Humana Gastrointestinal Motility Monitoring Form

Description

Gastrointestinal (GI) motility describes the movement of food and liquids through the digestive system. In normal digestion, contents are propelled through the digestive tract by peristalsis (wavelike muscle contraction and relaxation). If the nerves or muscles along the digestive tract do not function normally, motility problems may exist. Examples of motility disorders include, but may not be limited to, constipation or gastroparesis (delayed gastric emptying).

Testing for GI motility disorders includes, but may not be limited to:

• Electrogastrography (EGG) is a noninvasive technique that purportedly records the electrical signals that travel through the muscles of the stomach controlling the muscles’ contractions. It also reportedly measures the nerve activity of the stomach wall before and after food ingestion via electrodes placed on the abdominal skin over the stomach. Supposedly, EGG can also be performed in conjunction with the administration of a drug in an attempt to manipulate conditions and provoke a measurable abnormality. Examples of EGG devices are the Gastric Alimetry System and the G-Tech wireless patch system. (Refer to Coverage Limitations section)
• Functional luminal imaging probe (FLIP) topography module (eg, EndoFLIP 2.0 system) reportedly allows clinicians to assess possible motility disorders during endoscopy by using impedance planimetry which is designed to measure the area across the inside of a gastrointestinal organ (eg, esophagus) and the pressure inside the organ. The procedure utilizes a balloon catheter in which a specially formulated conductive solution has been injected. The balloon also contains an array of electrodes that purportedly measures voltage, which estimates and displays the diameter at several points along the measurement area. A real time image of the measurements is created and displayed on a monitor. It is intended to be used as an adjunct to other diagnostic methods such as manometry.43 (Refer to Coverage Limitations section)
• Manometry is the measurement of pressure within various parts of the GI tract. This procedure utilizes a catheter that contains solid state or liquid filled pressure transducers that are placed into the lumen of the organ being studied (eg, through the mouth, anus) and typically in an individual where structural lesions have been ruled out by other studies.23 Conventional manometry is performed using 3 to 8 sensors spread at 3-to-5-centimeter intervals. High-resolution manometry (HRM) is performed using up to 36 pressure sensors that are spaced at 1-centimeter intervals and generates multiple line tracings. HRM reportedly converts the pressure magnitude into a color scale, utilizing cold colors to indicate low pressures and hot colors to represent higher pressures.41 The manometry studies that are utilized to evaluate GI motility disorders include, but may not be limited to: constipation or fecal incontinence to help determine if a defecatory disorder exists. The test measures the pressure of anal sphincter muscles, the sensation in the rectum and the neural reflexes that are needed for normal bowel movements. For information regarding anorectal manometry for fecal incontinence, please refer to Fecal Incontinence Evaluation and Treatments Medical Coverage Policy.

When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Colonic manometry is a diagnostic test that records intraluminal pressure or contraction activity of the large intestine. The majority of procedures are performed using a multilumen manometric probe that is placed via a colonoscope. (Refer to Coverage Limitations section)
• Esophageal manometry measures the pressures and muscle contractions in the esophagus. If there are abnormalities in the contractions, strength of the muscle or the sphincter at the lower end of the esophagus, the result may be pain, gastric reflux or difficulty swallowing.
• Gastroduodenal manometry (also known as antroduodenal) reportedly measures how well the smooth muscle of the stomach and small intestine contracts and relaxes by placing a catheter into the stomach to the small intestine, which measures the contractile responses when the individual is fasting and then eating. (Refer to Coverage Limitations section)
• Radiopaque marker testing is accomplished by ingesting a capsule or capsules that contain plastic beads or rings (approximately 20-24 markers per capsule). The passage of the markers through the colon is monitored by standard X-rays, typically taken 3 and 5 days after ingestion. The individual is determined to have delayed transit if greater than 20 percent of the markers are retained 5 days after ingestion of the capsule.
• Rectal sensation, tone and compliance testing may be performed along with anorectal manometry to evaluate anorectal pathology. A double lumen catheter inserted into the rectum measures the fullness and distension (sensation), relaxation and rigidity (tone) as well as the distensibility (compliance) of the rectum. The test is performed using a two-lumen catheter; one used to inflate the bag and the other to measure the pressure within the bag. Air is inflated into the bag slowly and measurements are taken. The balloon is deflated when the individual expresses discomfort and urgency that lasts more than 30 seconds. For information regarding rectal sensory testing for fecal incontinence, please refer to Fecal Incontinence Evaluation and Treatments Medical Coverage Policy.
• Scintigraphy is a test in which following the administration of a radiopharmaceutical, two-dimensional (2D) images of the distribution of radioactivity in tissues are recorded using a scintillation camera. The scintigraphy studies that may be utilized to evaluate GI motility disorders include, but may not be limited to:
• Colonic scintigraphy may be performed to aid in the diagnosis of colonic motility disorders (e.g., constipation). The test can be performed alone; however, typically a combined solid-liquid study method is used so the radiolabeled tracer can be followed from the upper to the lower GI tract providing a study of the whole gut. Images are taken at 1, 2 and 4 hours and then at 24, 48 and 72 hours.

Gastrointestinal Motility Monitoring Effective Date: 07/01/2023
Revision Date: 07/01/2023
Review Date: 03/23/2023
Policy Number: HUM-0304-019 Page: 4 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

A solid phase may be combined with a liquid phase examination.

Wireless gastrointestinal (GI) motility monitoring is a diagnostic procedure performed to evaluate gastroparesis (delayed gastric emptying) or colonic transit time. During wireless GI motility monitoring, the individual swallows a small capsule (approximately the size of a multivitamin) that contains sensors to measure peristaltic pressure, pH and temperature. As the capsule moves through the GI tract, radiofrequency signals are transmitted to a wireless data receiver, which is usually worn on the individual’s belt. After excretion, the receiver is returned to the physician, who downloads the data and analyzes the results. An example of a wireless GI motility monitoring system includes, but may not be limited to, the SmartPill Motility Testing System. (Refer to Coverage Limitations section)

For information regarding Gastric Emptying Breath Testing (GEBT), please refer to Exhaled Breath Tests Medical Coverage Policy.

For information regarding treatment of gastroparesis, please refer to Gastric Pacing Medical Coverage Policy

Gastrointestinal Motility Monitoring Effective Date: 07/01/2023
Revision Date: 07/01/2023
Review Date: 03/23/2023
Policy Number: HUM-0304-019 Page: 5 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Coverage Determination

Humana members may be eligible under the Plan for gastric emptying scintigraphy and/or radiopaque marker testing of the GI tract to evaluate gastric motility disorders (eg, gastroparesis) when the following criteria are met:

• Absence of obstruction based on prior imaging studies; AND
• Persistence of symptoms (eg, nausea, vomiting, early satiety, bloating, abdominal pain) greater than 3 months; AND
• Previous studies (eg, esophagogastroduodenoscopy [EGD], barium studies) have ruled out other diagnoses (eg, Crohn’s disease)

For information regarding diagnostic EGD, please refer to Diagnostic Esophagogastroduodenoscopy or Esophagoscopy (59 years of age or younger) Medical Coverage Policy.

Humana members may be eligible under the Plan for colonic scintigraphy and/or radiopaque marker testing of the GI tract to evaluate gastric motility disorders (eg, constipation) when the following criteria are met:

• Absence of obstruction based on prior imaging studies; AND
• Persistence of symptoms (eg, lumpy or hard stools, feeling of incomplete evacuation of stools, straining to have bowel movements) for greater than 3 months; AND
• Unresponsive to use of laxatives and/or increased fiber

Humana members may be eligible under the Plan for anorectal manometry and/or rectal sensation, tone and compliance testing to evaluate anorectal function.

For information regarding anorectal manometry and rectal sensory testing for fecal incontinence, please refer to Fecal Incontinence Evaluation and Treatments Medical Coverage Policy.

Gastrointestinal Motility Monitoring Effective Date: 07/01/2023
Revision Date: 07/01/2023
Review Date: 03/23/2023
Policy Number: HUM-0304-019 Page: 6 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Humana members may be eligible under the Plan for esophageal manometry to aid in the diagnosis of suspected motility disorders (eg, achalasia, dysphagia) if previous studies (eg, EGD, barium studies) have ruled out structural obstruction.

Note: The criteria for esophageal manometry are not consistent with the Medicare National Coverage Policy and therefore may not be applicable to Medicare members.

Refer to the CMS website for additional information.

Coverage Limitations

Humana members may NOT be eligible under the Plan for GI motility monitoring for any indications or testing methods other than those listed above including, but may not be limited to:

• Colonic manometry; OR
• Electrogastrography, diagnostic, transcutaneous (eg, Gastric Alimetry System, G- Tech wireless patch system); OR
• Electrogastrography, diagnostic, transcutaneous; with provocative testing; OR
• FLIP topography module (eg, EndoFLIP); OR
• Gastroduodenal manometry; OR
• Wireless GI motility monitoring (eg, SmartPill)

These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Additional information about gastrointestinal motility disorders may be found from the following websites: Background

• American College of Gastroenterology •
• American Gastroenterological Association

Gastrointestinal Motility Monitoring Effective Date: 07/01/2023
Revision Date: 07/01/2023
Review Date: 03/23/2023
Policy Number: HUM-0304-019 Page: 7 of 13

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

American Society of Colon and Rectal Surgeons • National Library of Medicine

Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.