Esophageal pH Monitoring

Policy ID: M-23-031

Section: Diagnostic Medical

Effective Date: July 01, 2018

Revised Date: September 20, 2022

Revision Effective Date: November 04, 2024

Last Reviewed: September 17, 2024

Applies To: Commercial and Medicaid Expansion

Description

Esophageal pH monitoring using wired or wireless devices can record the pH of the lower esophagus for a period of one (1) to several days. These devices may aid in the diagnosis of gastroesophageal reflux disease (GERD) in individuals who have an uncertain diagnosis after clinical evaluation and endoscopy.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

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

91034

91035

91037

91038

Diagnosis Codes

Covered Diagnosis for procedure Codes 91034, 91035, 91037 and 91038

F98.29

G47.30

G47.31

G47.32

G47.33

J31.2

J37.0

J45.20

J45.21

J45.22

J45.30

J45.31

J45.32

J45.40

J45.41

J45.42

J45.50

J45.51

J45.52

J45.901

J45.902

J45.909

J45.990

J45.991

J45.998

J69.0

J82.83

K20.80

K20.81

K20.90

K20.91

K21.00

K21.01

K21.9

P24.9

P28.0

P28.10

P28.11

P28.19

P28.2

P28.30

P28.31

P28.33

P28.39

P28.49

P28.5

P28.81

P28.89

P28.9

P92.5

P92.8

P92.9

R00.1

R05.3

R05.8

R06.1

R06.2

R06.81

R07.89

R13.10

R13.11

R13.12

R13.13

R13.14

R13.19

R63.30

R63.31

R63.32

R63.39

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-22-20 Annual Review

Internal Medical Policy Committee 9-21-2020 ICD-10 update

Removing diagnosis code K21.0;
Adding J82.83; K20.80; K20.81; K20.90; K20.91; K21.00 and K21.01.

Internal Medical Policy Committee 9-21-2021 Coding update - Effective October 01, 2021

Updated language for clarification, and
Removed Diagnosis code R05, and
Adding Diagnosis codes R05.3; R05.8; R13.10; R13.11; R13.13; R13.14 and R13.19.

Internal Medical Policy Committee 5-24-2022 Revision with coding updates

Added Diagnosis codes F98.29; P24.9; P92.5; P92.8; P92.9; R63.30; R63.31; R63.32; and R63.39.

Internal Medical Policy Committee 9-28-2022 - Effective October 01, 2022

Removed Diagnosis codes P28.3; P28.4 and
Added Diagnosis codes P28.30; P28.31; P28.33; P28.39; P28.49

Internal Medical Policy Committee 5-23-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 9-17-2024 Annual Review -no changes in criteria

Added Policy Application

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: M-23-029

Section: Diagnostic Medical

Effective Date: July 01, 2018

Revised Date: September 20, 2022

Revision Effective Date: October 01, 2022

Last Reviewed: May 23, 2023

Archived Date: November 03, 2024

Applies To: Commercial and Medicaid Expansion

Description

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

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

91034

91035

91037

91038

Diagnosis Codes

Covered Diagnosis for procedure Codes 91034, 91035, 91037 and 91038

F98.29

G47.30

G47.31

G47.32

G47.33

J31.2

J37.0

J45.20

J45.21

J45.22

J45.30

J45.31

J45.32

J45.40

J45.41

J45.42

J45.50

J45.51

J45.52

J45.901

J45.902

J45.909

J45.990

J45.991

J45.998

J69.0

J82.83

K20.80

K20.81

K20.90

K20.91

K21.00

K21.01

K21.9

P24.9

P28.0

P28.10

P28.11

P28.19

P28.2

P28.30

P28.31

P28.33

P28.39

P28.49

P28.5

P28.81

P28.89

P28.9

P92.5

P92.8

P92.9

R00.1

R05.3

R05.8

R06.1

R06.2

R06.81

R07.89

R13.10

R13.11

R13.12

R13.13

R13.14

R13.19

R63.30

R63.31

R63.32

R63.39

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-22-20 Annual Review

Internal Medical Policy Committee 9-21-2020 ICD-10 update

Removing diagnosis code K21.0;
Adding J82.83; K20.80; K20.81; K20.90; K20.91; K21.00 and K21.01.

Internal Medical Policy Committee 9-21-2021 Coding update - Effective October 01, 2021

Updated language for clarification, and
Removed Diagnosis code R05, and
Adding Diagnosis codes R05.3; R05.8; R13.10; R13.11; R13.13; R13.14 and R13.19.

Internal Medical Policy Committee 5-24-2022 Revision with coding updates

Added Diagnosis codes F98.29; P24.9; P92.5; P92.8; P92.9; R63.30; R63.31; R63.32; and R63.39.

Internal Medical Policy Committee 9-28-2022 - Effective October 01, 2022

Removed Diagnosis codes P28.3; P28.4 and
Added Diagnosis codes P28.30; P28.31; P28.33; P28.39; P28.49

Internal Medical Policy Committee 5-23-2023 Annual Review-no changes in criteria

Links

References (PDF)

Disclaimer

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Medical Policies Quick Search

Esophageal pH Monitoring

Description

Policy Application

Criteria

Procedure Codes

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Criteria

Procedure Codes

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer