Anthem Blue Cross Connecticut MED.00090 Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders Form

This document addresses a wireless capsule for the evaluation of suspected gastric and intestinal motility disorders (SmartPill™ Motility Testing System [Medtronic, Minneapolis, MN]). The capsule was designed to measure pH, temperature and pressure throughout the gastrointestinal tract and transmits measurements via radio signals to an external recording device. In the stomach, the SmartPill has been used to assess gastric emptying in individuals with suspected gastroparesis. In the intestine, the SmartPill has been used to assess small and large bowel transit times in those with chronic constipation or other motility disorders. The device is also referred to in this document as a wireless motility capsule (WMC).

Note: Please see the following related document for additional information: 

• CG-MED-70 Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule

Position Statement

Investigational and Not Medically Necessary:

A wireless capsule (SmartPill Motility Testing System) is considered investigational and not medically necessary for evaluation of all conditions including, but not limited to the following:

1. Suspected gastric motility disorders; or
2. Suspected intestinal motility disorders.