CurrentAmbetter NevadaPolicy CP.MP.143

Wireless Motility Capsule

Defines medical necessity and coverage stance for use of the wireless motility capsule (WMC) in evaluation of suspected gastroparesis, delayed gastric emptying, slow-transit constipation, and other gastrointestinal motility disorders for members/enrollees of Centene-affiliated health plans (Ambetter Nevada).

Policy Summary

PayerAmbetter Nevada

PolicyWireless Motility Capsule

Policy CodePolicy CP.MP.143

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionDo not submit claims for wireless motility capsule testing for suspected gastric or intestinal motility disorders because the service is considered not medically necessary under this policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

300 mingastric emptying cutoff

26x13 mmWMC size

5 daysbattery life

15%no pH drop in

Coverage Criteria — Medical Necessity

Not Medically Necessary

Covered when ALL of the following are met

Primary policy stance: Wireless motility capsule (WMC) is not medically necessary for the evaluation of suspected gastric and intestinal motility disorders, as well as all other indications due to insufficient peer-reviewed evidence demonstrating diagnostic performance and clinical utility superior to conventional gastric emptying measures.

Policy applies to Centene-affiliated health plans (Ambetter Nevada).

Use of the wireless motility capsule (WMC) is contraindicated or not appropriate in patients with a possible stricture, altered gastrointestinal anatomy, or severe pyloric stenosis. The device can fail to pass in these settings and may necessitate additional interventions such as serial x-rays to document passage or endoscopic or surgical removal if obstruction occurs. When planning testing, note that patients should ideally be able to discontinue proton pump inhibitors and H2-blockers prior to the procedure when clinically feasible to optimize data capture.

It is the policy of Centene-affiliated health plans (Ambetter Nevada) that the wireless motility capsule (WMC) is not medically necessary for the evaluation of suspected gastric and intestinal motility disorders, as well as for all other indications. The policy determination is based on a paucity of peer-reviewed, evidence-based literature demonstrating that WMC's diagnostic performance and clinical utility surpass conventional measures of gastric emptying.

Policy Summary

PayerAmbetter Nevada

PolicyWireless Motility Capsule

Policy CodePolicy CP.MP.143

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

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Provider Actions, Prior Authorization & Documentation

Prior Authorization

Prior authorization / Coding Note

Prior authorization may be required by the plan. Billing/coding: report CPT 91112 for wireless motility capsule testing (Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report). Verify eligibility, prior authorization, and coverage with Ambetter Nevada prior to scheduling. Inclusion of CPT 91112 in this policy is informational; presence here does not guarantee payment. Providers should reference current coding guidance and the payer’s provider portal for claim submission rules.

Affected code: CPT 91112

Step Therapy

Step therapy requirements: none specified for wireless motility capsule testing in this policy. If the plan imposes any step edits or prior conservative therapy requirements, those will be listed on the payer’s authorization criteria — confirm via the Ambetter Nevada medical policy or prior authorization tool.

Documentation Required

Documentation Expectations

Documentation expectations: when requesting authorization or submitting a claim, include clinical documentation supporting the indication, prior relevant testing (e.g., gastric emptying scintigraphy, clinical evaluation), medication discontinuation when applicable (e.g., proton pump inhibitors or H2 blockers if clinically appropriate), and any contraindications (stricture, altered anatomy, severe pyloric stenosis). Document informed consent discussion about potential need for serial x-rays or device retention and any prior treatments tried and failed.

Denial Risk

Not Medically Necessary — Denial Risk

Denial risk: wireless motility capsule (WMC) is considered not medically necessary for the evaluation of suspected gastric and intestinal motility disorders and for all other indications per policy. Submissions for WMC for these indications are at high risk for denial unless coverage criteria (if any) are met and prior authorization is obtained. Confirm medical necessity with Ambetter Nevada prior to performing the test.

Background

The wireless motility capsule (WMC) is an orally ingested, nondigestible data-recording capsule that continuously measures temperature, pH, and pressure as it traverses the gastrointestinal tract. The device is approximately 26 x 13 mm with a battery life of about 5 days. After ingestion with a standard meal, the patient wears an external recorder that captures telemetry while the capsule moves through the gut by peristalsis. The WMC is used to assess regional and whole-gut transit: gastric emptying (established cutoff >= 300 minutes), small-bowel transit (identified by a sharp pH rise on entry into the duodenum and a pH fall at the ileocecal junction), and colonic transit. Advantages include being wireless, painless, and radiation-free; limitations include potential data loss requiring repeat testing and the possibility of delayed passage or retention of the capsule.

OpenPayer

Wireless Motility Capsule

Coverage Criteria — Medical Necessity

Coding and Clinical Thresholds

Provider Actions, Prior Authorization & Documentation

Background

Definitions