Clinical Policy: Wireless Motility Capsule Form

CENTENE Corporation

Clinical Policy: Wireless Motility Capsule
Reference Number: CP.MP.143
Date of Last Revision: 09/22

[Coding Implications](Coding Implications)
[Revision Log](Revision Log)

See [Important Reminder](Important Reminder) at the end of this policy for important regulatory and legal information.

Description
The wireless motility capsule (WMC) assesses gastroparesis or delayed gastric emptying.¹⁻³ The WMC is an orally ingested, nondigestible, data-recording device that enables the simultaneous assessment of regional and whole gut transit.²⁻⁴

Policy/Criteria
It is the policy of health plans affiliated with Centene Corporation® that wireless motility capsule (WMC) is not medically necessary for the evaluation of suspected gastric and intestinal motility disorders, as well as all other indications. There is a paucity of peer-reviewed, evidence-based literature to determine that the diagnostic performance and clinical utility surpass conventional means of measuring gastric emptying.

Background
The U.S. Food and Drug Administration approved wireless motility capsule (WMC) for the evaluation of patients with suspected gastroparesis, even though there is no sign of a blockage.¹⁻³ The WMC, which is a 26 x 13 mm size capsule with a battery life of five days, is also proposed to evaluate colonic transit time in patients with chronic idiopathic constipation.³ Additionally, the WMC is noted to continuously measure the temperature, pH, and pressure of its surrounding environment while traveling through the gastrointestinal tract, via gut peristalsis, until exiting the body through the anus.¹⁻⁵⁻⁶

After eating a standard meal, the member/enrollee swallows the capsule and wears a small monitor that makes telemetry recordings. The established cutoff point for gastric emptying time is 300 minutes. Gastric emptying of the WMC seems to occur with the Phase III migrating motor complex, signifying completion of postprandial phase and return of the fasting state. It assesses small bowel transit time by a sharp increase in pH on entry into duodenum and by a fall in pH at the ileocecal junction. However, in 15% of patients, this pH drop is not observed, and this may be related to the ileocecal valve incompetence.⁶ An example of a wireless GI motility monitoring system is the SmartPill® GI monitoring system 2.0.¹

Advantages of the WMC include that it is wireless and painless and contains no radiation.⁴ Disadvantages of the capsule include failure to capture data that would require repeat testing, and delay or total failure to pass the capsule, requiring serial x-rays to document passage or endoscopic or surgical removal. Another disadvantage is that it should not be used in patients with a possible stricture, altered anatomy, or severe pyloric stenosis.⁷ Patients ideally should be able to tolerate not using proton pump inhibitors and histamine 2 blockers before testing.⁸

CENTENE Corporation

CLINICAL POLICY
Wireless Motility Capsule

Agency for Healthcare Research and Quality
Based on current literature, the WMC appears to be accurate in detection of gastroparesis and slow-transit constipation and may provide increased diagnostic gain as compared with standard motility testing.¹ However, evidence is insufficient to determine whether use of the WMC will improve outcomes of care.¹ One goal would be to define the populations who would benefit most from motility testing, including WMC testing.⁷

American College of Gastroenterology
Scintigraphic gastric emptying of solids is the standard for the evaluation of gastric emptying and the diagnosis of gastroparesis.¹ Alternative approaches for assessment of gastric emptying include WMC testing and 13C-spirulina breath testing. (conditional recommendation, low level of evidence)⁹

BlueCross BlueShield Association Technology Evaluation Center
This society concluded that the WMC does not meet the technology evaluation center criteria, but that the limited body of evidence on the diagnostic characteristics of SmartPill does reveal correlations between SmartPill and other tests that indicate some capability to distinguish diseased from non-diseased persons.¹⁰

American and European Neurogastroenterology and Motility Societies
Tests of gastrointestinal transit are available and useful in the evaluation of patients with symptoms suggestive of gastrointestinal dysmotility since they can provide objective diagnosis and a rational approach to patient management.¹¹

Studies note that WMC is comparable in accuracy to current modalities in use for detection of slow-transit constipation and gastric emptying delay and is therefore another viable diagnostic modality. However, little data are available to determine the optimal timing of this device for diagnostic algorithms.¹²

Other studies have noted that the sensitivity and specificity of the WMC is comparable to radiopaque marker test and scintigraphic gastric emptying.¹³ WMC is well tolerated, has good compliance, and avoids the risk of radiation exposure, however, it is not clear if it provides added clinical value in most patients.¹,⁶,⁸,¹⁴

Coding Implications
This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2020, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

CENTENE Corporation

CLINICAL POLICY
Wireless Motility Capsule

ICD-10-CM Diagnosis Codes Related to Procedure

Reviews, Revisions, and Approvals

Important Reminder
This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affect by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage

CENTENE Corporation

CLINICAL POLICY
Wireless Motility Capsule

decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.

This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members/enrollees. This clinical policy is not intended to recommend treatment for members/enrollees. Members/enrollees should consult with their treating physician in connection with diagnosis and treatment decisions.

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members/enrollees and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members/enrollees and their representatives agree to be bound by such terms and conditions by providing services to members/enrollees and/or submitting claims for payment for such services.

Note: For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.

Note: For Medicare members/enrollees, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.