Anthem Blue Cross Connecticut CG-SURG-70 Gastric Electrical Stimulation Form

This document addresses gastric electrical stimulation (GES) for gastroparesis and other indications.

GES refers to the use of an implantable device to treat gastroparesis, a chronic disorder in which there is delayed gastric emptying without evidence of obstruction. Symptoms include abdominal distension, nausea, and vomiting. GES has more recently been investigated as a technique to treat obesity.

Clinical Indications

Medically Necessary:

Gastric electrical stimulation is considered medically necessary in the treatment of chronic intractable nausea and vomiting secondary to severe gastroparesis of diabetic or idiopathic etiology when the following criteria are met:

1. Individual is refractory, intolerant or has contraindications to the use of prokinetic and antiemetic medications; and
2. Delayed gastric emptying as documented by standard scintigraphic imaging of solid food.

Removal of a gastric electrical stimulator is considered medically necessary when any of the following criteria are met (1or 2):

1. The individual has experienced complications associated with gastric electrical stimulation (for example, bowel obstruction, gastric wall perforation, infection, lead dislodgement or disruption, or generator site pain); or
2. When GES is unsuccessful after an adequate trial period, for example, one year, both the generator and the leads may be removed.

Revision or replacement of a gastric electrical stimulator is considered medically necessary when both of the following criteria are met (1 and 2):

1. The individual has demonstrated clinical benefit from gastric electrical stimulation; and
2. The device has malfunctioned.

Not Medically Necessary:

Gastric electrical stimulation is considered not medically necessary in all other indications, including but not limited to the treatment of obesity.

Revision, replacement, or removal of a gastric electrical stimulator is considered not medically necessary when the criteria above have not been met.