Esophageal Manometry Form

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Esophageal Manometry

Notes: Coverage is contingent on the determination that the procedure is reasonable and necessary for the individual patient.

Indications

(997456) Is the esophageal manometry being used to assist in the diagnosis of esophageal pathology such as aperistalsis, spasm, achalasia, esophagitis, esophageal ulcer, esophageal congenital webs, diverticuli, scleroderma, hiatus hernia, congenital cysts, benign and malignant tumors, hypermobility, hypomobility, or extrinsic lesions? 
(997457) Is the esophageal manometry being used in difficult diagnostic cases? 
(997458) Is the esophageal manometry being used as an adjunct to X-rays or direct visualization of the esophagus through endoscopy? 

Effective Date

10/02/1978

Last Reviewed

NA

Original Document

  Reference



Background for this Policy

The major use of esophageal manometry is to measure pressure within the esophagus to assist in the diagnosis of esophageal pathology including aperistalsis, spasm, achalasia, esophagitis, esophageal ulcer, esophageal congenital webs, diverticuli, scleroderma, hiatus hernia, congenital cysts, benign and malignant tumors, hypermobility, hypomobility, and extrinsic lesions. Esophageal manometry is mostly used in difficult diagnostic cases and as an adjunct to X- rays and direct visualization of the esophagus (endoscopy) through the fiberscope.

Esophageal manometry is covered under Medicare where it is determined to be reasonable and necessary for the individual patient.

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