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 patients who have an uncertain diagnosis after clinical evaluation and endoscopy.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person’s unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Criteria

Coverage is subject to the specific terms of the member’s benefit plan.

Esophageal 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.

Twenty-four (24) hour catheter-based esophageal pH monitoring may be considered medically necessary in infants or children unable to report or describe symptoms of reflux with:

• Unexplained apnea; or
• Bradycardia; or
• Refractory coughing, wheezing or recurrent aspiration; or
• Persistent or recurrent laryngitis; or
• Persistent or recurrent pneumonia.

Esophageal pH monitoring is considered not medical necessary when performed for indications other than those listed above.

Procedure Codes 

Multichannel intraluminal impedance-pH monitoring is considered not medically necessary. 

Procedure Codes 

Diagnosis Codes 

Covered Diagnosis Codes for Procedure Codes 91034 and 91035