069 Form

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Medical Policy Esophageal pH Monitoring
Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 069

BCBSA Reference Number: 2.01.20 (For Plan internal use only) Related Policies
None Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity

Esophageal pH monitoring using a wireless or catheter-based system may be considered MEDICALLY NECESSARY for the following clinical indications in adults and children or adolescents able to report symptoms:a • Documentation of abnormal acid exposure in endoscopy-negative individuals being considered for surgical anti-reflux repair,
• Evaluation of individuals after anti-reflux surgery who are suspected of having ongoing abnormal reflux, • Evaluation of individuals with either normal or equivocal endoscopic findings and reflux symptoms that are refractory to proton pump inhibitor therapy,
• Evaluation of refractory reflux in individuals with chest pain after cardiac evaluation and after a 1- month trial of proton pump inhibitor therapy,
• Evaluation of suspected otolaryngologic manifestations of GERD (i.e., laryngitis, pharyngitis, chronic cough) that have failed to respond to at least 4 weeks of proton pump inhibitor therapy, or • Evaluation of concomitant GERD in an adult-onset, non-allergic asthmatic suspected of having reflux- induced asthma.

Twenty-four-hour catheter-based esophageal pH monitoring may be MEDICALLY NECESSARY in infants or children who are unable to report or describe symptoms of reflux with: • Unexplained apnea,
• Bradycardia,
• Refractory coughing or wheezing, stridor, or recurrent choking (aspiration),
• Persistent or recurrent laryngitis,
• Recurrent pneumonia.

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Twenty-four-hour catheter-based impedance pH monitoring may be considered INVESTIGATIONAL in individuals with established gastroesophageal reflux disease (GERD) on proton pump inhibitor (PPI) therapy, whose symptoms have not responded adequately to twice-daily PPI therapy, in order to define refractory GERD.

aEsophageal pH monitoring systems should be used in accordance with FDA-approved indications and age ranges.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required. CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity: CPT Codes CPT codes: Code Description 91034 Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode(s) placement, recording, analysis and interpretation 91035 Esophagus, gastroesophageal reflux test; with mucosal attached telemetry pH electrode placement, recording, analysis and interpretation The following ICD Diagnosis Codes are considered medically necessary when submitted with the CPT codes above if medical necessity criteria are met ICD-10 Diagnosis Codes ICD-10-CM Diagnosis codes: Code Description G47.30 Sleep apnea, unspecified J37.0 Chronic laryngitis J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation J44.9 Chronic obstructive pulmonary disease, unspecified J45.20 Mild intermittent asthma, uncomplicated

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J45.21 Mild intermittent asthma with (acute) exacerbation J45.22 Mild intermittent asthma with status asthmaticus J45.30 Mild persistent asthma, uncomplicated J45.31 Mild persistent asthma with (acute) exacerbation J45.32 Mild persistent asthma with status asthmaticus J45.40 Moderate persistent asthma, uncomplicated J45.41 Moderate persistent asthma with (acute) exacerbation J45.42 Moderate persistent asthma with status asthmaticus J45.50 Severe persistent asthma, uncomplicated J45.51 Severe persistent asthma with (acute) exacerbation J45.52 Severe persistent asthma with status asthmaticus J45.991 Cough variant asthma K21.00 Gastro-esophageal reflux disease with esophagitis, without bleeding K21.01 Gastro-esophageal reflux disease with esophagitis, with bleeding K21.9 Gastro-esophageal reflux disease without esophagitis P22.8 Other respiratory distress of newborn P22.9 Respiratory distress of newborn, unspecified P24.30 Neonatal aspiration of milk and regurgitated food without respiratory symptoms P24.31 Neonatal aspiration of milk and regurgitated food with respiratory symptoms P24.81 Other neonatal aspiration with respiratory symptoms P28.2 Cyanotic attacks of newborn P28.30 Primary sleep apnea of newborn, unspecified P28.31 Primary central sleep apnea of newborn P28.32 Primary obstructive sleep apnea of newborn P28.33 Primary mixed sleep apnea of newborn P28.39 Other primary sleep apnea of newborn P28.40 Unspecified apnea of newborn P28.41 Central neonatal apnea of newborn P28.42 Obstructive apnea of newborn P28.43 Mixed neonatal apnea of newborn P28.49 Other apnea of newborn P28.5 Respiratory failure of newborn P28.81 Respiratory arrest of newborn P28.89 Other specified respiratory conditions of newborn P29.12 Neonatal bradycardia P84 Other problems with newborn R05.3 Chronic cough R05.4 Cough syncope R05.8 Other specified cough R05.9 Cough, unspecified R06.1 Stridor R06.2 Wheezing R06.81 Apnea, not elsewhere classified Z87.01 Personal history of pneumonia (recurrent)

The following CPT codes are considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity:

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CPT Codes CPT codes: Code Description 91037 Esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation; 91038 Esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation; prolonged (greater than 1 hour, up to 24 hours)

Description Gastroesophageal Reflux Disease Acid reflux is the cause of heartburn and acid regurgitation esophagitis, which can lead to esophageal stricture. Acid reflux can also cause or contribute to some cases of asthma, posterior laryngitis, chronic cough, dental erosions, chronic hoarseness, pharyngitis, subglottic stenosis or stricture, nocturnal choking, and recurrent pneumonia.

Diagnosis Gastroesophageal reflux disease is most commonly diagnosed by clinical evaluation and treated empirically with a trial of medical management. For patients who do not respond appropriately to medications, or who have recurrent chronic symptoms, endoscopy is indicated to confirm the diagnosis and assess the severity of reflux esophagitis. In some patients, endoscopy is nondiagnostic, or results are discordant with the clinical evaluation (in these cases, further diagnostic testing may be of benefit).

Monitoring Esophageal monitoring is done using a tube with a pH electrode attached to its tip, which is then passed into the esophagus to approximately 5 cm above the upper margin of the lower esophageal sphincter. The electrode is attached to a data recorder worn on a waist belt or shoulder strap. Every instance of acid reflux, as well as its duration and pH, is recorded over a 24-hour period. Wireless pH monitoring is achieved using endoscopic or manometric guidance to attach the pH measuring capsule to the esophageal mucosa using a clip. The capsule records pH levels for up to 96 hours and transmits them via radiofrequency telemetry to a receiver worn on the patient’s belt. Data from the recorder are uploaded to a computer for analysis by a nurse or doctor.

Another technology closely related to pH monitoring is impedance pH monitoring, which incorporates pH monitoring with measurements of impedance, a method of measuring reflux of liquid or gas of any pH. Multiple electrodes are placed along the length of the esophageal catheter. The impedance pattern detected can determine the direction of flow and the substance (liquid or gas). Impedance monitoring can identify reflux events in which the liquid is only slightly acidic or nonacidic.

Summary Description Esophageal pH monitoring, using wired or wireless devices, can record the pH of the lower esophagus for a period of several days. Impedance pH monitoring measures electrical impedance in the esophagus to evaluate reflux episodes concurrent with changes in pH. These tests are used for certain clinical indications in the evaluation of gastroesophageal reflux disease (GERD).

Summary of Evidence For individuals who have gastroesophageal reflux disease (GERD) who receive catheter-based pH monitoring, the evidence includes cross-sectional studies evaluating test performance in different populations. Relevant outcomes are test validity, symptoms, and functional outcomes. Positive pH monitoring tests correlate with endoscopically defined GERD and with GERD symptoms, but because there is no reference standard for clinical GERD, diagnostic characteristics cannot be determined. There are no studies of clinical utility showing improved outcomes, and the chain of evidence supporting the utility of the test is weak. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

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For individuals who have GERD who receive wireless pH monitoring, the evidence includes a systematic review and cross-sectional studies evaluating test performance and diagnostic yield in different populations. Relevant outcomes are test validity, symptoms, and functional outcomes. Positive wireless pH monitoring tests correlate with endoscopically defined GERD and GERD symptoms, but because there is no reference standard for clinical GERD, diagnostic characteristics cannot be determined. Some studies have shown higher positive test rates with prolonged wireless monitoring compared with catheter- based pH monitoring, but the effect of this finding on patient outcomes is uncertain. There are no studies of clinical utility showing improved outcomes, and the chain of evidence supporting the utility of the test is weak. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals who have GERD who receive impedance pH testing, the evidence includes cross- sectional studies evaluating test performance and diagnostic yield in different populations. Relevant outcomes are test validity, symptoms, and functional outcomes. Positive impedance pH tests correlate with endoscopically defined GERD and with GERD symptoms, but because there is no reference standard for clinical GERD, diagnostic characteristics cannot be determined. Some studies have shown higher positive test rates with impedance pH testing compared with pH testing alone, but the effect of this finding on patient outcomes is uncertain. There are no studies of clinical utility showing improved outcomes, and the chain of evidence supporting the utility of the test is weak. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Additional Information Clinical input obtained in 2010 has suggested that catheter-based and wireless pH monitoring may aid in the diagnosis of GERD in patients who have an uncertain diagnosis after clinical evaluation and endoscopy. Esophageal pH monitoring is not considered a standard diagnostic test for most patients with GERD, but there is strong clinical support for its use in selected subpopulations for certain indications. Clinical guidelines support pH testing for patients with GERD being considered for surgical intervention. Wireless pH monitoring measurements appear to correlate closely to catheter-based monitoring and may be more comfortable for patients or may be an option for patients unable to tolerate catheter-based monitoring.

Policy History
Date Action 1/2026 Annual policy review. Policy updated with literature review through September 12, 2025; references added. Policy statements unchanged. 1/2025 Annual policy review. References updated. Policy statements unchanged. 1/2024 Annual policy review. Policy updated with literature review through September 25, 2023; references added. Minor editorial refinements to policy statements; intent unchanged. 1/2023 Medicare information removed. See MP #132 Medicare Advantage Management for local coverage determination and national coverage determination reference.
1/2023 Annual policy review. Policy clarified. Not Medically Necessary policy statement language changed to Investigational and other minor editorial refinements to policy statements; intent unchanged. 10/2022 Clarified coding information. 1/2022 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 10/2021 Clarified coding information 1/2021 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 10/2020 Clarified coding information 1/2020 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 1/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged.

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1/2018 Annual policy review. New references added. 10/2015 Clarified coding information. 12/2014 Clarified coding information. 9/2014 Annual review. New references added. 5/2014 Updated Coding section with ICD10 procedure and diagnosis codes. Effective 10/2015. 4/2014 Clarified coding information. 12/2013 Annual review. Removed “24-hour” from the policy statement on impedance monitoring; catheter- based impedance monitoring for any length of time is considered not medically necessary. Effective 12/1/2013. Removed ICD-9 diagnosis codes 427.89, 462; 464.00; 464.01; 486; 493.00; 493.01; 493.02; 493.81; 493.90; 493.91; 493.92 as these do not meet the intent of the policy. ICD-9 diagnosis code V12.61 was added as it meets the intent of the policy. 2/2013 Annual review. Changes to policy statements. Effective 2/4/2013 11/2011-4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates.
No changes to policy statements.
12/2011 Annual policy review. Changes to policy statements. 11/2010 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplantation. No changes to policy statements. 8/2010 Annual policy review. Changes to policy statements. 11/2009 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplantation. No changes to policy statements. 11/2008 Reviewed - Medical Policy Group - Gastroenterology, Nutrition and Organ Transplantation. No changes to policy statements. 12/2008 New policy, effective 12/01/2008, describing covered and non-covered indications. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

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3. Blue Cross and Blue Shield Association Technology Evaluation Center (TEC). Special Report: Wireless pH Monitoring. TEC Assessments. 2006;21(2).
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8. Sweis R, Fox M, Anggiansah A, et al. Prolonged, wireless pH-studies have a high diagnostic yield in patients with reflux symptoms and negative 24-h catheter-based pH-studies. Neurogastroenterol Motil. May 2011; 23(5): 419-26. PMID 21235685
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28. National Institute for Health and Care Excellence (NICE). Catheterless esophageal pH monitoring [IPG187]. 2006; https://www.nice.org.uk/Guidance/IPG187. Accessed September 11, 2025.
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30. Yadlapati R, Gawron AJ, Gyawali CP, et al. Clinical role of ambulatory reflux monitoring in PPI non- responders: recommendation statements. Aliment Pharmacol Ther. Oct 2022; 56(8): 1274-1283. PMID 35971888