Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Esophageal pH monitoring or multichannel intraluminal impedance-pH monitoring may be considered medically necessary in adults, children, or adolescents capable to report symptoms for the following:
- Documentation of abnormal acid exposure in endoscopy-negative individual being considered for surgical anti-reflux repair; or
- Evaluation of individual after anti-reflux surgery who are suspected of having ongoing abnormal reflux; or
- Evaluation of individual with either normal or equivocal endoscopic findings and reflux symptoms that are refractory to proton pump inhibitor (PPI) therapy; or
- Evaluation of refractory reflux in individual with chest pain after cardiac evaluation and after a four (4) week trial of PPI therapy; or
- Evaluation of suspected otolaryngologic manifestations of GERD (laryngitis, pharyngitis, chronic cough) in individuals who have failed to respond to at least four (4) weeks of PPI therapy; or
- Evaluation of concomitant GERD in with adult-onset, non-allergic asthma suspected of having reflux-induced asthma; or
- Evaluation of dysphagia
Twenty-four (24) hour catheter-based esophageal pH monitoring or multichannel intraluminal impedance-pH monitoring may be considered medically necessary in infants or children unable to report or describe symptoms of reflux with:
- Dysphagia; or
- Unexplained apnea; or
- Bradycardia; or
- Refractory coughing, wheezing or recurrent choking (aspiration); or
- Persistent or recurrent laryngitis; or
- Feeding difficulties; or
- Persistent or recurrent pneumonia.
Esophageal pH monitoring and multichannel intraluminal impedance-pH monitoring not meeting the criteria as indicated in this policy is considered not medically necessary.
Procedure Codes
