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.
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:
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:
Esophageal pH monitoring is considered not medical necessary when performed for indications other than those listed above.
Multichannel intraluminal impedance-pH monitoring is considered not medically necessary.