoms of gastroesophageal reflux; OR
  • Evaluation of alkaline reflux; OR
  • Verification of simple postcibal regurgitation in infants; OR
  • Evaluation of dysphagia or dyspepsia; OR
  • To establish a diagnosis of GERD in individuals with Barrett’s esophagus.


91034 91035

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.

91037 91038

Denial Statements

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.

Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites. 

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. 

These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.


CPT® codes copyright American Medical Association® 2022. All rights reserved.

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