Medical Policy
Effective Date:01/01/2008 Title:Gastrointestinal Function Tests
Revision Date: Document:BI190:00
CPT Code(s):91132, 91133
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1.    Gastrointestinal function testing using the following modalities is considered experimental and investigational:

a.    Cutaneous electrogastrography (EGG);

b.    Colonic motility studies utilizing colonic manometry;

c.    Ambulatory monitoring of gastric motility using, the SmartPill.

2.    There is not yet adequate published evidence that they are capable of adding any meaningful information to other conventional means of measuring gastric or colonic function.
Medical Statement
  1. Percutaneous Electrogastgrography (EGG) is considered experimental/Investigational as this approach has not been standardized for routine clinical use
  2. Colonic manometry is considered experimental/investigational as its use has not been standardized for routine clinical use.
  3. Wireless capsule for measuring gastric emptying parameters (SmartPill GI Monitoring System) is considered experimental and investigational because of inadequate published evidence of its diagnostic performance and clinical utility over conventional means of measuring gastric emptying.

 

Codes Used In This BI:

91132

Electrogastrography

91133

Electrogastrography w/test
Limits
Intentially left empty
Reference

Electrogastrography

  1. Sanmiguel CP, Mintchev MP, Bowes KL. Electrogastrography: A noninvasive technique to evaluate gastric electrical activity. Can J Gastroenterol. 1998;12(6):423-430.
  2. Levanon D, Chen JZ. Electrogastrography: Its role in managing gastric disorders. J Pediatr Gastroenterol Nutr. 1998;27(4):431-443.
  3. Di Lorenzo C, Reddy SN, Flores AF, et al. Is electrogastrography a substitute for manometric studies in children with functional gastrointestinal disorders? Dig Dis Sci. 1997;42(11):2310-2316.
  4. Atanassova E, Daskalov I, Dotsinsky I, et al. Non-invasive electrogastrography. Part 2. Human electrogastrogram. Arch Physiol Biochem. 1995;103(4):436-441.



 

Colonic motility studies:

  1. American Gastroenterological Association (AGA). American Gastroenterological Association medical position statement: Nausea and vomiting. Gastroenterology. 2001;120(1): 261-263. Available at: http://www2.us.elsevierhealth.com/inst/serve?article=a123066&nav=abs
  2. Drossman DA. Review article: An integrated approach to the irritable bowel syndrome. Aliment Pharmacol Ther. 1999;13(Suppl 2):3-14.
  3. Bassotti G, Iantorno G, Fiorella S, et al. Colonic motility in man: Features in normal subjects and in patients with chronic idiopathic constipation. Am J Gastroenterol. 1999;94(7):1760-1770.
  4. Altomare DF, Portincasa P, Rinaldi M, et al. Slow-transit constipation: Solitary symptom of a systemic gastrointestinal disease. Dis Colon Rectum. 1999;42(2):231-240.
  5. Locke GR, Pemberton JH, Phillips SF. American Gastroenterological Association medical position statement: Guidelines on constipation. Gastroenterology. 2000;119(6):1761-1766.

 

Wireless Capsule for Measuring Gastric Emptying (SmartPill GI Monitoring System):

  1. Kuo B, McCallum R, Kock K, et al. Smartpill, a novel ambulatory diagnostic test for measuring gastric emptying in healthy and disease. Gastroenterology. 2006;130:A-434.

2.      SmartPill Corp. Officially Launches its SmartPill GI Monitoring System. Available at: http://www.smartpillcorp.com/index.cfm?prid=36&pagepath=Home/NEWS_EVENTS/Press_Releases&id=416
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.