This policy version was replaced June 27, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, 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).
Gastroparesis is a chronic disorder characterized by delayed gastric emptying in the absence of mechanical obstruction. Possible causes of gastroparesis include diabetes, surgery or the use of certain medications. Gastric emptying scintigraphy (GES) is considered to be the standard method of assessing gastric motility because it provides a noninvasive, physiologic, and quantitative measurement of the emptying process.
In 2006, a wireless capsule designed to measure gastric emptying, the SmartPill Gastrointestinal Motility Monitoring System®, received 510(k) marketing clearance from the U.S. Food and Drug Administration (FDA). The SmartPill system involves use of an ingestible capsule which measures pH, pressure and temperature as it moves through the gastrointestinal (GI) tract. These measurements are transmitted by a radiofrequency signal from the capsule to a receiver worn on a belt around the patient’s waist. The data are then downloaded and evaluated through a software program to determine gastric emptying time, total transit time, and combined small-large bowel transit time. Following completion of transit through the GI tract, the capsule is expelled naturally.
Use of a wireless gastric motility monitoring system for any indication, including, but not limited to, the evaluation of gastroparesis, is considered EXPERIMENTAL/INVESTIGATIVE due to a lack of evidence demonstrating its impact 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.
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.
Acknowledgements:
CPT® codes copyright American Medical Association® 2022. All rights reserved.
CDT codes copyright American Dental Association® 2022. All rights reserved.