Electrogastrography (EGG) Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 04|01|2001 POLICY LAST REVIEWED: 01|07|2026

OVERVIEW Electrogastrography (EGG) describes the recording and interpretation of electrical activity of the stomach.

MEDICAL CRITERIA Not applicable

PRIOR AUTHORIZATION Not applicable

POLICY STATEMENT Medicare Advantage Plans Electrogastrography is not covered as the evidence is insufficient to determine the effects of the technology on health outcomes.

Commercial Products Electrogastrography is not medically necessary as the evidence is insufficient to determine the effects of the technology on health outcomes.

COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate section of the Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable not medically necessary/not covered benefits/coverage.

BACKGROUND The electrical activity of the stomach can be subdivided into two general categories: electrical control activity (ECA) and electrical response activity (ERA). ECA is characterized by regularly recurring electrical potentials, originating in the gastric pacemaker located in the corpus of the stomach and sweeping in an annular band with increasing velocity toward the pylorus. ECA is not associated with contractions of the stomach unless coupled with action potentials, referred to as ERA.

The usual practice is to record several cutaneous electroencephalographic (EEG) signals from various standardized positions on the abdominal wall and to select the one with the highest amplitude for further analysis. Nonetheless, the recorded signal is relatively weak and difficult to distinguish from the surrounding background “noise” related to unwanted signals, such as cardiac, respiratory, duodenal, and colonic electrical activity. For this reason, direct visual analysis of the EGG signals is problematic. Various methods of filtering out background noise and automated analysis have been developed; running spectral analysis is most common. The EGG is usually evaluated in terms of changes in the EGG amplitude and frequency. Deviations from the normal frequency of 3 cycles per minute may be referred to as brady- or tachyarrhythmia.

The use of EGG has been most widely studied in patients with gastroparesis and functional dyspepsia. Gastroparesis is defined as a chronic disorder of gastric motility as evidenced by delayed gastric emptying of a solid meal. Symptoms include bloating, distention, nausea, and vomiting. When severe and chronic, gastroparesis can be associated with dehydration, poor nutritional status, and poor glycemic control in diabetics. While most commonly associated with diabetes, gastroparesis is also found in chronic pseudo- obstruction, connective tissue disorders, Parkinson’s disease, and psychological pathology. Functional Medical Coverage Policy | Electrogastrography (EGG)

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

dyspepsia is an enigmatic disorder characterized by persistent symptoms of abdominal discomfort with no identifiable etiology, including gastric emptying. In this setting, disorders in gastric motility may be considered. Treatment of gastric motility disorders typically includes the use of prokinetic agents, such as cisapride, domperidone, or metoclopramide.

Scintigraphic gastric emptying is considered the gold standard test for evaluating gastroparesis. The test consists of ingestion of a solid meal spiked with 99-technetium. Serial scintigraphic measurements are then performed every 20 minutes for 2-3 hours after the meal. Delayed gastric emptying is diagnosed if more than 50% of the radiolabeled food is retained at the end of the study period. While gastric emptying evaluates the efficiency of gastric emptying, EGG focuses on the underlying myoelectrical activity.

EGG recording faces several technical challenges, many of them related to measuring cutaneous signals, rather than directly measuring electrical activity along the stomach mucosa or serosa. Several studies have compared EGG with gastric emptying tests and have reported a poor correlation between the two. There are inadequate data to determine how the results of this test may be used to benefit patient management.

A position statement on the diagnosis and treatment of gastroparesis from the American Gastroenterological Association in 2004 reported that the guideline developers discussed, but did not recommend, the use of EGG to test for gastric myoelectrical activity.

Validation of the clinical use of any diagnostic test focuses on 3 main principles: 1) the technical feasibility of the test; 2) basic statistical measurements, such as sensitivity, specificity, and positive and negative predictive values in different populations of patients and compared to the gold standard; and 3) how the results of the diagnostic test will be used in the management of the patient and whether or not the change in treatment will result in an overall improvement in health outcomes. Based on a review of the published peer-reviewed literature, there are inadequate data to evaluate any of the above principles, therefore electrogastrography is considered not medically necessary as there is no proven efficacy.

CODING Medicare Advantage Plans and Commercial Products The following CPT code(s) are not covered for Medicare Advantage Plans and not medically necessary for Commercial Products: 91132 Electrogastrography, diagnostic, transcutaneous 91133 Electrogastrography, diagnostic, transcutaneous; with provocative testing

RELATED POLICIES Not applicable

PUBLISHED Provider Update, March 2026 Provider Update, March 2025 Provider Update, April 2024 Provider Update, April 2023 Provider Update, June 2022

REFERENCES

1. Verhagen MA, Van Schelven LJ, Samsom M et al. Pitfalls in the analysis of electrogastrographic recordings. Gastroenterology 1999; 117(2):453-60.
2. Bortolotti M. Electrogastrography: a seductive promise, only partially kept. Am J Gastroenterol 1998; 93(10):1791-4.
3. Koch KL, Medina M, Bingaman S et al. Gastric dysrhythmia and visceral sensations in patients with functional dyspepsia. Gastroenterology 1992; 102:A469.
4. Koch KL, Stern RM, Stewart WR et al. Gastric emptying and gastric myoelectrical activity in patients with diabetic gastroparesis: effect of long-term domperidone treatment. Am J Gastroenterol 1989; 84(9):1069-75.

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

5. Smout AJ, Jebbink HJ, Akkermans LM et al. Role of electrogastrography and gastric impedance measurements in evaluation of gastric emptying and motility. Dig Dis Sci 1994; 39(12 suppl):110S-113S.
6. Chen JD, Lin Z, Pan J et al. Abnormal gastric myoelectrical activity and delayed gastric emptying in patients with symptoms suggestive of gastroparesis. Dig Dis Sci 1996; 41(8):1538-45.
7. Parkman HP, Miller MA, Trate D et al. Electrogastrography and gastric emptying scintigraphy are complementary for assessment of dyspepsia. J Clin Gastroenterol 1997; 24(4):214-9.
8. Brzana RJ, Koch KL, Bingaman S. Gastric myoelectrical activity in patients with gastric outlet obstruction and idiopathic gastroparesis. Am J Gastroenterol 1998; 93(10):1803-9.
9. Kawagishi T, Nishizawa Y, Emoto M et al. Gastric myoelectrical activity in patients with diabetes: Role of glucose control and autonomic nerve function. Diabetes Care 1997; 20(5):848-53.
10. Mantides A, Stefanides G, Kioulanis J et al. Cutaneous electrogastrography for the assessment of gastric myoelectrical activity in type I diabetes mellitus. Am J Gastroenterol 1997; 92(7):1190-3.
11. Aktay AN, Splaingard ML, Miller T et al. Electrogastrography in children with cystic fibrosis. Dig Dis Sci 2002; 47(4):699-703.
12. Levy J, Harris J, Chen J et al. Electrogastrographic norms in children: toward the development of standard methods, reproducible results, and reliable normative data. J Pediatr Gastoenterol Nutr 2001; 33(4):455-61.
13. Koch KL. Electrogastrography: physiological basis and clinical application in diabetic gastropathy. Diabetes Technol Ther 2001; 3(1):51-62.
14. Mathur R, Pimentel M, Sam CL et al. Postprandial improvement of gastric dysrhythmias in patients with type II diabetes: identification of responders and nonresponders. Dig Dis Sci 2001: 46(4):705-12.
15. Koch KL, Hong SP, Xu L. Reproducibility of gastric myoelectrical activity and the water load test in patients with dysmotility-like dypepsia symptoms and in control subjects. J Clin Gastroenterol 2000; 31(2):125-9.
16. Lin Z, Eaker EY, Sarosiek I et al. Gastric myoelectrical activity and gastric emptying in patients with functional dyspepsia. Am J Gastroenterol 1999; 94(9):2384-9.
17. Simonian HP, Panganamamula K, Chen JZ et al. Multichannel electrogastrography (EGG) in symptomatic patients: a single center study. Am J Gastroenterol 2004; 99(3):478-85.
18. American Gastroenterological Association. American Gastroenterological Association medical position statement: nausea and vomiting. Gastroenterology 2001; 120(1):261-3.
19. Chen CL, Hu CT, Lin HH et al. Clinical utility of electrogastrography and the water load test in patients with upper gastrointestinal symptoms. J Smooth Muscle Res 2006; 42(5):149-57.
20. Jonderko K, Kasicka-Jonderko A, Krusiec-Swidergol B et al. How reproducible is cutaneous electrogastrography? An in-depth evidence-based study. Neurogastroenterol Motil 2005; 17(6):800-9.
21. Parkman HP, Hasler WL, Fisher RS. American Gastroenterological Association medical position statement: diagnosis and treatment of gastroparesis. Gastroenterology 2004; 127(5):1589-91.
22. Abid S, Lindberg G. Electrogastrography: poor correlation with antro-duodenal manometry and doubtful clinical usefulness in adults. World J Gastroenterol 2007; 13(38):5101-7.

23. Krusiec-Świdergoł B, Jonderko K. Multichannel electrogastrography under a magnifying glass - an indepth study on reproducibility of fed state electrogastrograms. Neurogastroenterol Motil 2008 Feb 19. [Epub ahead of print]

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